4) What about the primary care doctor or hospitalist who wants to switch careers?
Is the Society of Hospital Medicine going to require that a physician who has been in practice for 5 or 10 years and decides to switch to hospital medicine go through further training? Is that likely to occur? Alternatively, what about the hospitalist who gets tired of that field and wishes to become a primary care doctor? Might not office-based internists move to create their own specialty and thereby exclude hospitalists from work in that setting?
5) What about the malpractice risks that a new specialty will create?
Let’s imagine a world in which there are internists certified as hospitalists or as primary care physicians. Imagine this malpractice scenario. An office-based doctor caring for his/her own patients in the hospital is sued for some issue or another. The plaintiff attorney standing near the jury faces the doctor and asks “Doctor [he sighs, looking gravely serious], I understand there is a subspecialty in hospital medicine. Are you [now facing the jury] certified in that specialty? The doctor responds “No.” The attorney [turning abruptly back towards the nervous doctor] asks “No? Why not?” Let’s imagine another scenario. A hospitalist working part-time in an office-based practice 1 or 2 days a week faces a similar malpractice situation where he or she is sued. Attorney: “Doctor, I understand there is a subspecialty in primary care medicine? Are you certified in that specialty? Doctor: “No.” Attorney: “No? Why not?”
6) Why create more tests and expenses?
7) Do you want to bite the hand that feeds you?
In our hospital the vast majority of hospitalist admissions are from primary care doctors. Try to eliminate their admitting privileges and see what happens. It will be like the Flu vaccine fiasco this year. There is little vaccine available, but now everyone who has never gotten it in the past is asking for it. My guess is that most primary care doctors will protect their privileges and start admitting and caring for their own patients.
Why don’t we consider a more modest proposal? Here are three ideas.
First, identify areas of expertise that hospitalists actually develop. For instance, can they become procedural experts? Certainly the performance of lumbar punctures, thoracenteses, paracenteses, and central lines is something that most office-based doctors are not comfortable in carrying out any longer. Can we help create credentialing for these important procedures? That would go a long way towards initiating a set of skills that differentiates a hospitalist from an office-based doctor. Why not become a credentialing society for performance of these and other procedures? Monitoring numbers of procedures might constitute one measure, for example, of how to initiate credentialing. For instance, most centers no longer allow a cardiologist who has not performed a certain number of cardiac catheterizations a year to maintain privileges for that procedure. This does not seem discriminatory. It seems wise. I do not think office-based doctors would view credentialing for procedures as discriminatory.
Secondly, what about working to modify existing internal medicine training to perhaps provide added qualifications within hospital medicine for residents committed to the field? The board exams might actually differ then for primary care residents and for those interested in hospital medicine.
Thirdly, what about concentrating efforts on recertification? My guess is that very few residents coming out of practice would not feel qualified to take the hospital medicine or the ambulatory portion of an internal medicine exam. On the other hand, 10 years later during recertification many office-based doctors will not feel qualified to take an exam that emphasizes the treatment of vancomycin-resistant enterococci or management of cardiac arrests. Perhaps the recertification exam is the time to ask doctors to differentiate themselves. Some may wish to maintain certification in both hospital-based and ambulatory care, while others may choose one path or the other.