Glass of wine in one hand and the Sept. 30 copy of Wine Spectator in the other, I intended to relax a bit—the future of hospital medicine not necessarily uppermost in my mind. But then I was struck by an article by Matt Kramer titled “10,000 hours.” In it he discusses the implications Daniel Levitin’s new book This Is Your Brain on Music: The Science of a Human Obsession (Dutton) may have for the field of wine tasting.
Levitin notes that “ten thousand hours of practice is required to achieve the level of mastery associated with being a world-class expert—in anything.” It turns out it doesn’t matter what you are trying to master.
“In study after study of composers, basketball players, fiction writers, ice skaters, concert pianists, chess players, master criminals, and what have you, this number comes up again and again,” he says. “No one has yet found a case in which true world-class expertise was accomplished in less time.” This is consistent with how we learn. “Learning requires the assimilation and consolidation of information in neural tissue,” writes Levitin. “The more experiences we have with something the stronger the memory/learning trace for the experience becomes.”
Ten thousand hours. Are you an expert in hospital medicine? Have you compiled the requisite 10,000 hours? The average hospitalist working approximately 200 shifts a year of 10 to 12 hours each would take four to five years to master the practice of hospital medicine. On the other hand, a provider spending 10 hours a week in the hospital would require 20 years to achieve the numeric equivalent of expert status.
While Levitin was discussing the impact of this calculation on music and Kramer on wine expertise, it struck me as applicable to one of the great debates surrounding hospital medicine. Early in the days of the hospitalist movement, many inside and outside the field opined as to whether hospitals should be the domain of hospitalists and clinics the domain of primary care doctors, without overlap. SHM and I proclaimed hospitals should be open to all providers, regardless of primary practice site.
Over time the argument has died down as the threat of a hospitalist takeover has given way to the realization that many primary care doctors prefer a practice without inpatient obligations.
Recently the American Board of Internal Medicine (ABIM) has decided to move forward with a Recognition of Focused Practice in hospital medicine (RFP-HM) certification. This designation will utilize the structure of the ABIM Maintenance of Certification (MOC) program. It will be available to those who have practiced hospital medicine at least three years, meet inpatient volume requirements, and successfully complete hospital medicine-specific Self-Evaluation Process (SEP) modules, Practice Improvement Modules (PIM) and a secure exam.
This has again raised concerns about the growth and direction of hospital medicine and the implications for internal medicine. Would this confer specialty status to hospitalists while leaving primary care doctors as the remaining generalists? Would this further fracture the field of internal medicine? Would this allow hospital-credentialing boards to preferentially allow only those with RFP-HM to practice within their walls, effectively outlawing the primary care doctor?
Having been a member of the task force that worked on RFP-HM, I can say emphatically that it is not intended to confer specialty status to hospitalists or exalt them above other general internists. Rather, it is meant to recognize that a practitioner has focused his or her practice in a manner that demonstrates greater proficiency in the practice of hospital medicine. While this denotes a presumably higher level of proficiency by RFP-HM providers, it does not mean those without it are not capable providers.
How then should we define who is a capable provider in the hospital setting? According to the Dreyfus Model of Skills Acquisition, as learners develop along the continuum from novice to beginner to competent to proficient to expert, their skills become more developed, letting them tackle more complex issues and tasks more efficiently.
For example, the novice knows that a patient with dyspnea might have pneumonia and orders a chest X-ray but little more. The competent provider realizes many other disease states can cause dyspnea and would assess for those as well, often getting bogged down in extraneous details. The proficient provider immediately focuses on the important details and determines pneumonia as the cause of the dyspnea, applying the proper treatment algorithms with a level of efficiency beyond that of the competent peer.
The expert intuitively diagnoses the pneumonia and prescribes the proper diagnostic and therapeutic evaluation. He does so while considering the patient’s immune status, the impact of the hospital’s antimicrobial resistance patterns, and the potential risks and benefits of short-course antimicrobial therapy—all through the prism of quality core measures, cost, and throughput.
In a healthcare system at best strained and by most evidence severely fractured, we can no longer accept competence as the determinant of a capable provider. Rather, we should use proficiency moving toward expertise as the measuring stick for caring for increasingly more complex patients.
The designation “hospitalist” or even RFP-HM should not determine if one is proficient to practice hospital medicine, just as the designation of primary care provider should not exclude one from practicing in the hospital. Certainly, there are practitioners able to seamlessly cross the inpatient/outpatient boundary without losing a step. However, I suspect the more likely scenario is expertise in one and at best proficiency in the other.
Levitin’s 10,000-hour threshold supports this assumption, as it would take at least 10 years to amass 10,000 hours in each practice setting. Most likely, development of expertise in one arena means mere competence in another. As exhibit A, I tremble at the thought of the mischief I would cause if I took my stethoscope to the primary care clinic.
Instead, the ethical standards of our profession should dictate that each provider determines if they meet this pursuit-of-expertise standard. Employers and credentialing boards need to raise the bar toward expertise, ensuring these thresholds are met.
In the end, hospital or clinic sites should be the domain of capable providers, regardless of their primary practice site. However, we need to recalibrate how we define a capable provider who is moving away from competence toward proficiency verging on expertise. Experience as a surrogate for expertise, more than primary practice setting or RFP-HM status, should be the major determinant for who cares for hospitalized patients. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.