“I don’t want to be rude or sarcastic,” he implored rudely and sarcastically, a pretentious smirk materializing, “but for hospital medicine to be considered a specialty, don’t you need to do something ‘special’?”
As I spun my internal Rolodex of responses for a setting-appropriate rebuttal, he exchanged knowing glances with the group of grizzled subspecialist academics surrounding him. The crowd, sensing its young prey was cornered, looked on with pitch-forked stares. The prey, sweaty-palmed and tachycardic, made a valiant yet ultimately futile attempt to stave off the questioner.
This exchange came during the question-and-answer portion of a medical grand rounds presentation that I made as a visiting professor at a major academic medical center many years ago. I was asked to talk about the growing specialty of HM, then a relatively new concept to the starched white coats in the academic ivory tower. To be fair, my interpretation of this interaction might be tainted by transference of an early-career inferiority complex. The inquiry had more than a kernel of legitimacy. Is HM really anything special? That query has lived with me for years in the form of a running internal discussion I’ve had with that questioner’s visage.
A Hospitalist is Born
I distinctly remember the day I became a hospitalist. Unlike for most of you, it wasn’t the day I began practicing as a hospitalist. Rather, it was about two years after I started, when my boss dropped off a brochure to join the National Association of Inpatient Physicians (NAIP). “You should probably join this group, whatever it is,” my nonhospitalist boss said dismissively. I nodded my head approvingly, my face contorting into a deferential and admiring look that indicated appreciation for the boss’s all-knowing greatness (note to my hospitalist group: Read that last sentence again). Moments later, I accessed this group’s Web page and found that the position I’d really been filling, what we called “attending on the medical wards 10 months a year,” was called a “hospitalist.”
OK, I had a name.
But was I special?
Growing Up and Finding Our ‘Disease’
Over the ensuing years, NAIP became SHM, HM textbooks were written, national and local CME meetings sprouted up, and a newsmagazine (this one) and medical journal for hospitalists (Journal of Hospital Medicine) were born.
“That’s terrific,” my imaginary grand rounds visage patronizes, “but a specialty needs more than a few people. It needs a critical mass of providers.”
By the beginning of this decade, the number of hospitalists had surpassed the number of practitioners in such time-honored specialties as geriatrics, critical care, and infectious diseases. By 2005, estimates had hospitalists trumping the number of cardiology and emergency medicine doctors. It is likely that the next decade will see the field mushroom to as many as 50,000, even 70,000, providers.
“But you don’t ‘own’ a disease,” exclaims the organ-centric visage. “You can’t be a specialty without ‘owning’ something.”
About five years ago, SHM decided to embrace VTE as a “hospitalist disease.” For sure, we treat the vast majority of pulmonary embolisms and DVTs, and we are best positioned to prevent the hospital-acquired variants. This, along with the realization that hospitalists care for the vast majority of myocardial infarctions, pneumonia, and stroke cases, provided us several diseases to “own,” or at least share with our subspecialist colleagues. The past decade has seen hospitalists take—and eventually run with—the QI and patient-safety baton. These are not diseases per se, but efforts poised to define the next generation of U.S. healthcare.
“Let’s be clear,” my visage chides grumpily. “Owning a disease means more than caring for patients with it. You have to build a research agenda and advance the science of that field.”
HM now counts numerous primary research-based training fellowships and hospitalist researchers. The result is a growing cadre of research-funded hospitalists establishing careers in QI, patient safety, and comparative-effectiveness work around inpatient disease states. Additionally, SHM recently decided to begin funding early-career researchers to bolster the ranks of hospitalist researchers.
Training: The Next Frontier
“That’s cute,” the visage condescends, “but come on—you just can’t be a specialty without training programs. How can you be special if anyone coming out of residency training can do what you do?”
This is a question that has preoccupied me for years. Is there really something that hospitalists do that the typical graduating resident isn’t trained to do? The answer is clear to anyone who has reviewed the published literature—or practiced HM.1,2 Necessity dictates that hospitalists become experts in the perioperative management of surgical patients, provide the bulk of care for acute stroke and many neurosurgical patients, be front-line palliative-care providers, and grant a level of medical consultation that is infrequently stressed in residency training.
Moreover, hospitalists require a strong understanding of healthcare finance, transitions of care, and leadership and communication skills that are underemphasized in most training programs. On top of that, we are tasked with improving hospital efficiency, stewarding hospital resources, and tackling the myriad patient safety and QI initiatives being foisted upon American hospitals. Traditional residency training falls short in most of these categories. Educators are taking note, quickly adapting their HM-focused programs.3
“All right, maybe you’re right there, but you can’t be a specialty without certification. Period, end of story,” my friend, now exasperated, states.
Enter the recently announced American Board of Internal Medicine’s (ABIM) Recognition of Focused Practice (RFP) in Hospital Medicine program. Although the full details have yet to be released, the RFP in HM will utilize the ABIM’s maintenance of certification (MOC) process that all internists are required to partake in at least every 10 years after their initial certification. Certification in HM will most likely include successful completion of four baseline requirements, starting with the ability to document that an applicant has truly focused their practice on inpatient medicine.
Next, diplomates will have to apply their QI skills to HM-based PIMs, or practice improvement modules. Additionally, diplomates will have to complete hospitalist-specific Self-Evaluation Program (SEPs) modules in medical knowledge. And, of course, there will be a secure examination written specifically for hospitalists that is focused on inpatient medicine (see “A-Plus Achievement,” p. 1).
So, as I reminisce fondly with my imaginary visage, it is with the clarity that the next time I give medical grand rounds, I will do so as an unquestioned specialist. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado 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.
- Plauth WH III, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3):247-254.
- Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7): 727-728.
- Glasheen JJ, Siegal EM, Epstein K, Kutner, J, Prochazka AV. Fulfilling the promise of hospital medicine: Tailoring internal medicine training to address hospitalists’ needs. J Gen Intern Med. 2008;23(7): 1110-1115.