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HM DEBATE CON: Should Internal-Medicine Residency Training Be Extended?


Should internal-medicine residency training be extended? Dr. Atchley
Dr. Atchley

In the 25 years since I completed my internal-medicine residency, 16 of those as a hospitalist, I’ve begun to look at the recent Accreditation Council for Graduate Medical Education (ACGME) program requirements with some concern. It is true that the training I received as a medical resident is vastly different from the training today. I also would not suggest returning to the hours I worked as a resident, either! After all, there are only so many night shifts in a hospitalist, and if not properly managed, those hours can be used up before age 50.

The present 36-month training program covers the clinical conditions and procedures outlined in SHM’s core competency recommendations.1 It is the section of training concerning competency in health systems that I believe requires additional time in training.

What I did as a hospitalist 16 years ago is vastly different from what I do now. In 1995, the focus was more clinically oriented. Fast-forward to the present, and we all are aware of what we are being asked to do. In addition to clinical expertise in care of patients, our hospital administrators rely on hospitalists to be the stewards of patient safety, quality, throughput, information technology, and comanagement. I think we all would agree that nowhere in our training did we learn the skill set to perform these additional duties.

Working as an HM chief and being responsible for five programs and more than 50 hospitalists, I would have difficulty trying to structure additional training in early employment. Community hospitalist programs usually are understaffed and overworked, and many lack the structure to offer on-the-job training. Certainly, academic hospitalist programs and the larger hospitalist companies would have such infrastructure in place to achieve these additional competencies.

What is being asked of HM today raises the question of whether we are entering a stage for serious consideration of fellowship programs. There are few HM-specific fellowship programs out there. Perhaps we are reaching that crucial junction where our academic colleagues need to think about this.

Historically, when we look at emergency medicine, the early ED doctors came from other disciplines. Our trajectory and acceleration in growth of our field will require us to think about this sooner rather than later.

I consider the American Board of Internal Medicine’s (ABIM) Focused Practice in Hospital Medicine (FPHM) the starting point for vigorous debate about movement towards HM fellowship programs. I would suggest that the time is right for SHM to consider developing a task force to address fellowship programs. TH

Dr. Atchley is chief of the division of hospital medicine at Sentara Medical Group in Norfolk, Va. He is a former SHM board member and is a Team Hospitalist member.


  1. Dressler DD, Pistoria MJ, Budnitz TL, McKean SC, Amin AN. Core competencies in hospital medicine: development and methodology. J Hosp Med. 2006;1 Suppl 1:48-56.

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