Quality

Position Paper on Critical-Care Debate Did Not Address Family Practice Physicians in ICU


 

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

  1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
  2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

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Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

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