A family medicine trained doctor, fresh out of residency, visits a career website to scout out prospective hospitalist jobs in their region. As they scroll through the job listings, they come across one opportunity at a nearby hospital system that seems like a good fit. The listing offers a competitive salary and comprehensive benefits for the position, and mentions hospitalists in the department will have the opportunity to teach medical students.
The only problem? The position is for internal medicine trained doctors only. After searching through several more listings with the same internal medicine requirement, the pool of jobs available to the family medicine doctor seems much smaller.
When Robert M. Wachter, MD, MHM, and Lee Goldman, MD coined the term “hospitalist” in a 1996 New England Journal of Medicine article, hospitalists were primarily clinicians with an internal medicine background, filling the gap created by family medicine doctors who increasingly devoted their time to patients in their practice and spent less time rounding in the hospital.
As family medicine doctors have returned to hospital medicine, it has become difficult to find positions as hospitalists due to a preference by some recruiters and employers that favors internal medicine physicians over those who are trained in family medicine. The preference for internal medicine physicians is sometimes overt, such as a requirement on a job application. But the preference can also surface after a physician has already applied for a position, and they will then discover a recruiter is actually looking for someone with a background in internal medicine. In other cases, family medicine physicians find out after applying that applicants with a background in family medicine are considered, but they’re expected to have additional training or certification not listed on the job application.
The situation can even be as stark as a hospital system hiring an internal medicine doctor just out of residency over a family medicine doctor with years of experience as a board-certified physician. Hiring practices in large systems across multiple states sometimes don’t just favor internal medicine, they are entirely focused on internal medicine hospitalists, said experts who spoke with The Hospitalist.
Outdated perceptions of family medicine
Victoria McCurry, MD, current chair of the Society of Hospital Medicine’s family medicine Special Interest Group (SIG) Executive Committee and Faculty Director of Inpatient Services at UPMC McKeesport (Pa.) Family Medicine Residency, said hearsay inside the family medicine community influenced her first job search looking for hospitalist positions as a family medicine physician.
“I was intentional about choosing places that I assumed would be open to family medicine,” she said. “I avoided the downtown urban academic hospitals, the ones that had a large internal medicine residency and fellowship presence, because I assumed that they would not hire me.
“There’s a recognition that depending on the system that you’re in and their history with family medicine trained hospitalists, it can be difficult as a family physician to seek employment,” Dr. McCurry said.
“When I graduated from my residency in 2014, I did not have the same opportunities to be a hospitalist as an internal medicine resident would have,” said Shyam Odeti, MD, a family-practice-trained hospitalist who works at Ballad Health in Johnson City, Tenn. “The perception is family medicine physicians are not trained for hospitalist practice. It’s an old perception.”
This perception may have to do with the mindset of the leadership where a doctor has had residency training, according to Usman Chaudhry, MD, a family medicine hospitalist with Texas Health Physicians Group and leader of the National Advocacy subcommittee for the Family Medicine Executive Council in SHM. Residents trained in bigger university hospital systems where internal medicine (IM) residents do mostly inpatient – in addition to outpatient services – and family medicine (FM) residents do mostly outpatient – including pediatrics and ob/gyn clinics in addition to inpatient services – may believe that to be the case in other systems too, Dr. Chaudhry explained.
“When you go to community hospital residency programs, it’s totally different,” he said. “It all depends. If you have only family medicine residency in a community hospital, they tend to do all training of inpatient clinical medicine, as IM training would in any other program”
Dr. McCurry noted that there seems to be a persisting, mental assumption that as a family medicine doctor, you’re only going to be practicing outpatient only or maybe urgent care, which is historically just not the case. “If that’s ingrained within the local hospital system, then it will be difficult for that system to hire a family medicine-trained hospitalist,” she said.
Another source of outdated perceptions of family medicine come from hospital and institutional bylaws that have written internal medicine training in as a requirement for hospitalists. “In many bigger systems, and even in the smaller hospital community and regional hospitals, the bylaws of the hospitals were written approximately 20 years ago,” Dr. Chaudhry said.
Unless someone has advocated for updating a hospital or institution’s bylaws, they may have outdated requirements for hospitalists. “The situation right now is, in a lot of urban hospitals, they would be able to give a hospitalist position to internal medicine residents who just graduated, not even board certified, but they cannot give it to a hospitalist trained in family medicine who has worked for 10 years and is board certified, just because of the bylaws,” said Dr. Odeti who is also co-chair for the SHM National Advocacy subcommittee of hospitalists trained in family medicine. “There is no good rhyme or reason to it. It is just there and they haven’t changed it.”
Dr. Chaudhry added that no one provides an adequate reason for the bias during the hiring process. “If you ask the recruiter, they would say ‘the employer asked me [to do it this way].’ If you ask the employers, they say ‘the hospital’s bylaws say that.’ And then, we request changes to the hospital bylaws because you don’t have access to them. So the burden of responsibility falls on the shoulders of hospitalists in leadership positions to request equal privileges from the hospital boards for FM-trained hospitalists.”
Experience, education closes some gaps
Over the years, the American Board of Family Medicine (ABFM) and SHM have offered several opportunities for family medicine doctors to demonstrate their experience and training in hospital medicine. In 2010, ABFM began offering the Focused Recognition of Hospital Medicine board examination, together with the American Board of Internal Medicine. SHM also offers hospitalist fellowships and a designation of Fellow in Hospital Medicine (FHM) for health care professionals. In 2015, ABFM and SHM released a joint statement encouraging the growth of hospitalists trained in family medicine (HTFM) and outlining these opportunities.
These measures help fill a gap in both IM and FM training, but also appear to have some effect in convincing recruiters and employers to consider family medicine doctors for hospitalist positions. An abstract published at Hospital Medicine 2014 reviewed 252 hospitalist positions listed in journals and search engines attempted to document the disparities in job listings, the perceptions of physician recruiters, and how factors like experience, training, and certification impacted a family medicine physician’s likelihood to be considered for a position. HTFMs were explicitly mentioned as being eligible in 119 of 252 positions (47%). The investigators then sent surveys out to physician recruiters of the remaining 133 positions asking whether HTFMs were being considered for the position. The results of the survey showed 66% of the recruiters were open to HTFMs, while 34% of recruiters said they did not have a willingness to hire HTFMs.
That willingness to hire changed based on the level of experience, training, and certification. More than one-fourth (29%) of physician recruiters said institutional bylaws prevented hiring of HTFMs. If respondents earned a Recognition of Focused Practice in Hospital Medicine (RFPHM) board examination, 78% of physician recruiters would reconsider hiring the candidate. If the HTFM applicant had prior experience in hospital medicine, 87% of physician recruiters said they would consider the candidate. HTFMs who earned a Designation of Fellow in Hospital Medicine (FHM) from SHM would be reconsidered by 93% of physician recruiters who initially refused the HTFM candidate. All physician recruiters said they would reconsider if the candidate had a fellowship in hospital medicine.
However, to date, there is no official American College of Graduate Medical Education (ACGME)-recognized hospitalist board certification or designated specialty credentialing. This can lead to situations where family medicine trained physicians are applying for jobs without the necessary requirements for the position, because those requirements may not be immediately obvious when first applying to a position. “There’s often no specification until you apply and then are informed that you don’t qualify – ‘Oh, no, you haven’t completed a fellowship,’ or the added qualification in hospital medicine,” Dr. McCurry said.
The 2015 joint statement from AAFP and SHM asserts that “more than two-thirds of HTFMs are also involved in the training of residents and medical students, enhancing the skills of our future physicians.” But when HTFMs do find positions, they may be limited in other ways, such as being prohibited from serving on the faculty of internal medicine residency programs and teaching internal medicine residents. When Dr. Odeti was medical director for Johnston Memorial Hospital in Abingdon, Va., he said he encountered this issue.
“If you are a hospitalist who is internal medicine trained, then you can teach FM or IM, whereas if you’re family medicine trained, you cannot teach internal medicine residents,” he said. “What happened with me, I had to prioritize recruiting internal medicine residents over FM residents to be able to staff IM teaching faculty.”
A rule change has been lobbied by SHM, under the direction of SHM family medicine SIG former chair David Goldstein, MD, to address this issue that would allow HTFMs with a FPHM designation to teach IM residents. The change was quietly made by the ACGME Review Committee for Internal Medicine in 2017, Dr. McCurry said, but implementation of the change has been slow.
“Essentially, the change was made in 2017 to allow for family medicine trainied physicians who have the FPHM designation to teach IM residents, but this knowledge has not been widely dispersed or policies updated to clearly reflect this change,” Dr. McCurry said. “It is a significant change, however, because prior to that, there were explicit policies preventing a family medicine hospitalist from teaching internal medicine residents even if they were experienced.”
FM physicians uniquely suited for HM
Requirements aside, it is “arguably not the case” that family medicine physicians need these extra certifications and fellowships to serve as hospitalists, Dr. McCurry said. It is difficult to quantify IM and FM hospitalist quality outcomes due to challenges with attribution, Dr. Odeti noted. One 2007 study published in the New England Journal of Medicine looked at patient quality and cost of care across the hospitalist model, and family medicine practitioners providing inpatients care. The investigators found similar outcomes in the internist model and with family practitioners providing inpatient care. Dr. Odeti said this research supports “the fact that family medicine physicians are equally competent as internists in providing inpatient care.”
Dr. Odeti argued that family medicine training is valuable for work as a hospitalist. “Hospital medicine is a team sport. You have a quarterback, you have a wide receiver, you have a running back. Everybody has a role to play and everybody has their own strength,” he said.
Family medicine hospitalists are uniquely positioned to handle the shift within hospital medicine from volume to value-based care. “That does not depend solely on what we do within the hospital. It depends a lot on what we do for the patients as they get out of the hospital into the community,” he explained.
Family medicine hospitalists are also well prepared to handle the continuum of care for patients in the hospital. “In their training, FM hospitalists have their own patient panels and they have complete ownership of their patient in their training, so they are prepared because they know how to set up things for outpatients,” Dr. Odeti explained.
“Every hospitalist group needs to use the family medicine doctors to their advantage,” he said. “A family medicine trained hospitalist should be part of every good hospitalist group, is what I would say.”
HTFMs are growing within SHM
HTFMs are “all over,” being represented in smaller hospitals, larger hospitals, and university hospitals in every state. “But to reach those positions, they probably have to go over more hurdles and have fewer opportunities,” Dr. Chaudhry said.
There isn’t a completely accurate count of family medicine hospitalists in the United States. Out of an estimated 50,000 hospitalists in the U. S., about 16,000 hospitalists are members of SHM. A number of family medicine hospitalists may also take AAFP membership instead of SHM, Dr. Odeti explained.
However, there are a growing number of hospitalists within SHM with a family medicine background. In the 2007-2008 Society of Hospital Medicine Annual Survey, 3.7% of U.S. hospitalists claimed family medicine training. That number increased to 6.9% of physicians who answered the SHM membership data report in 2010.
A Medscape Hospitalist Lifestyle, Happiness & Burnout Report from 2019 estimates 17% of hospitalists are trained in family medicine. In the latest State of Hospital Medicine Report published in 2020, 38.6% of hospital medicine groups containing family medicine trained physicians were part of a university, medical school, or faculty practice; 79.6% did not have academic status; 83.8% were at a non-teaching hospital; 60.7% were in a group in a non-teaching service at a teaching hospital; and 52.8% were in a group at a combination teaching/non-teaching service at a teaching hospital.
Although the Report did not specify whether family medicine hospitalists were mainly in rural or urban areas, “some of us do practice in underserved area hospitals where you have the smaller ICU model, critical access hospitals, potentially dealing with a whole gamut of inpatient medicine from ER, to the hospital inpatient adult cases, to critical care level,” Dr. McCurry said.
“But then, there are a large number of us who practice in private groups or at large hospitals, academic centers around the country,” she added. “There’s a range of family medicine trained hospitalist practice areas.”
Equal recognition for HTFM in HM
The SHM family medicine SIG has been working to highlight the issue of hiring practices for HTFMs, and is taking a number of actions to bring greater awareness and recognition to family medicine hospitalists.
The family medicine SIG is looking at steps for requesting a new joint statement from ABFM and SHM focused on hiring practices for family medicine physicians as hospitalists. “I think it’s worth considering now that we’re at a point where we comprise about one-fifth of hospitalists as family medicine docs,” Dr. McCurry said. “Is it time to take that joint statement to the next step, and seek a review of how we can improve the balance of hiring in terms of favoring more balanced consideration now that there are a lot more family medicine trained hospitalists than historically?
“I think the call is really to help us all move to that next step in terms of identifying any of the lingering vestiges of expectation that are really no longer applicable to the hiring practices, or shouldn’t be,” she said.
The next step will be to ask hospitals with internal medicine only requirements for hospitalists to update their bylaws to include family medicine physicians when considering candidates for hospitalist positions. If SHM does not make a distinction to grant Fellow in Hospital Medicine status between internal medicine and family medicine trained hospitalists, “then there should not be any distinction, or there should not be any hindrance by the recruiters, by the bigger systems, as well as by the employers” in hiring a family medicine trained physician for a hospitalist position, Dr. Chaudhry said.
Dr. Odeti, who serves in several leadership roles within Ballad Health, describes the system as being friendly to HTFMs. About one-fourth of the hospitalists in Ballad Health are trained in family medicine. But when Dr. Odeti started his hospitalist practice, he was only one of a handful of HTFMs. He sees a future where the accomplishments and contributions of HTFMs will pave the way for future hospitalists. “Access into the urban hospitals is key, and I hope that SHM and the HTFM SIG will act as a catalyst for this change,” he said.
Colleagues of family medicine hospitalists, especially those in leadership positions at hospitals, can help by raising awareness, as can “those of our colleagues who sit on medical executive committees within their hospitals to review their bylaws, to see what the policies are, and encourage more competitiveness,” Dr. McCurry said. “Truly, the best candidate for the position, regardless of background and training, is what you want. You want the best colleagues for your fellow hospitalists. You want the best physician for your patients in the hospital.”
If training and all other things are equal, family medicine physicians should be evaluated on a case-by-case basis, she said. “I think that that puts the burden back on any good medical committee, and a good medical committee member who is an SHM member as well, to say, ‘If we are committed to quality patient care, we want to encourage the recruitment of all physicians that are truly the best physicians to reduce that distinction between FM and IM in order to allow those best candidates to present, whether they are FM or IM.’ That’s all that we’re asking.”
Dr. Chaudhry emphasized that the preference for internal medicine trained physicians isn’t intentional. “It’s not as if the systems are trying to do it,” he said. “I think it is more like everybody needs to be educated. And through the platform of the Society of Hospital Medicine, I think we can make a difference. It will be a slow change, but we’ll have to keep on working on it.”
Dr. Odeti, Dr. McCurry, and Dr. Chaudhry have no relevant financial disclosures.