Hours to Expertise
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.
