What’s Next for Hospital Medicine?
"We continue to have significant variation in hospital practice models and the types of measurements that are available to those hospitalists for practice improvement," he says. "We continue to see significant turnover in the field with kind of a lack of maturity"—and not the kind of experience base that "you would like to see 15 years in."
"There is really no confidence that everyone at the base of that iceberg will ever make it to the tip because it’s still not viewed by many who entered the field as being a long-term career choice," Dr. Michota says. For many, he said, it is "a look-and-see proposition."
HM came into its own quickly, growing at a pace that even its biggest supporters might not have foreseen. So will the next 15 years be the period when an HM certification board is formed? Will there be full certification for hospitalists beyond the Focused Practice in Hospital Medicine pathway offered through the American Board of Internal Medicine’s (ABIM) Maintenance of Certification process?
As of now, probably not.
Dr. Wellikson, SHM’s CEO, says there are no plans for a certification board at this point. And opinions vary as to whether the field should have its own certification.
Dr. Wachter, ABIM’s chair-elect, says there will be refinements to the Focused Practice pathway, but that a subspecialty certification for HM probably wouldn’t happen until "unique training programs emerge," which he says is unlikely in the next several years.
"We’re pretty comfortable that we have created a pathway for hospitalists to demonstrate their focus on hospital medicine and their expertise borne of their experience," he says.
Dr. Michota says certification would reflect the depth of knowledge needed for today’s hospitalist. "The one thing that emergency medicine had by 15 years that we don’t is a board of emergency medicine, and they had the establishment of training programs that allowed for certification," Dr. Michota says. "I believe that if we’re going to meet the expectations for hospital medicine, we can’t just know everything that a general internal-medicine board would provide. We need to know it at the depth and breadth of the specialist. And we can, in fact, know more and be tested on more than what’s on the internal-medicine board exam."
Dr. Fisher agrees certification is an important step.
"My personal view is that there should be some certification to show that a hospitalist has completed formal training and can pass certain tests. Those tests might be knowledge-based, experience-based, or other," she says. "I believe there needs to be more formal proof that the training a hospitalist has received has been given by those who know how to train. Who performs this training has yet to be determined and may or may not follow current classic certification agency models."
Dr. Wachter says emergency medicine is different in that to be an emergency medicine doctor, you have to know internal medicine, some pediatrics, some surgery, orthopedics, and other areas, and that "to get those competencies, you needed a distinct training program."
"I don’t feel like hospital medicine is like that. My own feeling is that hospital medicine, for the care of adults, is to a large extent an extension of adult internal medicine," he says. "When we have surveyed hospitalists in the past, and asked them ‘What do you do for a living?’ ‘How well were you trained in those things in your residency?’ What they told us was, ‘I was trained very well to do the clinical portions of this job during my residency.’ Where they told us there were gaps was in less traditional areas of medicine," such as quality improvement (QI), communications skills, and leadership.
"It doesn’t strike me that to obtain those competencies, one needs to do a whole different training program than my internal-medicine training," Dr. Wachter adds. "But I do think that one has to modify internal medicine or pediatrics training to make sure that people have those competencies."—TC
