Published in the May 2007 issue of Today’s Hospitalist.
James Lim, MD, had practiced medicine for 10 years and had been a full-time hospitalist for the last two when he requested a transfer to another hospitalist group last year, due to his wife’s job relocation.
The California hospital was affiliated with the one where Dr. Lim worked and had completed his training. But the transfer was denied “not because he lacked experience, he was told, but because he was a family practitioner and not an internist.
"I came from a hospital where other family medicine hospitalists were doing exactly the same things as the internists," he says. At the hospital where he wanted to transfer, however, family practitioners handled the urgent care and didn’t do inpatient work. "I was told that while some people supported my application, the hospitalist group would be ‘more comfortable’ with an internist."
While Dr. Lim decided to stay where he was, he was stung by the rejection. He was also astounded that his hospitalist experience, which included administrative roles and service on his hospital’s quality and utilization management committees, carried so little weight. "It was like I was being judged on the basis of something as arbitrary as ethnicity," he recalls, "rather than merit."
Jasen W. Gundersen, MD, who is also a family medicine hospitalist, had a similar experience. As a third-year resident, he completed several inpatient rotations, and his first job was working for a community health center where he did mostly inpatient work. But when he and his wife, also a family medicine hospitalist, went job hunting a few years ago, many places wouldn’t even let them interview.
Today, Dr. Gundersen is chief of the hospital medicine division at UMass Memorial Medical Center in Worcester, Mass., and a passionate advocate for making hospital medicine an equal opportunity for family physicians. While he does not deny that there’s a natural progression from internal medicine residency to a career as a hospitalist, he points out that "some family practitioners do an extensive amount of inpatient work during and after training."
Those physicians, he insists, should be recognized and welcomed as hospitalists. "An experienced hospitalist is an experienced hospitalist," Dr. Gundersen says, "no matter what field his or her training is in."
More hospitalist groups may be coming to the same conclusion. In the meantime, family medicine hospitalists say that, in addition to hiring hurdles, they have to find their way around other barriers, including a lack of concrete support from their own specialty and looming certification issues.
Perceived training gaps
According to 2005-2006 survey results, family practitioners make up only 3% of practicing hospitalists, fewer than pediatricians or even other internal medicine subspecialists. But Dr. Gundersen suspects those data don’t tell the whole story and that many more family practitioners are working in hospital medicine.
While many recruitment ads for hospitalists ask specifically for internist candidates, the tremendous shortage of qualified physicians has some programs reconsidering their internal medicine-only stance.
But the tough recruiting environment may go only so far to convince hospitalist programs to open their doors to family physicians. That’s because some program directors say they favor board-certified or board-eligible internists for a good reason: Internists’ training is geared more to hospital medicine.
"On average, traditional internal medicine residents spend 90% of their time caring for inpatients," explains Per Danielsson, MD, medical director of the hospitalist program at Swedish Medical Center in Seattle. "For family medicine residents, it’s closer to 50% or less. Family medicine residents have a much greater breadth of material to cover."
Experience trumps training
According to officials at the American Academy of Family Physicians (AAFP), less than one-half of the required curriculum for family practice residencies takes place in the inpatient setting. Officials point out, however, that family practice residents have six months of electives they can devote to inpatient medicine.
Family practitioner Scott W. Tongen, MD, has been a hospitalist since 1991 and was medical director of the United Hospitalist Service of the Allina Medical Clinics in St. Paul, Minn. (He is now medical director in charge of implementing the electronic health record in one of the Allina hospitals, and still does hospitalist shifts.) He says he had no problem finding inpatient rotations.
"When I was a resident in the late ’80s, I was never prevented from aggressively seeking out as many inpatient opportunities as I could," he says.
And when it comes to hospitalist skills, "experience always trumps training," he continues. "My internist colleagues may have had an extra month of cardiology when we were residents 10 years ago, but at this point, I’ve been a hospitalist for 16 years, longer than any internist I know."
Dr. Tongen admits that today’s internal medicine residency programs may provide more preparation for hospitalist careers than family medicine training programs. But he points out that some programs are moving to change that by creating hospitalist fellowships targeted to family practitioners.
Dr. Gundersen, for instance, is starting one such program at UMass that will provide extra training in inpatient and critical care, as well as in clinical research and quality improvement. (The fellowship will be a fourth year for physicians who have already completed residency.) His will be one of a half-dozen family practice fellowships across the country in hospital medicine.
And the University of Florida College of Medicine in Gainesville also offers a one-year hospitalist fellowship that is open to both family practitioners and internists. It lists competency and excellence in hospital medicine clinical skills as one of its goals.
An underappreciated advantage?
Even without additional training, some physicians argue that family practitioners are better prepared to work as hospitalists, particularly in key situations.
"Besides receiving more training in OB/GYN and pediatrics, family practitioners are better trained in family dynamics, geriatrics and behavioral medicine," says Dr. Tongen. Michael D. Kedansky, MD, a family practitioner who leads the hospitalist program at UPH Hospital at Kino, which is part of the University of Arizona in Tucson, Ariz., adds that "family practitioners are trained to practice in remote sites and rural areas where there’s less access to specialists." That training makes them, he points out, "ideally suited to dealing complex and difficult patients."
Beverly Walker, supervisor of physician recruitment for University Health Systems of Eastern Carolina, a six-hospital system anchored by Pitt County Memorial Hospital in Greenville, N.C., notes that rural areas and small communities are precisely the locations where family medicine hospitalists may find the most opportunities.
"There’s a greater presence of family medicine hospitalists in our smaller hospitals because those physicians are more flexible and can see children and adults," Ms. Walker says. She’s now recruiting for two hospitalist positions in a critical access hospital in Edenton, N.C., and she’s received a lot of interest from family practitioners.
"I like to keep the field as wide as possible," she says. "I tell our hospital presidents that they might be missing out by advertising only for internists."
A plus or minus for referrals?
Another factor in the bias against family practitioners may have to do with perceptions about referral networks. Practice management experts point out that hospitalist programs, particularly those just being established, may think that internal medicine subspecialists and outpatient internists will feel more comfortable referring to internal medicine-trained hospitalists, at least initially.
But Dr. Gundersen notes that because of their outpatient training, family practitioners can develop strong relationships with primary care physicians, which can facilitate referrals and continuity of care “and be a boon to programs just getting off the ground.
And Alpesh Amin, MD, executive director of the hospitalist program at the University of California, Irvine, points out that the family physicians who are part of his multidisciplinary academic hospitalist program have been a plus for referrals from community family practitioners.
"The family practice hospitalists have positive relationships with their referral providers," Dr. Amin says, "maintaining communication and seamless care between the inpatient and outpatient settings."
While Dr. Lim looks forward to broader hiring opportunities, he is concerned about pressure from another front: board certification. He notes that the American Board of Internal Medicine is in the process of creating a credential for hospital medicine as a subset of internal medicine. The American Board of Family Medicine is likewise discussing a similar credential for family practitioners as part of its maintenance of certification program. But Dr. Lim worries that separate will mean unequal.
"As long as board certifications are separate, they could still be used to favor internists over non-internist hospitalists," he says. "There really should be one board exam that is open to any qualified physician."
Dr. Lim is concerned that he and his hospitalist colleagues could face the same plight as family practitioners who found themselves unable to continue practicing emergency medicine when the American Board of Emergency Medicine was created in 1979.
"Some were grandfathered in," he says, "but ultimately family practitioners were pushed out of that specialty."
Other family medicine hospitalists point to another barrier: the fact that they are outliers in their own specialty, which translates into less support from professional organizations. AAFP officials admit that “unlike internal medicine organizations, such as the American College of Physicians “the academy is not actively promoting hospitalist careers for its members. It instead tends to focus its advocacy and educational efforts on the outpatient arena, where the majority of its members are dealing with problems related to reimbursement and overhead.
That leaves family medicine hospitalists looking for more professional support. "The AAFP harbors a pervasive belief in the idea that family physicians should be providing ‘womb to tomb’ care," says Dr. Tongen, an opinion that Dr. Kedansky shares.
"I don’t think the AAFP really knows which way to go on this issue," Dr. Kedansky says. "It has to deal with the competing interests of family medicine hospitalists who want additional certification and family practitioners who may lose hospital privileges if they don’t have that certification. That’s a real dilemma."
Moving to more integration
While family physicians try to persuade their leaders to take a new view of their role in hospital medicine, they are also pursuing more grassroots channels.
Dr. Gundersen, for example, is chairing a Society of Hospital Medicine family practice task force to identify family medicine hospitalists and convince them to play a more visible role. He hopes that as family medicine hospitalists stand up and be counted, they will make an even greater impact on hospital medicine.
"We shouldn’t need to convince everyone that family practitioners are not second-class citizens," he says. "Overcoming blatant discrimination and removing barriers to enter the field are our biggest challenges." There are signs that as more family physicians enter the hospitalist workforce, Dr. Gundersen says, segregated situations such as the one that Dr. Lim ran into where family practitioners are not delegated to inpatient work are no longer the norm. At his own hospital, he moved to merge the internist and family practice hospitalist groups last fall. "Except for separate resident supervision duties," Dr. Gundersen says, "we do exactly the same things."
Finally, there appears to be some movement toward broader acceptance among hospitalist companies both large and small. Adam D. Singer, MD, is chief executive officer of IPC-The Hospitalist Company, which has 600-plus hospitalists in private practices that serve more than 200 facilities across the country. According to Dr. Singer, IPC has hired family medicine hospitalists since the company was founded in 1995. The whole debate about whether family physicians should work as hospitalists misses the point, he says, because hospitalists need more than clinical skills to do their job.
"Being a hospitalist is all about managing teams, coordinating care across specialties, understanding health care economics and applying best practices," Dr. Singer points out. Internists need to learn those management skills, he adds, as do family practitioners. Both make excellent hospitalists, once they are trained.
"Those who are hiring only internists consider hospitalists to be ‘internists without offices,’ " Dr. Singer says, "but that’s not hospital medicine, in my opinion."
For some groups, the increasing acceptance of family medicine hospitalists stems from growing familiarity. Brian J. Bossard, MD, who founded the hospitalist program at BryanLGH Medical Center in Lincoln, Neb., says he now has more experience working with family practitioners because a few have provided moonlighting coverage on BryanLGH’s hospitalist service.
"They’ve done a fabulous job," Dr. Bossard says. "Depending on the experience family medicine physicians have with procedures and critical care management, they can potentially do everything that an internist would do." Still, during all of his recruitment drives, Dr. Bossard says he’s advertised only for internists when looking to fill full-time slots, which he’s never had a problem filling.
"However, if I were a family practitioner with hospitalist experience, I’d apply anyway," says Dr. Bossard. "There’s such a need for hospitalists that I believe a motivated individual could break throughthat barrier."
Dr. Gundersen, on the other hand, points out that there are still hospitals that won’t give family medicine hospitalists an interview, "no matter how much we try," he says. "It seems obvious that there is a need, but that hasn’t helped, and we need advocacy from different groups to work with us."
Yasmine Iqbal is a freelance writer based in Wallingford, Pa., who specializes in health care.