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Family practice and hospital medicine

February 2011

There has been a fair amount written recently about family practice trained physicians practicing as hospitalists. In fact, I just noticed a new subcategory in the NEJM physician recruitment section: “FP–Hospitalist.” As someone who is actively recruiting hospitalists, I have given this topic a lot of thought.

Here’s a look at NP hospitalists: NP hospitalists: the right rural staffing model, January 2017.

I work in a hospital that sponsors a family practice residency program, and I have talked to a few of these doctors about careers in hospitalist medicine. Through those conversations and based on what I have read, I gather that the subject of FP hospitalists has become more charged for two reasons: FP as a specialty is struggling, at least in terms of the number of medical students who are choosing this residency track, and that primary care, in general, is dying. You could spend hours counting off the reasons primary care is chronically ill but most telling is that only 2% of medical students planned to take this path as of 2008.

(As an aside, like most chronically ill patients, they will bounce back, a good thing, but few really believe that accountable care organizations and the like will provide them sustained good health.)

Certainly the field of hospital medicine has aided and abetted the decline in interest in primary care, and unintended consequence of our success. And this may only accelerate now that the ABIM has joined with the ABFM to offer focused practice in hospital medicine.

You don’t have to look any further than emergency medicine and its certification process to understand why many in family practice, and internal medicine, for that matter may have reason to be concerned. Around 2000, at least in many urban areas, most IM and FP doctors who were not grandfathered into ER medicine were uprooted from their jobs as the supply of board-certified ER physicians became more plentiful.

The fact that FP as a specialty is struggling has more to do with the state of outpatient medicine than it does with the growth of hospital medicine. That said, I believe that many who would otherwise consider a career in family practice are not taking that route because they do not want to close down their option to be a hospitalist. When examined in this light, FPHM could actually serve as a boom for family medicine.

Remember, by the time we have to choose a residency in medical school, we are only about a third of the way through our clinical rotations. Decisions about what we want to be when we grow up are difficult–and many who are considering outpatient medicine choose an internal medicine residency because that gives them the most flexibility down the road.

So, what is my current recruiting philosophy? I would hire any doctor who is an accomplished hospitalist, IM- or FP-trained. However, I do admit that I have some concern hiring someone directly out of a family practice residency and would likely be more inclined to hire someone who was IM-trained, all other things being equal.

In many ways, it is similar to what I would have needed if I had decided to practice outpatient medicine at the end of my residency. I spent so little time in outpatient medicine in training; I suspect I would have needed at least two years of private practice before I was fully competent and efficient. Of course, this is a catch-22 for family practice doctors: Sure, you can work as a hospitalist once you get experience, but we won’t hire you until you have the experience.

All of that said, a good doctor is a good doctor. A psychiatrist could learn to be a hospitalist with their one year of core internal medicine training, albeit with a much more challenging learning curve than someone out of medicine training.

One of the family practice residents at my hospital complained to me that there are very few fellowships in hospital medicine (or any in emergency medicine for that matter) for those trained in FP medicine.

I think creating more of these fellowships is a good idea. FP and IM residencies could jointly create one-year fellowships for FP physicians who want to go into hospital medicine. My understanding is that for most current hospital medicine fellowships, you must be IM-trained. Further, I believe the focus of most existing programs is to prepare doctors for hospitalist academic medicine.

There are plenty of excellent FP doctors out there who could fill our current hospitalist shortage after a year of intensive inpatient training. And with a one-year fellowship in hospital medicine, FP doctors should be eligible for the hospital medicine boards after, say, only one year of clinical practice, as opposed to the three years that are required now.

We have such a need for good hospitalists, I think our field has an obligation to look for creative ways to enable physicians from different training backgrounds to join our growing ranks.

But no one should hold their breath waiting for said fellowships, and many well-trained FP residents might argue they would be an unneeded burden for a doctor who can quickly adapt to the rigors of inpatient medicine. So I believe kudos is in order for the ABIM and ABFM for creating a joint program. As someone who just hired a family practice resident to join our group, I believe this was a win-win for both those looking to employ hospitalists and those wanting to become one, regardless of physicians’ initial training background.