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Family practice and hospital medicine

May 2011

Published in the May 2011 issue of Today’s Hospitalist

While it’s hardly hospital medicine’s deep, dark secret (and I’m curious: Do we have one?), there seems to be a majority belief that internal medicine is the preferred training route for aspiring hospitalists. Of course, many would beg to differ. Given the new “FP-Hospitalist” subcategory in the physician recruitment section of the New England Journal of Medicine, some might suggest that the bias toward internal medicine is moot.

But for every “FP-Hospitalist” ad, many more openly state “BE/BC internal medicine trained physician wanted,” with the implicit “FP need not apply.” Because I am constantly recruiting, I have given this issue much thought.

The hospital system where I work sponsors a family practice residency program, so I have spoken to many of these doctors about hospitalist careers. Based on those conversations and on what I have read, I gather that the subject of FP hospitalists has become more charged. That’s because FP as a specialty is struggling, at least in terms of the number of medical students choosing this residency track. It’s also because primary care in general is on the ropes.

The hospital medicine migration
If that last statement caught you off guard, then you must have just woken up from a 20-year nap; only 2% of medical students planned to take this path as of 2008. As an aside: Like most chronically ill patients, primary care will bounce back, which is good. But few really believe that accountable care organizations and the like will result in the sustained good health of primary care.

Certainly, hospital medicine has aided and abetted primary care’s decline, an unintended consequence of our success. The migration to hospital medicine may only accelerate now that the American Board of Internal Medicine (ABIM) has joined with the American Board of Family Medicine (ABFM) to offer a focused practice in hospital medicine recertification option. (See “Focused practice gets its first class.”)

You don’t have to look any further than emergency medicine and its board certification process to understand why many in family practice “and in internal medicine, for that matter “have good reason to worry about their ability to practice traditional (read inpatient and outpatient) medicine if they choose. Around 1990, at least in many urban areas, most IM and FP doctors who were not grandfathered into emergency medicine were uprooted from their jobs as board-certified ED physicians became more plentiful. I am not suggesting that ED board certification and focused practice for hospitalists are analogous. But flash forward 10 years, and I suspect you will see a similar evolution in practice restrictions.

I believe that many physicians who would have otherwise considered a career in family practice didn’t take that route because they did not want to close down their option to be a hospitalist. Instead, many considering outpatient medicine probably chose an internal medicine residency because that gave them the most flexibility down the road. In this light, FPHM may actually be a boon for family medicine.

One-year fellowships?
So what is my current recruiting philosophy? I would hire any doctor who is an accomplished hospitalist, IM- or FP-trained. But I admit that I have some uncertainty hiring a candidate directly out of a family practice residency and would be more inclined to hire an IM-trained doctor, everything else being equal.

If I’d chosen to become an internist, I would have expected that same bias against me. After all, one half-day a week hardly trained me to be an efficient outpatient practitioner, and I suspect I would have needed at least two years of private practice before I could pull my own weight. Obviously, this is a catch-22 for family practice doctors: Sure, you can work as a hospitalist once you have experience, but we won’t hire you until you get it.

Then again, a good doctor is a good doctor. Psychiatrists could learn to be a hospitalist with their one year of core internal medicine training from their intern year, albeit with a much more challenging learning curve.

One family practice resident at my hospital complained that there are very few fellowships in hospital medicine (or in emergency medicine, for that matter) for physicians trained in family 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.

There are plenty of excellent FP doctors out there who could fill hospitalist slots 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 focused-practice recertification after, say, only one year of clinical practice, as opposed to the three years now required. Given the 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.

Removing barriers, building others
But no one should hold their breath waiting for said fellowships. And many well-trained FP residents might argue that the extra year would be an unneeded burden for a doctor who can quickly adapt on the job to the rigors of dedicated inpatient medicine.

So kudos to the ABIM and the ABFM for creating a joint program for focused practice recognition. That should eliminate some barriers to entry in our field. It may also perhaps someday justifiably create some barriers to the practice of low-volume inpatient medicine. As someone who just hired a graduating family practice resident to join his group, I believe this is a win-win for both those looking to employ hospitalists and those wanting to become one.

Erik DeLue, MD, MBA, is medical director of the hospitalist program at Virtua Memorial in Mt. Holly, N.J.