Published in the April 2004 issue of Today’s Hospitalist
A few years ago, internal medicine residents at the University of California, San Francisco (UCSF) could devote four to six weeks of their training to a rotation in hospital medicine. The elective was designed to give future internists the skills they needed to work as a hospitalist that the standard internal medicine curriculum didn’t focus on.
No longer. After a four-year run, UCSF’s general internal medicine residency eliminated its special hospitalist track in 2002. Today, most internal medicine residents who choose hospitalist jobs after training at UCSF enter the workforce without any special training.
The track was cut because of several factors, including curriculum changes, resident work hour restrictions and faculty turnover. But perhaps most importantly, residents were wary about giving up extra training in cardiology, critical care or infectious diseases to spend more time learning “hospital medicine,” which calls for skills in those exact areas.
The experience at UCSF illuminates the million-dollar question that leaders of hospital medicine are grappling with as they debate the future of training for their field: How can educators retain the best of internal medicine education “the focus on inpatient training “while teaching future hospitalists the skills they need to find a job “and help the specialty grow?
Squeezing it all in
When it comes to training hospitalists, educators face a time crunch. The list of skills that hospitalists need to master above and beyond internal medicine is long and includes communication, end-of-life care, quality improvement and patient safety, medical economics, care of surgical patients and post-acute care.
The dilemma is how to find time to focus on these topics without taking anything away from internal medicine’s already-packed curriculum. Most educators, after all, agree that internal medicine residencies do a better job of preparing physicians for inpatient practice than outpatient medicine. As a result, few educators “or residents, for that matter “are willing to scale back inpatient electives to make room for the hospitalist agenda.
Residents at UCSF who selected the hospitalist elective, for example, were forced to forego some other rotation, usually in a clinical area, that many thought were just as important to their future. That helped doom UCSF’s hospitalist track, recalls Robert M. Wachter, MD, professor of medicine and chief of UCSF’s medical service.
“It seemed weird that people in a hospitalist track should do less inpatient work” than other internal medicine residents, he says.
In fact, educators like Dr. Wachter argue that internal medicine residents, even those headed straight for a career as a hospitalist, should still learn the basics of outpatient primary care medicine. “Even if you want to be a hospitalist,” he says, “I’m not convinced that you should do less outpatient work than we presently give residents. The problem is that there isn’t anywhere else to give.”
Other educators say that all general internists, not just hospitalists, could benefit from an expanded skill set. Preetha Basaviah, MD, a hospitalist and assistant clinical professor of medicine at UCSF, says it is hard to argue that only doctors in training to be hospitalists need to know more about end-of-life care, communication, quality improvement, patient safety and medical economics.
“We are trying to find where these topics fit in the general medicine curriculum so that everybody can benefit,” she explains.
The good news is that some training programs are focusing on hospitalist skills. New requirements from the Accreditation Council for Graduate Medical Education (ACGME) in “systems-based practice and continuous quality improvement,” for example, are encouraging programs around the country to co-opt much of the curricula that hospitalists had created in a few places for their own special rotations and tracks, Dr. Basaviah explains.
And as more hospitalists work as attendings on the general medicine wards in teaching hospitals, Dr. Wachter adds, their way of thinking and practicing is creeping into general internal medicine training in general.
Building a core curriculum
Hospitalist educators, however, say that much remains to be done. They worry that the effort to properly train the next generation of hospitalists will fail or succeed based on the specialty’s ability to define itself.
Dr. Basaviah acknowledges that while it may be difficult to define what the ideal hospitalist training should look like “given how little has been studied about it, it is an increasingly important area as our field grows exponentially.”
Alpesh Amin, MD, director of the hospitalist program at the University of California, Irvine and chair of the Society of Hospital Medicine (SHM) education committee, compares hospitalists’ struggle for definition to other specialties. “It is no different than what people did fairly recently for palliative medicine, geriatrics or even emergency medicine,” he explains. While there is a core knowledge that is different, he notes, it is not entirely separate from internal medicine.
Defining that knowledge is one of the tasks the SHM has taken on. SHM’s education committee formed a core curriculum task force headed by Dr. Amin and Michael Pistoria, DO. The committee has been developing a standardized curriculum that internal medicine and pediatric training programs will be able to adopt for themselves. (Other organizations will also be able to use the curriculum to create CME courses.) The committee expects to finish its work and publish a core curriculum for hospital medicine by the end of the year.
That core curriculum will include a list of critical topics that hospitalists consider essential to effective practice. These include pulmonary embolism/deep venous thrombosis, heart failure, preoperative evaluation/medical consultation, chronic obstructive pulmonary disease, pain management, pneumonia, acute renal failure, stroke, delirium and dementia.
In addition, Dr. Amin says, the curriculum will include chapters on nonclinical topics hospitalists have identified as important, including guideline implementation, patient safety, discharge planning and quality improvement.
Whether all of this material can be taught during the existing training period of three post-graduate years and augmented by CME is a bigger question.
Internal medicine training, which is the backbone of hospitalist training, is undergoing a major rethinking. The Society of General Internal Medicine (SGIM) last fall released a wide-ranging report on the future of general internal medicine that called for a “radical restructuring” of internal medicine training programs.
The report specifically suggested adding a year or two to internists’ training to allow future generations to tailor their residency to meet their needs as either future outpatient generalists, inpatient doctors, primary care physicians in rural areas or subspecialists. (The report is available online.)
The SGIM report also called on the ACGME and the American Board of Internal Medicine (ABIM) to “think creatively about how to create tracks within training programs so that interested residents could quality for certificates of added qualification as value-added evidence of their training.”
Eric Larson, MD, director of the Center for Health Studies at Group Health Cooperative in Seattle and chair of the task force that produced the report, explains that SGIM views hospitalists as exactly the kind of general internist whose training would benefit from such a restructuring.
Dr. Larson practicing hospitalists have told him that most internists coming right out of training programs are not very good hospitalists “yet. “There are things they haven’t learned, like how to function as a key person in the quality improvement and risk management efforts of their hospital,” he says.
He adds that training programs need to focus on the needs of the labor force. “You are in a training program to become something,” he explains, “and you have to design the training program for that purpose.”
SGIM has proposed revamping general internal medicine training so everyone undergoes a basic core training in general internal medicine. After a period of perhaps two years, Dr. Larson explains, residents “could take a single year to become a limited kind of general internist, or maybe two more years to get a certificate of added qualifications as an intensivist, a hospitalist, a geriatrician, an officist, or a person who is going to do rural medicine.”
“We are saying that within the one-size-fits-all, you have to have enough flexibility so that the individual can tailor what they are learning to reflect what they are going to practice.”
The fellowship path
A handful of hospital medicine fellowships have sprung up to help residents prepare to work as hospitalists. Most of those programs, however, focus on training future academicians for careers in clinical research.
Future hospitalist Vineet Arora, MD, is currently the first fellow in hospital medicine at the University of Chicago. She says she needed more training in clinical research before embarking on her career as an academic hospitalist.
“Coming straight out of residency training, some physicians lack skills in quality improvement, administration and research,” she explains. “Hospitalist fellowships are really designed to round out those areas that people might feel deficient in before they would join a successful hospitalist practice, whether that is in an academic or private setting.”
Dr. Arora also wants to hone her skills in research, particularly focusing on quality improvement and patient safety.
Because none of the nine hospital medicine fellowships currently in existence are accredited, each one is unique. Some pay the fellow through an unfilled residency position; others credential the fellow as an attending and pay the fellow’s salary through billings or lucrative consulting services or perioperative clinics. Some tag-team off other departments with existing fellowships, such as geriatrics.
In addition, some of the programs come and go according to shifting interest. Not all the programs are filled every year, for example. A lack of funding, faculty or interest among qualified applicants puts some on the sidelines for a year at a time.
At the University of Texas, San Antonio, for instance, a pediatric hospitalist fellowship disappeared when several faculty members changed jobs and left the department. “It worked beautifully for one year, and we would have continued to do it if we had enough faculty to do it well,” explains George Powers, MD, the fellowship’s director and a pediatric hospitalist for six years. (He himself changed career directions, becoming a neonatal fellow last year.)
“Each fellowship program is unique and takes advantage of local resources and expertise to structure its training program,” explains Sunil Kripalani, MD, assistant professor of medicine at Emory University in Atlanta. “The curriculum may even borrow from other well-established fellowships or degree programs at the same institution,” says Dr. Kripalani, a hospitalist who completed Emory’s fellowship in hospital medicine in 2001 with a master of science in clinical research.
Despite hospital medicine’s rapid growth, he adds, the number of fellowships has remained relatively constant over the past three years. “As one pops up, another might close,” he says. “I expect this trend will continue in the near future. However, as hospital medicine carves out its own teaching and research agenda, the number of fellowship programs should increase steadily, training young hospitalists for these academic roles.”
Hospital medicine rotations
If fellowship is not the way the vast majority of hospitalists will get the training they need to function as top-notch hospitalists, hospital medicine residency rotations may be an answer.
Unlike UCSF, several other general internal medicine residency programs and medical schools have designed hospital medicine rotations that continue successfully. (The same is true in pediatrics.) Some of these tracks, like the one Emory offers, are elective, and function much like any other elective in a subspecialty.
Some, like the hospitalist rotation at the University of California, Irvine, was designed by Dr. Amin about six years ago. All third-year internal medicine residents spend about a month on the track.
Residents who select Emory’s month-long rotation get more training in areas like evidence-based medicine and collaborative medicine. Dr. Kripalani says these residents spend a few days with physical therapists, nutritionists and other ancillary services to learn how to better utilize them.
“Learning how to coordinate teams better is not a well-defined skill,” he explains. “An elective in hospital medicine can expose residents to basic principles of multidisciplinary collaboration and quality improvement.”
Giving residents even more exposure to these principles though a special residency track for hospitalist training would provide even more opportunities for young physicians to work with practicing hospitalists and quality improvement committees. “They could see how to make even more system-wide contributions to patient care,” Dr. Kripalani explains.
As medical leaders debate training needs, he says it is important to remember that being a hospitalist is more than being a doctor who takes care of patients in a hospital.
“It’s setting up quality improvement initiatives,” Dr. Kripalani explains. “It’s coordinating multidisciplinary teams. It’s interacting with pharmacists and administration and nursing and other specialty services. It’s ramping up the effectiveness of perioperative management programs. It’s working with orthopedic services to improve care to fracture patients.”
Dr. Kripalani is quick to note, however, that as groups like SHM develop training recommendations, hospital medicine electives, residency tracks and fellowships will begin to teach these skills in a more uniform manner.
Deborah Gesensway is a freelance writer specializing in health care. She is based in Glenside, Pa.