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Is a family medicine practitioner the right fit for your hospitalist program?

Hospitalist Management Advisor, June 1, 2008

Editor’s note: This article is the first in a series that will explore the benefits of using family medicine hospitalists as a response to the current hospitalist shortage.

At first glance, the numbers jump off the page. In hospitals, the reality is even more staggering. The Society of Hospital Medicine (SHM) estimates that there are about 20,000 hospitalists in the United States today. It also projects the need to exceed 40,000 during the next five years.

The demand for qualified hospitalists has far outgrown the supply, and hospitals are scrambling to staff their hos- pitalist programs with qualified physicians.

Unfortunately, it’s just not that easy.

“This issue has arisen out of a significant shortage of physicians when compared to current and projected need,” says Robert Harrington, Jr., MD, the vice president of medical affairs at IN Compass Health, Inc., in Alpharetta, GA. And although the cause of the issue might be black and white, the solution is all shades of gray.

In November 2007, Harrington was invited to participate on a task force to brainstorm a strategy “that might allow us to better serve the needs of the rapidly expanding patient population in the fastest-growing specialty in medicine,” he says.

The task force identified a handful of undertapped pools of potential hospitalists that included foreign medical graduates, mid-level providers (nurse practitioners and physician assistants), medical students, and family medicine physicians.

Although many hospitalist programs have already begun to look toward family physicians to meet staffing needs, it’s important to know exactly how well this group of physicians matches up with your program.

Harrington says that even though these practitioners might be excellent candidates, the marriage between physician and program should ultimately come down to individual traits, abilities, skills, and experiences rather than mere titles.

Training program in the works

Hospital medicine appeared after the development of traditional residency curriculums for internal medicine (IM) and family medicine (FM). At that time, hospitals staffed their programs with internists because the IM training program provides applicable inpatient experiences and exposure to medical subspecialties, including critical care. “However, even most IM programs lack the education in physician documentation, metrics, resource utilization, etc. ... necessary to be an ‘ideal hospitalist,’ ” Harrington says.

This idea of training the ideal hospitalist has been addressed by SHM’s recent creation of a fellowship in hospital medicine, Harrington adds. SHM designed it to meet needs that traditional training programs do not address.

“I feel strongly that we want to avoid drawing a line in the sand between the traditional IM and FM residency training,” says Harrington. “I believe the characteristics that make someone an ideal hospitalist are more a series of individual traits and skill sets that can be adequately obtained through either an IM or FM residency training program, and individual physicians should be evaluated on a case-by-case basis.”

Unique training and perspectives

Still, the FM residency training program does tend to give physicians the background that can lead to a successful career as a hospitalist.

Shannon Jenkins, MD, associate chief of hospital medicine at the University of Massachusetts Medical School in Worcester, says her hospitalist service boasts a one-day-shorter length of stay and decreased cost of hospitalization than its IM counterparts.

That’s “because there is an understanding of what is possible, and sometimes easier, with an outpatient work-up,” Jenkins says. “The heavy outpatient component of FM residency training has proven to be an asset with the family physicians in our hospitalist program, and likely in others.”

The FM physicians in Jenkins’ program also understand the key components that they must communicate with the patient and the primary care physician for a successful handoff from the inpatient to the outpatient setting.

Financially, it makes sense as well. “Family medicine physicians are trained in adult, pediatric, and obstetrical medicine, so they are ideal for smaller hospitals that could not sustain the cost of three separate hospitalist services,” Jenkins says.

Harrington adds that the following FM residency training aspects could prove useful for FM physicians transitioning into hospital medicine:

The training received by FM physicians in the psychosocial aspects of medical care brings a unique understanding of serious illness and end-of-life discussions to the bedside.

Exposure to palliative care programs and treatment models, an emerging need in hospital medicine, are part of the curriculum.

There is a focus on the system in which FM physicians practice and deliver care. This instills an awareness of available community resources and allows for improved coordination of care and effective discharge planning.

Because of their pediatric training in residency, FM-trained hospitalists may be a good fit for smaller, community-based hospitals that have a need for adult internal medicine and pediatric coverage.

There is a patient-centered approach to care, which plays into improving patient satisfaction and the ability to ensure that the patient and/or family is at the center of the medical decision-making process.

FM physicians have an awareness of family dynamics and their role in treating acute and chronic illness.

FM physicians also tend to have certain skill sets that can make them strong hospitalist candidates. For example, the extensive procedural training of FM physicians helps a great deal. “No consult is needed for arthrocentesis, lumbar puncture, central lines, paracentesis, thoracentesis, or PICC lines,” Jenkins says.

This has a dual benefit of providing the following:

Comfort for the patient, because, in most cases, they can have a procedure done in their room rather than within another hospital department

Increased revenue for hospitalists

Transition of care expertise

FM physicians also have extensive experience in the outpatient setting during the residency program.

“The detail in transition of care is what sets FM hospitalists apart,” Jenkins says. “We know what information is crucial to communicate with the referring physicians to ensure good care at follow-up. We understand the continuity of care that the referring physicians desire and communicate any change in status to them.” 

For example, the patient’s family often will call the primary physician for guidance on how to proceed when a family member is in the ICU. 

“It is important for them to know those details,” says Jenkins.

Broad experience can trump training

 As a physician in a multipractice hospitalist group who has exposure to many physicians of various training backgrounds, Harrington says physicians with a broad base of experience make ideal hospitalists.

“Those who have had previous private practice experience, emergency department [ED] experience, and especially those who have had medical staff leadership experiences usually rise to the top,” he says. “I think this relates to their ability to understand the interface between hospitalist and another physician—whether it be an ED physician, a primary care provider, or a specialist—from both sides.”

They understand what it is like to reevaluate a patient after they’ve been hospitalized, and they understand what information is important to have at that follow-up visit.

“They also understand the difficulty an ED physician might have in getting a patient admitted that might not meet strict admission criteria, but certainly is not medically safe to send home,” Harrington adds. “They tend, in these instances, to do what is right for the patient and find a way to make the system work so that the needs of all parties are addressed. Family medicine training programs provide this broad base of exposure.”

Challenges recruiting FM physicians

The biggest draw for a FM physician interested in a hospitalist program is the opportunity for growth and change within a system, Jenkins says.

“I think most family physicians that enter into hospital medicine see it as a long-term commitment,” she says. “They are less likely to take a position as a workhorse for 23 shifts a month or just to fill time prior to a fellowship.”

However, the biggest problem is communicating these opportunities and advertising hospital medicine as a viable and sustainable career for FM-trained physicians, says Harrington.

“Because of the lack of widespread acceptance, it has not traditionally been a door that has been open to most graduates of FM programs,” Harrington says. “However, I do think, because of focused efforts on the part of organizations like the SHM, that the word is getting out, and, consequently, there will be more interest among family physicians in the future.”

SHM has been proactive on this subject and has begun discussions with the American Board of Family Practice and the American Academy of Family Physicians to design a recertification process for physicians who choose a career in the hospital.

Feedback from SHM Workforce Summit participants was overwhelmingly positive in terms of their acceptance of the concept, Harrington adds.

For many FM-trained physicians, hospital medicine is an optimal career. Initial interest came from a “small group of family physicians who enjoy acute care and were reluctant to give up that portion of their practice despite enormous pressure from hospitals, managed care [organizations], and the economic forces driving the surge in hospitalist programs,” says Harrington.

Keep the big picture in mind

Although hospital medicine is certainly entrenched in a staffing crisis, it’s important to remember that primary care is suffering as well, Harrington says.

“Increasing the number of physicians in hospital medicine must not be done in a bubble and must be sensitive to the possibility of stealing from the other primary care specialties, which are also in desperate need,” he says. “There is no benefit to us, as hospitalists, to have an adequate work force when we don’t have enough primary care physicians to meet the needs of the population.” In such a scenario, hospitalists would ultimately feel the burden stemming from a lack of access to preventive care.