A formal clinical track should allow experienced hospitalists to function as inpatient subspecialists: a so-called “focused practice in inpatient subspecialty.” This proposal makes sense on multiple levels.
First, there is a shortage of inpatient subspecialists, particularly in small community settings. Hospitalists, qualified and certified as inpatient subspecialists, could fill this gap.
Second, the practice of hospital medicine is an ideal launching pad for a focused practice in an inpatient subspecialty. Hospitalists are continuously exposed to inpatient subspecialty cases over years of practice. Thus, a conscientious and studious hospitalist can accrue substantial knowledge of inpatient subspecialty management. By working with numerous subspecialists in any particular field, hospitalists have a unique opportunity to observe (and learn from) variations in their practice patterns. Although every subspecialty is admittedly complex, it is my experience that the number of common clinical conditions managed as an inpatient for each subspecialty is quite limited and well within the capacity of a board-certified internist to manage. In other words, there is no magic wand received by completing a formal fellowship training—we all have access to the same knowledge resources.
Third, older hospitalists, in particular, would benefit from this personally and professionally stimulating career path that would promote continued professional development and provide the respect their experience deserves. Currently, hospitalists with decades of experience are still sometimes treated, in my experience, as “glorified residents,” with their clinical decisions regarding subspecialty issues sometimes not trusted by other clinicians.
Fourth, hospitalists generally have more extensive core training and clinical experience than many inpatient mid-level (NP/PA) subspecialty providers who are currently providing an increasing proportion of inpatient subspecialty care under diminishing degrees of supervision. Yet, the current system essentially places board-certified hospitalists in a subordinate role to such mid-level providers. To some, this can be professionally awkward and demoralizing.
Fifth, while formal subspecialty fellowship training is the standard path for internists to become subspecialists, that path is impractical and arguably unnecessary for most practicing hospitalists. A “focused practice in inpatient subspecialty” track could offer equivalent quality subspecialty training specifically tailored to the inpatient setting. Consider that if mid-level providers were required to undergo formal, multi-year fellowship training, their numbers would be significantly reduced. Yet, we currently accept them as adequate in this role with minimal formal training.
Sixth, the reality is that hospitalists working at smaller community hospitals without certain subspecialists available are already making clinical assessments and decisions that would typically be made by a subspecialist if the patient were at a larger facility. So, it isn’t at all irrational to allow them to do the same thing on a formal basis—with supplemental subspecialty training to fine-tune their knowledge and skills.
Consider the following potential requirements for a “focused practice in inpatient subspecialty”:
- A board-certified hospitalist with ten or more years of active inpatient clinical practice (or less?).
- A six-month focused apprenticeship under a board-certified subspecialist.
- A defined curriculum with written and/or oral examinations to assess clinical knowledge.
Of course, regulations defining oversight, co-management, procedural skills, and billing criteria for these physicians would have to be created, but the effort would be worth it.
It’s a clear win-win proposal. By creating a subspecialty track for experienced board-certified hospitalists, we can rejuvenate their professional practice and increase the number of subspecialty physicians in areas of greatest need.
David M. Mitchell is a hospitalist.
