Shortcut in Critical Care Training Is Wrong Route for Hospitalists

Recently, the Society of Hospital Medicine and the Society of Critical Care Medicine released a position paper that proposed a 1-year expedited training pathway for experienced hospitalists to achieve critical care board eligibility. This proposal was in response to the worsening shortage of intensivists in the United States and the reality that the vast majority of hospitalists already report working in the intensive care unit. The primary goal would be to increase the pool of qualified intensivists to better meet the LeapFrog safety standard of 24/7 ICU coverage by critical care specialists and thus improve patient outcomes.

The SHM/SCCM position paper acknowledges that such a cohort of hospitalist-trained intensivists would need to be formally evaluated and studied against patient outcomes, but presumed that the hospitalist-trained intensivists would improve care compared with the gap that currently exists (J. Hosp. Med. 2012;7:359-64).

I commend SHM for engaging subspecialty groups seeking solutions to a problem that is clearly affecting us all. However, I am left with an overall sense that SHM is putting the cart before the horse.

By current numbers, hospitalists are 34,000 strong with a good chance to reach nearly 50,000 some day. We have come a long way from the 200 or so names on the Win Whitcomb and John Nelson Rolodex of 1997. Yet despite being woven into the very fabric of the U.S. health care system, we remain a heterogeneous workforce with no standards for training, no board certification of our own, and ultimately little consistency from one hospitalist to another. Board-eligible internists with little practice experience are otherwise called hospitalists just like board-certified (and recertified) internists with 15 years under their belt. The variability in procedural competency is even greater than the cognitive divide. If the prerequisite for an expedited training pathway to board certification in critical care begins with an experienced hospitalist, don’t we need to address what a hospitalist is first?

In 2006, SHM developed and published the Core Competencies in Hospital Medicine. This seminal work should have become the foundation for a 1-year hospitalist fellowship and a requirement for board eligibility in hospital medicine. Instead, you may complete any residency you wish and call yourself a hospitalist if your primary professional focus is the general medical care of the hospitalized patient. The Focused Practice in Hospital Medicine Maintenance of Certification program developed by SHM in concert with the American Board of Internal Medicine and the American Board of Family Practice was a landmark achievement, but we continue to set the bar too low. This program is voluntary and lacks the supervised practice experience that a fellowship would provide.

It is interesting to note that the SHM/SCCM proposal mandates that the hospitalist participate in the Focused Practice in Hospital Medicine Maintenance of Certification program (i.e., it is not voluntary) – thus ensuring that hospitalists are certified in their primary board, that hospital medicine modules are completed, and that scholarly work in the form of quality improvement is accomplished. But I can’t help but agree with the recent response from the American College of Chest Physicians (ACCP) and American Association of Critical-Care Nurses (ACCN), which states that they "believe that 1 year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine" (Chest 2012;142:5-7).

Why do you suppose that the ACCP/ACCN feels this way? Could it be they have worked with "hospitalists" who are not up to par? Could it be they have observed variability in both cognitive and procedural skill?

I appreciate that the critical care shortage is not going away and that the SHM/SCCM proposal will produce more trained physicians to work in the ICU. But creating a new variability among intensivists may not be much of a solution. Five years ago, Larry Wellikson, CEO of SHM, referred to the hospitalist with ICU training being potentially viewed as an "intensivist-lite." I doubt any hospitalist who is critical care boarded will appreciate this moniker.

(Continued from first page)

Any training pathway to critical care board certification must be as rigorous as the existing pathways. We must resist replacing rigor with expediency. The frenetic pace of hospitalist growth is the reason we never developed hospitalist fellowships and our own board in the first place. We have taken the path of least resistance in regard to our own identity and training. Before we look at a new expedited training path for another subspecialty board, I propose we get our own house in order. SHM should put the horse back in front of the cart.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

PDF: Training a Hospitalist Workforce to Address the Intensivist Shortage in American Hospitals

Recently, the Society of Hospital Medicine and the Society of Critical Care Medicine released a position paper that proposed a 1-year expedited training pathway for experienced hospitalists to achieve critical care board eligibility. This proposal was in response to the worsening shortage of intensivists in the United States and the reality that the vast majority of hospitalists already report working in the intensive care unit. The primary goal would be to increase the pool of qualified intensivists to better meet the LeapFrog safety standard of 24/7 ICU coverage by critical care specialists and thus improve patient outcomes.

The SHM/SCCM position paper acknowledges that such a cohort of hospitalist-trained intensivists would need to be formally evaluated and studied against patient outcomes, but presumed that the hospitalist-trained intensivists would improve care compared with the gap that currently exists (J. Hosp. Med. 2012;7:359-64).

I commend SHM for engaging subspecialty groups seeking solutions to a problem that is clearly affecting us all. However, I am left with an overall sense that SHM is putting the cart before the horse.

By current numbers, hospitalists are 34,000 strong with a good chance to reach nearly 50,000 some day. We have come a long way from the 200 or so names on the Win Whitcomb and John Nelson Rolodex of 1997. Yet despite being woven into the very fabric of the U.S. health care system, we remain a heterogeneous workforce with no standards for training, no board certification of our own, and ultimately little consistency from one hospitalist to another. Board-eligible internists with little practice experience are otherwise called hospitalists just like board-certified (and recertified) internists with 15 years under their belt. The variability in procedural competency is even greater than the cognitive divide. If the prerequisite for an expedited training pathway to board certification in critical care begins with an experienced hospitalist, don’t we need to address what a hospitalist is first?

In 2006, SHM developed and published the Core Competencies in Hospital Medicine. This seminal work should have become the foundation for a 1-year hospitalist fellowship and a requirement for board eligibility in hospital medicine. Instead, you may complete any residency you wish and call yourself a hospitalist if your primary professional focus is the general medical care of the hospitalized patient. The Focused Practice in Hospital Medicine Maintenance of Certification program developed by SHM in concert with the American Board of Internal Medicine and the American Board of Family Practice was a landmark achievement, but we continue to set the bar too low. This program is voluntary and lacks the supervised practice experience that a fellowship would provide.

It is interesting to note that the SHM/SCCM proposal mandates that the hospitalist participate in the Focused Practice in Hospital Medicine Maintenance of Certification program (i.e., it is not voluntary) – thus ensuring that hospitalists are certified in their primary board, that hospital medicine modules are completed, and that scholarly work in the form of quality improvement is accomplished. But I can’t help but agree with the recent response from the American College of Chest Physicians (ACCP) and American Association of Critical-Care Nurses (ACCN), which states that they "believe that 1 year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine" (Chest 2012;142:5-7).

Why do you suppose that the ACCP/ACCN feels this way? Could it be they have worked with "hospitalists" who are not up to par? Could it be they have observed variability in both cognitive and procedural skill?

I appreciate that the critical care shortage is not going away and that the SHM/SCCM proposal will produce more trained physicians to work in the ICU. But creating a new variability among intensivists may not be much of a solution. Five years ago, Larry Wellikson, CEO of SHM, referred to the hospitalist with ICU training being potentially viewed as an "intensivist-lite." I doubt any hospitalist who is critical care boarded will appreciate this moniker.

(Continued from first page)

Any training pathway to critical care board certification must be as rigorous as the existing pathways. We must resist replacing rigor with expediency. The frenetic pace of hospitalist growth is the reason we never developed hospitalist fellowships and our own board in the first place. We have taken the path of least resistance in regard to our own identity and training. Before we look at a new expedited training path for another subspecialty board, I propose we get our own house in order. SHM should put the horse back in front of the cart.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

PDF: Training a Hospitalist Workforce to Address the Intensivist Shortage in American Hospitals

Recently, the Society of Hospital Medicine and the Society of Critical Care Medicine released a position paper that proposed a 1-year expedited training pathway for experienced hospitalists to achieve critical care board eligibility. This proposal was in response to the worsening shortage of intensivists in the United States and the reality that the vast majority of hospitalists already report working in the intensive care unit. The primary goal would be to increase the pool of qualified intensivists to better meet the LeapFrog safety standard of 24/7 ICU coverage by critical care specialists and thus improve patient outcomes.

The SHM/SCCM position paper acknowledges that such a cohort of hospitalist-trained intensivists would need to be formally evaluated and studied against patient outcomes, but presumed that the hospitalist-trained intensivists would improve care compared with the gap that currently exists (J. Hosp. Med. 2012;7:359-64).

I commend SHM for engaging subspecialty groups seeking solutions to a problem that is clearly affecting us all. However, I am left with an overall sense that SHM is putting the cart before the horse.

By current numbers, hospitalists are 34,000 strong with a good chance to reach nearly 50,000 some day. We have come a long way from the 200 or so names on the Win Whitcomb and John Nelson Rolodex of 1997. Yet despite being woven into the very fabric of the U.S. health care system, we remain a heterogeneous workforce with no standards for training, no board certification of our own, and ultimately little consistency from one hospitalist to another. Board-eligible internists with little practice experience are otherwise called hospitalists just like board-certified (and recertified) internists with 15 years under their belt. The variability in procedural competency is even greater than the cognitive divide. If the prerequisite for an expedited training pathway to board certification in critical care begins with an experienced hospitalist, don’t we need to address what a hospitalist is first?

In 2006, SHM developed and published the Core Competencies in Hospital Medicine. This seminal work should have become the foundation for a 1-year hospitalist fellowship and a requirement for board eligibility in hospital medicine. Instead, you may complete any residency you wish and call yourself a hospitalist if your primary professional focus is the general medical care of the hospitalized patient. The Focused Practice in Hospital Medicine Maintenance of Certification program developed by SHM in concert with the American Board of Internal Medicine and the American Board of Family Practice was a landmark achievement, but we continue to set the bar too low. This program is voluntary and lacks the supervised practice experience that a fellowship would provide.

It is interesting to note that the SHM/SCCM proposal mandates that the hospitalist participate in the Focused Practice in Hospital Medicine Maintenance of Certification program (i.e., it is not voluntary) – thus ensuring that hospitalists are certified in their primary board, that hospital medicine modules are completed, and that scholarly work in the form of quality improvement is accomplished. But I can’t help but agree with the recent response from the American College of Chest Physicians (ACCP) and American Association of Critical-Care Nurses (ACCN), which states that they "believe that 1 year is an inadequate training period for hospitalist physicians to achieve competence in the subspecialty of critical care medicine" (Chest 2012;142:5-7).

Why do you suppose that the ACCP/ACCN feels this way? Could it be they have worked with "hospitalists" who are not up to par? Could it be they have observed variability in both cognitive and procedural skill?

I appreciate that the critical care shortage is not going away and that the SHM/SCCM proposal will produce more trained physicians to work in the ICU. But creating a new variability among intensivists may not be much of a solution. Five years ago, Larry Wellikson, CEO of SHM, referred to the hospitalist with ICU training being potentially viewed as an "intensivist-lite." I doubt any hospitalist who is critical care boarded will appreciate this moniker.

(Continued from first page)

Any training pathway to critical care board certification must be as rigorous as the existing pathways. We must resist replacing rigor with expediency. The frenetic pace of hospitalist growth is the reason we never developed hospitalist fellowships and our own board in the first place. We have taken the path of least resistance in regard to our own identity and training. Before we look at a new expedited training path for another subspecialty board, I propose we get our own house in order. SHM should put the horse back in front of the cart.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.

PDF: Training a Hospitalist Workforce to Address the Intensivist Shortage in American Hospitals