Training and certification for hospital medicine programs support the essential role of hospitalists for complex multi-morbid patients in acute care
Vandad Yousefi, MD, William Coke, MD, and James Eisner, MD
The current COVID-19 pandemic has resulted in significant strain on acute care delivery in Canada and around the world. It has highlighted the importance of hospitals rapidly increasing their resources to meet the capacity demands brought on by a disruptive change. Hospital medicine teams have become central to many acute care sites, caring for increasingly complex hospitalized patients. We believe that the ongoing implementation of hospitalist teams of generalist physicians is critical in ensuring that health care organizations are well positioned to provide high-quality care in uncertain times. We also highlight the need for adequate training and certification for physicians who aim to work as part of such programs.
KEY WORDS: hospital medicine, hospitalist, training programs, certification, COVID-19
CITATION: Yousefi V, Coke W, Eisner J. Training and certification for hospital medicine programs support the essential role of hospitalists for complex multi-morbid patients in acute care. Can J Physician Leadersh 2021;7(3):125–131. https://doi.org/10.37964/cr24738
In the last few decades, the Canadian health care system has seen seismic changes in the care of patients in hospitals. With the rapid proliferation of new knowledge and technology, the management of many clinical conditions has changed profoundly, often with dramatically improved outcomes. Much of this success has occurred because hospital care has become increasingly interprofessional, relying not only on the expertise and input of highly specialized physicians, but also on the unique knowledge and skills of other health care professionals.
This shift to team-based care is the result of a number of systemic drivers; patient populations, care providers, and the health care system have rapidly evolved in the face of increasing medical acuity, care complexity, and the emergence of novel illnesses. Arguably the greatest pressures have resulted from the rapidly rising prevalence of chronic illnesses.1 Patients with one or more chronic medical conditions have become the largest group requiring admission to acute care hospitals.2-4 As the population continues to age, the challenge of caring for complex patients is expected to continue.5-7 During the COVID-19 pandemic, for example, patients with co-morbidities and increasing age were most likely to require hospital admission and have a longer length of stay.8 Top
Health care providers have also experienced significant changes in their scopes of practice over the past decades, including ongoing trends toward subspecialization and the expanding roles of various health professions.9-11 Physician burnout and the need for better work–life balance is increasingly being recognized as a priority, particularly among newer graduates with new (and perhaps healthier) attitudes and expectations.12 At the same time, the health care system is facing ongoing resource constraints, with growing pressures to control the rising costs of services.
Within this evolving environment, many medical admissions no longer fit into discrete diagnostic categories or even specialty areas. Physicians serving as most responsible providers (MRPs) for hospital patients today are working under unprecedented pressures to effectively diagnose and treat patients presenting with a range of acute and chronic conditions, while at the same time responding efficiently to meet ongoing capacity issues. Surgeons and subspecialists are increasingly finding it difficult to manage complex patients admitted under their care with multiple comorbidities outside their areas of expertise. Community-based family physicians and specialists are similarly facing increasing difficulties in continuing to serve as MRPs for complex patients while maintaining busy office practices.13,14 The net effect is a steady decline in the number of physicians who provide traditional MRP coverage for medical inpatients across the health care system. Top
In response, over the past two decades, a growing number of organizations across Canada and internationally has been adopting new models for physician coverage. These models (broadly referred to as “hospital medicine”) involve groups of physicians (“hospitalists”) working in teams to provide 24/7 MRP coverage for medical inpatients.15 Many hospital medicine programs also support the care of increasingly complex patients admitted to other services (most commonly orthopedics, neurosurgery, and psychiatry) through formal or informal co-management agreements.16
During the COVID-19 pandemic, many patients were admitted to acute care with a hospitalist as the MRP.17-19 Having hospitalist teams already established as an integral component of the multidisciplinary care model demonstrated that hospital medicine programs are valuable in the acute care of complex patients.19 For example, across the network of acute care hospitals operated by Fraser Health in British Columbia, hospitalists quickly became the default providers for non-critically ill hospital patients with COVID-19 pneumonia, caring for 80% of inpatients across 10 facilities. Top
The value of hospital medicine programs
Studies have found that hospital medicine programs in the United States are associated with shorter length of stay, higher patient satisfaction, variable impact on select clinical measures of quality, and similar performance regarding mortality and readmissions.20,21 Studies from Canada also suggest that, although hospitalist care does not result in shorter length of stay, it may be associated with reductions in mortality and readmissions.22-24 In both countries, hospital medicine programs have generally demonstrated that they can not only provide effective inpatient coverage, but also produce real savings for the health care system without compromising standards of care, quality, and patient satisfaction.
Hospital medicine programs can also facilitate standardization of services based on best evidence/best practices and promote interprofessional collaboration. By allowing more predictable workloads and, in turn, better work–life balance, they can also help prevent burnout and facilitate physician retention.25-28 Moreover, hospitalist programs can play an important role in improving teamwork and help retention of other health professionals in the acute care setting.29 Top
Finally, hospitalists have increasingly become key players in a range of non-clinical activities, such as organizational leadership, quality improvement, and teaching.28,30-32 For example, 80% of hospitalists surveyed in Canada in 2012 indicated that they participated in non-clinical activities in addition to caring for patients.33
Generalist physicians function as hospitalists
To be effective, most hospital medicine programs require physicians who can function as generalists and are able to care for patients with a wide range of acute and chronic medical conditions. Both internal medicine and family medicine specialties have the potential to provide the training and experience needed to acquire the competencies of hospital-based medicine.
Hospital medicine programs in Canada are often made up of internists and family physicians working collaboratively as part of the same teams. For example, at Trillium Health Partners in Mississauga, Ontario, 55 internal medicine hospitalists currently work with 15 family medicine hospitalists to provide MRP coverage for over 13 000 acute medical admissions per year, involving up to 400 inpatient beds at a time. With admission volumes continuing to increase markedly year after year, recruitment for additional hospitalists (from both training backgrounds) will continue. At Fraser Health in British Columbia, hospitalists are responsible for over 50 000 admissions per year. Most are trained initially in family medicine; however, in recent years, an increasing number of internists have joined the program, and now account for almost 20% of new recruits. In the Calgary Zone of Alberta Health Services, the hospital medicine program is responsible for over 14 700 admissions a year, or 61% of all medical admissions in the zone. The program is staffed entirely by family medicine hospitalists. Over the past 6 years, admissions to the program have shown progressive increases in comorbidity and complexity, requiring routine collaboration with internal medicine providers to help ensure optimal care. Top
Hospitalist programs enhance system leadership
Hospitalists are uniquely positioned to take on leadership roles within the acute care setting. The enhanced on-site availability of hospitalists, where physicians are present continuously in the hospital throughout the day (and, in many cases, located in specific care units) is a defining core feature of the hospital medicine model.25 Although this enhanced presence and engagement may help explain improvement in outcomes associated with the introduction of the hospitalist model, it has also been shown to result in improvements in collegiality and interprofessional collaboration.34,35
As a result, hospitalists have the opportunity to not only better integrate into interprofessional acute care teams, but also to take on a leadership role within the care unit.36 Indeed, in some organizations, hospitalists have assumed formal leadership roles as part of physician–nursing dyads with significant positive impact on care outcomes.37 More broadly, hospitalists have also been increasingly involved in transformation throughout their organizations, for example, by leading quality improvement and patient safety initiatives.38 These leadership functions correlate well with the leadership domains described in the LEADS framework: Lead self, Engage others, Achieve results, Develop coalitions, and Systems transformation.39 Top
Hospital medicine is an evolving specialty
In 2012, Smith and Sivji40 identified a number of pressing challenges in the evolution of hospital medicine in Canada. These included the development of core competencies for hospital-based generalist care, clarification of scope of practice, measuring outcomes associated with hospitalist care, the need for formal training, and formal certification in hospital medicine.
Since then, there has been progress on some of these issues. For example, in 2015, the Canadian Society of Hospital Medicine (now the Society of Hospital Medicine – Canada Chapter) created a document defining core competencies required for those caring for hospital patients with acute general medical conditions.41 Similarly, various organizations have attempted to define hospitalist scopes of practice by developing guidelines and interdepartmental agreements42 or through credentialing and privileging standards.43 In addition, an increasing number of publications have aimed to assess outcomes associated with hospitalist care.22-24 However, challenges remain with regard to hospitalist training and certification in Canada. Top
Hospital medicine practice needs training
Based on our collective experience, we believe there will be an ongoing need across the country for physicians with comprehensive generalist training to provide MRP coverage for hospital patients, not only to fill current vacancies, but to also meet future physician resource requirements.
General internists in Canada complete extensive clinical training in inpatient care, including substantial experience on inpatient and critical care units. As a result, they are well trained to provide comprehensive care for inpatients. However, with fewer than 3500 general internists in active practice across the country, compared with over 42 000 family physicians,44 the latter constitute the largest group of generalists working as hospitalists.45 Top
In contrast with general internalist training, that for family medicine is shorter and is focused on primary care in the community, including chronic disease management and preventive health care. We have found that gaps in knowledge and expertise between internal medicine and family medicine hospitalists clearly diminish over time as physicians gain clinical experience by focusing their practices on inpatient care. However, some family medicine trained hospitalists can initially face a steep learning curve, and many are reluctant to participate in acute care as they feel underprepared after graduating from residency. If core family medicine training remains unchanged in duration and educational focus, there will be a growing need to provide additional enhanced training related to inpatient care for family physicians who wish to participate in hospital medicine services.
Indeed, a number of postgraduate hospital medicine training fellowships currently exist across Canada. These include non-accredited clinical fellowship programs that are administered by various academic hospitals46,47 as well as some category 2 enhanced skills programs offered by a few family medicine university departments that provide additional training opportunities for graduates.47-50 However, progress has been limited, and a standardized curriculum and many more training programs are still urgently needed to ensure that physicians wishing to pursue careers as hospitalists have the needed clinical competencies to take on these challenging roles regardless of their initial training.
Hospital medicine should have certification
Similarly, there is a pressing need for formal recognition and certification of hospitalists. The lack of formal certification for hospital medicine, particularly for family medicine graduates who currently make up the majority of the workforce, continues to be a major barrier to developing sufficient training opportunities and for motivating family physicians who want to practise as hospitalists to pursue additional training. Top
Precedents for certification and formal recognition of medical specialties, defined by how care is delivered as opposed to historical organ-body systems, have already been established. Both emergency and critical care medicine employ physicians from diverse training backgrounds. Like hospital medicine, these specialties have evolved around the setting where care is provided. More recently, palliative medicine has emerged as a specialty encompassing physicians with backgrounds in internal medicine, family medicine, and other disciplines.
Close collaboration between the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada has allowed for the development of certification and common standards, in turn helping to define these evolving fields. To date, this kind of cooperation among relevant stakeholders has been elusive for hospital medicine. Until it exists, establishing sufficient training programs to meet the growing need for physicians with the knowledge, skills, and experience required to work in hospital medicine programs will remain a challenge.
As the complexity of inpatient care increases, the need for qualified generalist physicians who can help both the patients and the health system navigate hospital admissions has become important. The COVID-19 pandemic made the valuable role of hospitalist teams even more apparent. To meet this demand, postgraduate family medicine training programs must either more fully incorporate acute care opportunities or implement dedicated training fellowships to allow for acquisition of the core competencies and skills that have been identified to be critical in providing care to general medical patients in hospitals. A national certification program for hospital medicine can be an important enabler of more widespread and standard training for prospective hospitalists. Top
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Vandad Yousefi, MD, is the former regional department head for hospital medicine, Fraser Health. He is currently associate department head in the Department of Family and Community Practice, Vancouver Coastal Health Shared Services.
William Coke, MD, is associate professor of medicine, University of Toronto, and vice chair of the Section on Hospital Medicine, Ontario Medical Association, Toronto.
James Eisner, MD, is a clinical assistant professor at the University of Calgary and lead, Section of Hospital Medicine, Medicine Strategic Clinical Network, Alberta Health Services, Edmonton.
Author declarations: Vandad Yousefi is co-founder and CEO of Hospitalist Consulting Solutions, Inc. William Coke and James Eisner have nothing to declare. This work is unfunded.
All authors contributed substantially to the conception and design, the acquisition of data, or analysis and interpretation of data. All drafted the article or revised it critically for important intellectual content and approved the final version.
This article has been peer reviewed.