Over the past two decades, delivery of inpatient care at acute care institutions has changed dramatically in Canada, with fewer family doctors following their patients in hospitals and the emergence of a growing number of hospitalists. Despite this growth, there is no uniform understanding of who hospitalists are, what they do and what types of clinical and non-clinical competencies constitute the field of hospital medicine. For example, in western Canada, hospitalists are primarily considered to be family doctors who have focused their practices to the hospital setting, whereas in eastern Canada, the working definition is broader and includes individuals of varying training backgrounds such as general internal medicine and even pediatrics. In my experience, hospitalists are still an unknown entity for many patients and their families, policymakers and even hospital administrators, who frequently mistaken hospitalists for “residents”, “interns” and “house doctors”.
The lack of a clear, shared understanding of the scope of hospital medicine and the skills and competencies of hospitalists has had a number of important implications:
- It has hampered our understanding – from a health services research perspective – of the prevalence of the model and its impact on improving quality and efficiency of care.
- It has led to an unclear scope of practice, resulting in wide variation amongst hospital medicine programs across the country, with a widely divergent spectrum of clinical activities
- It has stood in the way of efforts to find a sustainable funding formula for the growing number of hospitalist programs that rely on their host organizations for subsidies to complement fee-for-service billings.
Despite some recent attempts to study the prevalence of hospital medicine, surveys of self-identified hospitalists (such as those conducted by the Canadian Society of Hospital Medicine – CSHM) continue to remain the primary source for information about hospitalists in Canada. These surveys have identified at least 100 distinct programs in almost all provinces, and provide information on various aspects of hospitalist work such as scope of practice, workload and compensation. However like all surveys, selection and sampling bias limit generalizability. Similarly, research about the impact of hospitalists on quality of care and outcomes are limited, although our research suggests hospitalist care may reduce length of stay and aspects of clinical quality.
In our experience, there is wide variation in the type of clinical services provided by different hospital medicine programs. While some programs focus primarily on less acute patients (such as those requiring more time to recover from illness or those awaiting transfer to a nursing home facility), others may provide services in high acuity areas such as step down units, stroke wards or resuscitation services. This diverse variation in scope of practice can result in differing expectations of hospitalists by hospital leaders, and lead to misconceptions about their clinical expertise and abilities. The mismatch in expectations can in turn affect hospitalists’ job satisfaction and their retention. Moreover, for hospital or health authority managers, benchmarking in various areas like program costs or patient outcomes is more challenging without a clear understanding of the scope of practice provided by hospitalist programs.
Finally, in the absence of a defined identity and subsequent formal recognition by credentialing boards – such as the College of Family Physicians of Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada (RCPSC) – in most jurisdictions hospitalists are viewed simply as family doctors with a focus on inpatient care. As a result, current compensation schemes do not take into account the additional activities they undertake and the value of dedicated hospital-based generalist physicians for the broader health system efficiency.
In my opinion, hospital medicine is a distinct specialty with a unique set of clinical and non-clinical core competencies. Hospitalists are neither family doctors nor general internists (although individuals who have trained in either field can work as hospitalists). Hospital medicine has a set of competencies that are common with both family medicine and internal medicine, but there are also other areas such as systems thinking, leadership and quality improvement that are integral to the specialty. The scope of hospital medicine also comprises a spectrum of patient populations, complexity levels and clinical acuity.
There is precedent in modern medicine for the development and eventual recognition of new specialties. For example, doctors who provide emergency care have a range of training backgrounds, but they have special recognition as distinct specialty and are credentialed by both the Royal College of Physicians and Surgeons and the College of Family Physicians of Canada. The two Colleges have also collaborated in the past to standardize and jointly accredit specialties such as palliative care and preventive medicine.
The recent development of Canadian hospital medicine core competencies makes it easier for the the two credentialing Colleges to offer special accreditation for hospitalists. An official definition of a hospitalist that encompasses both the scope of practice of hospitalists and the non-clinical aspects of hospital medicine (such as quality improvement and leadership) would pave the wave for the development of standards and training programs. It would also allow for dedicated fee codes (or alternate funding models) that could result in proper funding of hospitalist programs and the long-term sustainability of the model.
The potential benefits that can arise from the formal recognition of hospital medicine by credentialing authorities can ultimately allow hospitalists to focus on improving patient experience and quality of care while enhancing the efficiency of the broader healthcare system. Instead of spending all their energy on fighting for recognition and stability, hospitalists will finally have the opportunity to take their place as important members of the Canadian healthcare system.
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What concerns me is when a Family Physician moves into a hospital setting while trying to maintain their private practice the quality of care for the patient is not always at the level it should be. They cover their practice with Locums and usually it is a different one each week.so my question is what is the long term goal for maintain a balance between clinics and the hospital.