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Completing the puzzle: the emergence of hospitalists in acute care

Much has been said about the ongoing trend in Medicine towards specialization. While some have expressed concerns about the decline in “generalism” (1), others have welcomed the trend as a strategy to enhance the competencies of providers and improving the ability of the profession to meet increasing patient expectations for excellence and quality (2).

Similar concerns have been voiced in Canada, where general practice is a major component of the health system. Many observers in the world of Canadian family practice have bemoaned the loss of comprehensive primary care and the emergence of specialization within family practice (3). Debates continue within the family practice community, and in particular the national organizations representing family medicine, about the pros and cons of recognizing more subspecialties (also referred to as Certificates of Added Competence) (4). Despite this, both the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada (CFPC) – the two “specialty boards” in the country- have continued to recognize new specialties and areas of focused practice. For example, the CFPC recently announced the creation of two new areas of added competence in Addictions Medicine and Enhanced Surgical Skills (5).

However, one emerging “specialty” that continues to face an uphill battle in gaining recognition in Canada is Hospital Medicine. While hospitalist programs in Canada emerged around the same time as those in the United States in the late 1990s (6), the development of the model of care as an emerging area of focus has diverged in recent years. Canadian hospitalists have watched their US colleagues gain recognition by both the American Board of Internal Medicine and the American Board of Family Medicine as an area of Focused Practice, while their own efforts have gained little traction with the Canadian specialty boards. Yet, in spite of this the hospitalist model continues to grow in Canada as more primary care providers continue to limit their practices to the outpatient setting and acute care institutions look to hospitalists to fill the resulting gap in care coverage.

In many respects the inevitable rise of hospital medicine completes the physician provider puzzle for an effective acute care system. Along with other “site-based” specialties (Emergency Medicine and Critical Care), hospital medicine completes the triad of provider specialties that constitute the bulk of inpatient care and have largely evolved around a specific “care setting”: the emergency department, the acute medical ward, and the critical care unit.

To illustrate this idea, let’s look at an example. Imagine a typical patient in his 70’s, who has congestive heart failure (CHF) as a result of a previous myocardial infarction along with a number of common comorbidities. This hypothetical patient would be managed by his primary care provider (a family physician or a general internist) in the community setting who would aim to manage the patient’s volume status, cardiac risk factors and lifestyle habits in order to keep the patient functioning with an acceptable quality of life and avoid hospitalizations. However, if this patient develops an acute illness (eg. irregular heart rhythm) that results in an exacerbation of his CHF and low oxygen levels, a visit to the emergency department may be necessary. There, he would be seen by an emergency physician who will try to manage the patient who has now developed a different level of acuity and requires care in a specialized setting that can provide continuous monitoring and skilled nursing care. The emergency physician will aim to address the acute exacerbation in order for the patient to return back to the community, however this may require a longer hospital stay and result in an admission to acute care. In this instance, the hospitalist physician will manage the patient in a different setting (the medical ward). This physician will require a different set of skills that focus on managing multiple acute illnesses (congestive heart failure, irregular heart rhythm) concurrently, and balancing that with patient’s other chronic comorbidities. The hospitalist will also have to ensure the patient is looked after in an efficient manner, with a focus on discharge planning and care coordination with other care providers that may include a specialist (eg. a cardiologist) and the patient’s community-based family physician. At times, these efforts may not be enough and the patient’s condition may deteriorate further to the point of needing respiratory support (eg. ventilator support), in which case he would need to be transferred to the Intensive Care Unit (ICU). There, the intensivist will manage the patient who is now suffering from the same illness (i.e. CHF and irregular heart rhythm) but at a different level of acuity. At this point, this patient requires a different set of interventions that can only be provided in the specialized ICU setting.

All the physicians mentioned above (the family physician, emergency physician, hospitalist and intensivist) have to know how to manage a patient with congestive heart failure. However their expertise and focus is on providing a treatment plan for the same clinical condition tailored to different care settings that are designed to manage different levels of acuity along a spectrum. Each of these physicians will have to have a broad knowledge about a wide array of clinical conditions, simultaneously managing many acute and chronic comorbidities. As such, each can be considered a “generalist”. However, each has to also develop a special set of knowledge and expertise that focus on different levels of acuity, care processes and unique requirements specific to different care settings. As such, each is a “specialist”.

Historically, one individual may have fulfilled all the above roles. However, with the explosion in medical knowledge, increasing complexity of care processes, and the increasingly complex medical profile of patients, this fragmentation in care and the emergence of new specialties was inevitable. Critical care was the first to emerge as a distinct site-based specialty in the 1950s (7,8), followed by emergency medicine in 1970’s (9) and hospital medicine in the 1990s (10). Hospital medicine is the latest arrival in this evolving field of “generalist specialties”.

Despite the trends outlined above, the formal family medicine establishment in Canada continues to debate the merits of specialization generally (4,5), and the acceptance of hospital medicine as a focused area particularly (11). While observers wax nostalgically about the merits of generalism (3) and question the value of physicians with dedicated inpatient care focus (12), hospitalist programs are adopted by more hospitals (13), dedicated training programs (such as Hospitalist Fellowships) continue to thrive (14), and hospitalists continue to define themselves through the work they do(15,16) and the way they organize themselves in the medical establishment (17). The arc of history is one of ongoing progress and diversification, and the history of medicine is no exception.

References

1. Grumbach K. Chronic illness, comorbidities, and the need for medical generalism. Annals of family medicine. 2003;1(1):4-7. https://www.ncbi.nlm.nih.gov/pubmed/15043173.

2. Cassel CK, Reuben DB. Specialization, subspecialization, and subsubspecialization in internal medicine. The New England Journal of Medicine. 2011;364(12):1169-1173. https://www.ncbi.nlm.nih.gov/pubmed/21428774.

3. Nicolson B. Where’s marcus welby when you need him? BC Medical Journal. 2016;58(2):63-64. https://www.bcmj.org/letters/where%E2%80%99s-marcus-welby-when-you-need-him.

4. Lerner J. Wanting family medicine without primary care. Canadian family physician Medecin de famille canadien. 2018;64(2):155. https://www.ncbi.nlm.nih.gov/pubmed/29449247.

5. Lemire F. Enhanced skills in family medicine: Update. Canadian family physician Medecin de famille canadien. 2018;64(2):160. https://www.ncbi.nlm.nih.gov/pubmed/29449251.

6. Vandad Yousefi, David Wilton. Re-­designing Hospital Care: Learning  from the Experience of Hospital  Medicine in Canada . Journal of Global Health Care Systems. https://canadianhospitalist.ca/sites/default/files/47-235-4-PB.pdf

7. Weil MH, Tang W. From intensive care to critical care medicine: A historical perspective. American journal of respiratory and critical care medicine. 2011;183(11):1451-1453. https://www.ncbi.nlm.nih.gov/pubmed/21257788

8. Kelly FE, Fong K, Hirsch N, Nolan JP. Intensive care medicine is 60 years old: The history and future of the intensive care unit. Clinical medicine (London, England). 2014;14(4):376-379. https://www.ncbi.nlm.nih.gov/pubmed/25099838

9. Robert E.Suter. Emergency medicine in the united states:A systemic review. World Journal of Emergency Medicine. 2012;3(1):5-10. http://lib.cqvip.com/qk/86073X/201201/74909068504849504849484850.html

10. Robert M. Wachter. An introduction to the hospitalist model. Annals of Internal Medicine. 1999;130(4 Part 2):338. http://www.annals.org/content/130/4_Part_2/338.abstract.

11. Wilson G. Are inpatients’ needs better served by hospitalists than by their family doctors?: No. Canadian family physician Medecin de famille canadien. 2008;54(8):1101. https://www.ncbi.nlm.nih.gov/pubmed/18697963.

12. Ladouceur R. Are attending physician rotations costing hospitalized patients their lives? Canadian family physician Medecin de famille canadien. 2017;63(4):264. https://www.ncbi.nlm.nih.gov/pubmed/28404692.

13. White HL, Stukel TA, Wodchis WP, Glazier RH. Defining hospitalist physicians using clinical practice data: A systems-level pilot study of ontario physicians. Open medicine : a peer-reviewed, independent, open-access journal. 2013;7(3):e74. https://www.ncbi.nlm.nih.gov/pubmed/25237402.

14. Sunnybrook Hospitalist Fellowship Program. https://sunnybrook.ca/education/content/?page=education-hospitalist-fellowship-program

15. Core Competency in Hospital Medicine: Care of the Medical Inpatient. https://canadianhospitalist.ca/blog/core-competencies

16. BC Medical Quality Initiative, Hospital Medicine Privileging Dictionary. http://bcmqi.ca/Published%20Dictionaries/HospitalMedicine(2017-11).pdf

17. Canadian Society of Hospital Medicine. www.canadianhospitalist.ca

Vandad Yousefi