Joint Statement from the Society of Hospital Medicine and the American Academy of Family Physicians on Hospitalists Trained in Family Medicine
Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. Both the Society of Hospital Medicine (SHM) and the American Academy of Family Physicians (AAFP) hold that the opportunity to participate as a hospitalist should be open to all interested physicians whose education, training, and current competence qualify them to serve effectively in this role.
During their training family physicians acquire the necessary attitudes, skills, and knowledge that enable them to provide continuing and comprehensive medical care across the spectrum of care settings, including the inpatient setting. Education in the primary management of hospitalized patients occurs during the required general inpatient ward and intensive care unit experiences. In addition, family physicians are required to train with general surgeons and surgical subspecialists, enhancing recognition and understanding of surgical disease states upon which hospitalists are frequently asked to consult or co-manage. Family medicine training also encompasses additional skills essential to the practice of hospital medicine, including participation in quality improvement, addressing the psychosocial needs of patients, coordinating across levels of care, and functioning as members of interdisciplinary teams. Given this training, many family physicians effectively manage their patients in an inpatient setting after the completion of their residency.
Demand for hospitalists continues to outweigh supply in the United States, including needs in underserved and rural areas. Hospitalists Trained in Family Medicine (HTFM) fulfill an important public health need by providing frontline inpatient services in a variety of geographic settings. In addition, while many HTFM focus exclusively on the care of adults, others are providing inpatient care across the spectrum of ages, as well as providing obstetric services. More than two-thirds of HTFM are also involved in the training of residents and medical students, enhancing the skills of our future physicians.
Recognition of achievement by HTFM from the SHM is available by meeting standards set for all hospitalists, regardless of residency training, in the form of the designation of Fellow of Hospital Medicine. HTFM also have the opportunity to professionally qualify and sit for the Recognition of Focused Practice in Hospital Medicine board examination. This examination is administered and recognized jointly by the American Board of Family Medicine and the American Board of Internal Medicine.
In consideration of the above factors, both the Society of Hospital Medicine and the American Academy of Family Physicians endorse and encourage the growing contribution of Hospitalists Trained in Family Medicine.
Note: This joint statement was developed by a joint task force of the American Academy of Family Physicians and the Society of Hospital Medicine.
Guidelines for Interaction in Hospitalist Models
Communication Between the Receiving Inpatient Care Management Physicians and the Referring Primary Care Physician
Family physicians are participating on both sides of the new models of health care delivery, which utilize a dedicated inpatient physician (or hospitalist) to manage the inpatient care of general adult medicine patients referred by primary care physicians in the community. The AAFP believes that family physicians are well trained and highly qualified to serve in these roles, and that participation in such arrangements should be voluntary for both the referring physician and the patient involved.
Because continuity of care has been a hallmark of the specialty of family practice, the AAFP is especially concerned about safeguarding continuity in these new models through adequate communication. The following guidelines are intended to support quality care to patients and their families, and to clarify expectations for communication between physicians participating in such systems.
- The overarching objective for all should be the best possible care for the patient.
- At the request of the family physician (or other primary care physician), the inpatient care physician (who may also be a family physician) should admit and coordinate the care of all patients admitted to the hospital regardless of the admitting diagnosis or type of insurance coverage.
- If patients present to the emergency department (ED) and the ED physician assesses them, the ED physician should then contact the patient's family physician to determine if admission is necessary or if close follow up or outpatient work up is more appropriate.
- If admission is necessary, the family physician should communicate information on pre-hospital treatment, work up, co-morbidities, and ongoing specialty consultations, along with family and social concerns, advance directives, etc., to the inpatient care physician who is assuming management of the patient's care.
- The inpatient care physician will assess the patient at admission and determine the best course of treatment. This may include treat and release, admit for general medical management, or admit for medical or surgical subspecialty care, while providing general medical oversight.
- During the period of hospitalization, decisions regarding care, consultation, admission, transfer, and discharge should be the sole responsibility of the inpatient care physician in consultation with the patient and, as appropriate, the patient's family physician and/or family members.
- The inpatient care physician should be readily available to discuss the patient's medical problems and hospital course with the family and should provide timely updates to the family physician designated by the patient. Communication with the family is extremely important at the time of any changes in the patient's status, complications or new diagnosis (e.g., cancer).
- The inpatient care physician should communicate the treatment plan and follow-up recommendations to the patient's family physician or the covering physician on the day of discharge.
- When family physicians refer their hospital patients to the care of an inpatient physician, ongoing communication should be maintained with the patients and their families throughout the hospitalization. Family physicians should also provide written communication to the inpatient care physician after the first post-hospital visit at the office where there may be an educational benefit.
- Health care systems which utilize inpatient care management models should seek to constantly monitor and improve their processes through the use of ongoing surveys for patient and physician satisfaction with the system. Data on health care outcomes is essential to the ultimate evaluation of these models.
Hospitalist Systems of Inpatient Care Management
As health care systems experiment with models of inpatient care management (hospitalist systems), the AAFP supports and encourages the following principles:
- The opportunity to participate as a hospitalist in such systems must be open to all interested physicians whose education, training, and current competence qualify them to serve effectively in this role.
- The decision of who should care for a family physician's hospitalized patients should be made by the patient and his or her family physician, in the interest of what is best for patient care (i.e., participation in hospitalist models should be voluntary).
- In the interest of preserving continuity, patient advocacy and health care decision-making which is in concert with the patient's values, generalists should be used for inpatient general medical management. Consultation with an intensivist, medical, or surgical subspecialist does not preclude the need for the continuing, comprehensive, and personal care provided by a generalist physician.
- In the event that family physicians elect to refer their patients for inpatient care management, open communication should be maintained with those patients and their families throughout the hospitalization.
- While family physicians may elect to refer patients for inpatient care management, they should strongly consider the mid- and long-range implications for their practices before they relinquish hospital privileges. Such implications may include:
- Difficulty being credentialed and/or reimbursed by managed care companies for services/procedures in the ambulatory setting if one does not have hospital privileges for those same services/procedures, and/or,
- being unable to successfully reapply for hospital privileges at future points of career transition, without the necessity of seeking substantial additional education and retraining.