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Here Come the Hospitalists

November 2003

By Bonnie Darves, a Seattle-based freelance health care writer.

Career Resources Editor’s Note: Becoming a hospitalist offers young physicians the chance to work in an acute care environment and shape a rapidly growing specialty that is in demand. Working in a hospital or institutional setting provides a wide variety of cases, predictable schedule, leadership of multidisciplinary treatment teams, and professional collegiality. However, these benefits come at the expense of not having long-term, patient-doctor relationships and the independence enjoyed by those in outpatient settings. In addition, keen awareness and sensitivity to the surrounding practice environment is crucial because hospitalists must admit and then discharge patients back to their referring physicians.

— John A. Fromson, M.D., Chairman of the Department of Psychiatry at MetroWest Medical Center

Young physicians in growing numbers are electing to go into hospital medicine, a fast-growing field that was hardly “on the map” a few years ago.

One of the fastest growing medical specialties is a field that barely existed a decade ago: hospital medicine. Variously called hospitalists or inpatient physicians, doctors who practice hospital medicine — most are trained in general internal medicine — usually work solely within hospitals, caring for patients from the time they are admitted to the time they’re discharged. Unlike most other specialties, hospital medicine is organized around the site of care, not a particular organ or disease.

Hospitalists work in many areas of the hospital, from the ICU and CCU to the ER and medical-surgical units. Their primary role is the direct management of inpatients, and in many cases, inpatient physicians now perform most of the tasks once handled by patients’ primary care physicians. As the field has evolved, a growing number of hospitalists have begun assuming a care-coordinator’s role. In some hospitals, inpatient physicians oversee many aspects of a patient’s hospital care: process management, communications among other physicians involved in the patient’s care, discharge planning, and patient/family communications, among others.

The ranks of hospitalists have increased exponentially in recent years. Numbering less than 1,000 five years ago, today an estimated 7,000 U.S. physicians have chosen to devote their practice to hospital medicine, according to the Society for Hospital Medicine (formerly the National Association of Inpatient Physicians). Hospitalists now practice at most of the country’s leading institutions — from Brigham and Women’s Hospital in Boston to Cedars-Sinai Medical Center in Los Angeles. Today, about half of all U.S. hospitals directly employ or use hospitalists in some capacity — often working through formally organized hospitalist groups. In addition, about half of all managed care organizations now operate hospitalist programs on either a voluntary or required basis.

Because the field itself is young — the term “hospitalist” was coined in 1996 by Drs. Robert Wachter and Lee Goldman, University of California–San Francisco, writing in a New England Journal of Medicine article — its ranks are primarily young physicians. “This is a young specialty, so most of the physicians in hospital medicine are young,” says Larry Wellikson, M.D., executive director of the Society of Hospital Medicine. “It’s one field in which being young is an advantage. It’s possible that a new physician joining a [hospitalist] group will have a boss who is only about 4 years older” than he or she is.

The relative infancy of the field was one of its attractions for Preetha Basaviah, M.D., a hospitalist at UCSF Medical Center and assistant clinical professor of medicine at University of California–San Francisco School of Medicine. “One of my first reasons for becoming a hospitalist was that it was an exciting time in the field. I really wanted to be part of the forefront . . . and to help shape the future of the field,” she says.

Dr. Basaviah studied medicine at Brown University and completed her internal medicine residency at Beth Israel Deaconess Medical Center in Boston, where she was among the institution’s first hospitalists. She was drawn by the professional diversity hospital medicine affords, especially in academic medicine. Besides working as an attending hospitalist, Dr. Basaviah also teaches medical students and residents, co-directs a medical-school course, and spends one afternoon a week in a primary care clinic.

“Everybody’s job description here is quite individualized, and the majority of hospitalists at UCSF have found a way to tailor their job descriptions to their individual interests,” Dr. Basaviah says.

Another chief draw was the diversity of cases and diagnoses. On a given day, Dr. Basaviah notes, she might care for a post-MI patient, a few with pneumonia, and another with an unusual infection or severe complications of end-stage renal disease. “The basic diversity is always there, and we have the opportunity to participate in the care of very complex patients,” she says.

“What we’re seeing is that this [hospital medicine] has become a generalist’s specialty since 88 percent of hospitalists are internists,” Dr. Wellikson says. “The physicians who are electing this field are those who find enjoyment in taking care of a broad range of medical conditions but like the acuteness of hospital medicine.”

It was that clinical diversity, combined with the excitement of the hospital environment and the flexible schedule, that drew Jonathan Sellman, M.D., to hospital medicine. A hospitalist at HealthPartners Medical Group in Minneapolis, Dr. Sellman works at two Twin Cities–area hospitals, where he encounters a broad range of cases and patients. “I like caring for the higher-acuity patients. It’s more exciting and challenging for me, and the inpatient setting is where you’re most likely to find those cases,” says Dr. Sellman, who recently completed a fellowship in infectious disease and now does some teaching. “I also wanted to be in a position where I would interact with medical students and residents on a frequent basis, and I have that opportunity here.”

The block scheduling — Dr. Sellman works in one-week blocks, working seven days on and seven days off at Regions Hospital, while also covering at North Memorial Medical Center — is also appealing because it allows him to pursue other interests. He is currently working toward obtaining his master’s in public health and is conducting research in zootic diseases. Eventually, he plans to receive a diploma in tropical medicine and to pursue a long-range desire to work abroad and treat rare infectious diseases.

Several trends drive hospitalist field’s rapid growth

The growth of the field has been fueled by many trends — the chief one being that the demands on office-based physicians’ time have become so intense that many no longer have the time to run their practice and spend up to a few hours a day traveling to facilities where their patients are hospitalized. In addition, research has shown that as medicine becomes more complex and technology dependent, and inpatients have generally higher acuity than in the past, using physicians who have constant exposure to acute illness can improve efficiency and consistency of care. While the hospitalist movement met with considerable controversy in its early days, it has become much more accepted as a viable and valuable approach to managing inpatient care, according to national surveys conducted in recent years.

Although the hospital medicine field is replete with opportunities at present, young physicians interested in going the hospitalist route should exercise extra due diligence in evaluating prospective positions, Dr. Wellikson urges. That’s because, as with any new field, hospitalist-program models are still being developed and “tweaked” — and the manner in which they are structured may have potential downsides. When looking at positions, Dr. Wellikson encourages physicians to consider and explore the following issues:

Work schedule and any additional duties. Physicians should ask what the hours will be, how many patients they will be responsible for, and what additional duties (call duty or committee or administrative work) will be required of them.

Program’s history and reputation. Physicians should find out how long the program has been established, how long current physicians have been with the program, and, perhaps more importantly, how the service has been received by the local medical community. To this end, Dr. Wellikson recommends asking the hiring physician for names of referring community doctors and then asking those physicians what they think of the program. Hospital nurses can also be a good resource on that issue, he adds

“If it [the hospitalist service] appears to be a revolving door, something may be wrong. You really have to do more due diligence when you’re entering a relatively new field,” he says.

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