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Hospitalist Movement Still on Fast Track, Evolving Rapidly

September 2007

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

Career Resources Editor’s Note: Hospitals need physicians to provide inpatient care at the highest levels of competency, safety, and cost effectiveness. Hospitalists meet this challenge and naturally fit into performance improvement and leadership roles. While this specialty is a logical transition from residency and is in great demand, physicians have to be extremely vigilant in terms of maintaining work, academic, and family balance. Job satisfaction does not result from just remuneration or proficiency at repetitive tasks. Instead, full appreciation of the work environment along with external influences, such as financial pressure from payers, must be taken into account when considering this specialty.

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

As the demand for hospitalists continues to outpace supply, and hospital medicine services expand to fill new needs, job opportunities are plentiful and positions increasingly multifaceted.

The current job market for young physicians looking for their first practice opportunity is brighter than it has been in many years, regardless of their specialty. But for graduating residents eyeing hospital medicine, it is positively electric. Positions are plentiful in virtually every location — from rural regions to urban centers — and in a wide range of practice settings, from academic teaching institutions, to suburban community hospitals or special facilities.

To add to the variety, hospitalists — a sector that has just marked its first decade — are now assuming an ever-expanding range of clinical roles in the hospital. They’re no longer just caring just for “med-surg” patients, the need that has catapulted the specialty from a little known subsector of internal medicine to the medical field’s fastest growing segment.

Today, hospitalists are found in the ICU, the CCU and the ED, in pre-op and post-op settings, and in pediatrics centers. Increasingly, hospitalists are even teaming up with their counterparts in specialties such as neurosurgery, orthopedics, nephrology and oncology in order to co-manage a wide range of patients.

In a more recent development, some hospitalists are electing to focus their careers more narrowly. Some are becoming nocturnists, for example, or proceduralists, a very new focus in hospital medicine in which hospitalists assume sole responsibility for performing lumbar punctures and thoracenteses, or placing central catheters, for example. Still, others are finding professional satisfaction in directing or helping to manage palliative care or hospice services, a fast-growing subsegment of hospital medicine.

“Hospital medicine is a great transition from residency because of all the hospital experience internists gain during training, and the job market is stronger than it’s ever been,” said Vineet Arora, MD, assistant professor of medicine at the University of Chicago and chair of the Society of Hospital Medicine (SHM) Young Physicians Committee. “No matter where you want to practice or what you want to focus on, there are tons of jobs out there — and the offers are very competitive,” Dr. Arora added.

Simply put, “The only thing limiting the growth of hospital medicine is the workforce — there is much greater demand than supply,” says SHM President Russell “Rusty” Holman, MD.

Of course, there is a flip side to the boom times that hospitalists — whose ranks have nearly doubled in five years to an estimated 20,000 in 2007 — are experiencing. Precisely because the field is evolving rapidly and expanding almost exponentially, hospitalists are feeling pressures from all quarters.

“The high demand is good for physicians entering the specialty, but that’s creating pressures, too,” said Dr. Holman, who is chief operating officer of Cogent Healthcare in Nashville, Tennessee. “Hospitalists are being asked to provide more and more services, and the field is struggling with how to manage those pressures.”

In addition, the workforce constraints are adding to the burden as hospitalists are working harder and longer to care for an ever-increasing patient volume while assuming larger roles in patient safety improvement and cost containment. “That’s become a big issue —how to strike an appropriate work-life balance to prevent burnout and promote career satisfaction,” Dr. Holman added. In fact, in the need to ensure a manageable workload and sustainable schedule emerged as one of the key challenges facing the field, based on survey findings reported in a recently published SHM white paper on hospitalist career satisfaction.

Based on her exchanges with younger hospitalist colleagues, Dr. Arora concurs with Dr. Holman’s view of the current state of hospital medicine. “This major growth and the ‘buyer’s market’ can be hard on hospitalists,” she said. “Some programs are expanding at almost exponential rates — doubling their size in a year. That can be very challenging for the hospitalist group, when new people are joining all the time, and it contributes to burnout.” As such, she urges hospitalists new to the field to press for candid answers to questions about turnover rates and burnout in the program they are considering — and to find out whether they would be filling a newly created position or taking over a recently vacated spot. That information, Dr. Arora maintained, can be instructive in helping physicians figure out what sort of practice environment they might be entering if they accept the position.

That’s not to say that new hospitalists are not willing to work hard and pull their weight for the team, but rather that after a few grueling years in residency, many physicians are hoping for at least a predictable professional life. One of the chief appeal factors of hospital medicine, after all, is its largely shift-based structure.

“It was the lifestyle that attracted me to the field,” said Sameer Badlani, MD, a hospitalist and instructor of medicine at the University of Chicago who also completed a fellowship in medical informatics. “I work a lot, but when I’m home, I’m truly home and not on duty.” To ensure that guarantee exists, first-time hospitalists should get their schedule in writing before accepting a position, Dr. Badlani added. And with jobs as plentiful as they are now, hospitalists “truly can go wherever their heart desires,” Dr. Badlani said, and needn’t accept a position that smacks of an untenable workload or an unworkable schedule.

Hospitalists taking lead in quality improvement (QI) initiatives

As the group in the hospital most connected to stakeholders and with the best knowledge of systems, hospitalists also face pressures to simultaneously improve quality and contain costs, Dr. Holman explained. “That has become a very big issue for hospitalists,” says Dr. Holman, especially as hospitals attempt to comply with an ever-increasing number of QI-associated regulatory requirements, Medicare Core Measures, and government and commercial payors’ push — via pay-for-performance programs — for improved safety and quality.

For hospitalists, there are ups and downs to the burgeoning hospital QI movement, according to Dr. Arora. The benefit is that the movement is opening up many new opportunities for hospitalists who wish to either take lead roles in their institutions’ quality and safety initiatives, or simply carve out 10 to 20 hours a month to participate in such endeavors. “Many hospitalists find that it’s a nice way to create more variety in their work and their professional lives,” says Dr. Arora, while at the same time taking little time away from the rigors of relentless clinical care duties.

Such hybrid hospitalist-QI professional career tracks are becoming more prevalent in both community hospitals and academic centers. In many institutions, hospitalists are using their QI expertise to take a further leap into leadership positions, according to
Dr. Holman. “Hospitalists are really blossoming into leadership and management roles now — as either medical directors of their own groups or, increasingly, moving from their QI role to become vice president of medical affairs,” says Dr. Holman. This is because of their knowledge of hospital systems and their ability to spearhead care-improving process changes.

All of this change in the field, coupled with the demand for hospitalist services in many areas of the hospital, is creating another source of pressure for academic teaching centers. Those institutions are wrestling mightily with how to address their dual and sometimes competing missions of patient care and teaching as they expand their hospitalist programs, Dr. Arora explained. Some centers are creating separate non-teaching hospitalist services to meet clinical care demands and allow a quasi-separate hospitalist service to focus on teaching and research. Others are attempting to combine teaching and clinical care duties in a variety of novel arrangements, according to Dr. Arora.

As these trends takes hold, hospitalists providing non-teaching services may find they have to advocate for themselves regarding how their work lives will be structured and how their careers will progress, given that teaching centers generally promote and reward physicians based on the time-honored “publish-or-perish” model. At the very least, Dr. Arora cautioned, hospitalists eyeing a non-teaching service position should inquire about both the possibility of and the process for promotion, should they stay on for three years or longer.

“Academic centers are really struggling with this issue right now,” adds Dr. Arora. As a result, hospitalists should try to find out where they fit into the picture if they plan to remain with an institution.

‘Proceduralist’ hospitalists may signal field’s next wave

In concert with the move toward hospitalist co-management or primary management of patients traditionally followed by specialists, hospitalists are also assuming greater oversight of certain services that aren’t attached to a specific patient population. A case in point is the nascent but growing “proceduralist” trend, which is opening up new avenues for hospitalists who like doing the diverse procedures they did, perhaps rarely during residency, and who wish to standardize their hospital’s approach to doing catheter placements or removals, for example, and improve safety overall.

Bradley Rosen, MD, medical director of the non-teaching hospitalist service at Cedars-Sinai Medical Center in Los Angeles and assistant director of that institution’s relatively new procedure center, predicts that proceduralist positions will soon start cropping up everywhere. “You won’t necessarily see jobs advertised as proceduralist positions, but they are out there,” he said. Interested hospitalists can certainly carve out a niche for themselves as proceduralists, he added, especially as specialists, by their own choice, move away from handling the non-surgical procedures associated with patient care.

“It’s a very big movement — many places are moving toward setting up dedicated procedure units now, and hospitalists are the best pool to draw from because they’re actually in the hospital all the time,” Dr. Rosen said. “Hospital medicine as a field is booming, and I think we’ll also see a boom in the number of hospitalists who are doing more and more of the procedures in their institutions,” he added.

The sky is the limit right now in hospital medicine, as supply and demand continues to favor job-seeking hospitalists. But that doesn’t mean that physicians should focus solely on “how good the offer or the compensation is,” advised Sumant Ranji, MD, associate director of the internal medicine residency program at University of California-San Francisco and an active participant on SHM’s Young Physicians Committee. “The job opportunities are extraordinarily good — and you can have your pick of the jobs you want. The challenge becomes finding a position that is sustainable over time and that won’t lead to burnout,” he added.

Physicians heading into the job market should also endeavor to find a position that offers the right kind of professional challenge, and ideally, a varied enough work life to deter burnout. “One thing that residents should understand is that a hospitalist isn’t just a hospitalist anymore — there are many kinds of positions out there that combine clinical care with other duties,” said Sanjiv Panwala, MD, a nocturnist hospitalist at Providence St. Vincent Hospital in Portland, Oregon, who frequently makes presentations to residents about hospitalist careers. “Whatever clinical or professional interests a hospitalist has can likely be readily pursued within the context of hospital medicine these days,” Dr. Panwala suggested.

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