Hospitalist is a rather modern term to describe a particular field of medical professionals. In general terms, a hospitalist is a doctor or physician who specializes in treatment of patients in a hospital. More specifically, a hospitalist is a medical professional whose duties include clinical care, teaching, research, and/or leadership in the field of hospital medicine. Occupations within the field of hospital medicine include physicians, nurse practitioners and physician assistants.
Hospitalists provide prompt and complete attention to all patient care needs including diagnosis, treatment and the performance of medical procedures, employing quality and process improvement techniques, collaborating, communicating and coordinating with other physicians and healthcare providers, and ensure the safe transitioning of patient care within the hospital, and from hospital to their primary care provider or alternative medical facility, which may include oversight of care in post-acute care facilities.
A hospitalist performs a variety of professional activities and duties and has a wide range of responsibilities. There are a large number of physicians and health care professionals that work in a hospital at one time, and they all have their specialties and sub-specialties of focus. A hospitalist may also occasionally perform non-hospital activities as well, such as outpatient care. It's not unusual for hospitalists to work a portion of their shifts in post-acute facilities such as nursing homes and rehabilitation hospitals, which allows them to follow their patients in the transition from short to longer-term care, thus providing smoother transitions between these settings (ACP, 2017).
The term “hospitalist” encompasses a broad range of medical professionals. Internists, family practitioners and pediatricians may all serve as hospitalists when they provide care in a hospital setting. Further, hospitalists can be involved exclusively in-patient care, research, teaching, or leadership or in a combination of these roles (Pantilat, 2006). The common goal of the profession is to provide the best care possible to hospitalized patients.
What Does a Hospitalist Do?
A hospitalist is responsible for multiple duties that may vary day to day in order to provide continuity of care to their hospitalized patients. Some of their responsibilities may include: managing the care of people recovering from acute injury or illness, including heart attack, stroke, and trauma, working with the surgical team to coordinate patient care after an operation, providing palliative care to help manage pain and relieve distressing symptoms, educating patients and families on health-related topics, and ordering and interpreting medical tests (Career, 2017).
Additional duties may include writing and refilling prescriptions, both chronic and acute, consulting with various specialists, facilitating the patient's transition to the next care setting (e.g. - home, rehabilitation hospital, nursing home) and leading and supporting quality initiatives that improve patient care (Career, 2017).
In general, the duties of the hospitalist are to provide prompt, efficient, and competent care to hospitalized patients who are often referred to hospitalists by primary care providers, emergency physicians, or subspecialists (Marinella, 2002). They may also provide consultative services to patients admitted to orthopedic, surgical, rehabilitation, and other subspecialty services, but the bulk of the hospitalist’s workload, however, typically involves acute admissions from the emergency department or an outpatient clinic (Marinella, 2002). Preoperative consultations may also be part of a hospitalist’s activities.
A hospitalist may also perform a wide variety of medical procedures, including central venous catheterization, endotracheal intubation, lumbar puncture, thoracentesis, paracentesis, arthrocentesis, and arterial puncture (Marinella, 2002). Proficiency in these procedures is important to minimize complications and eliminate the cost of an outside physician performing the procedure. Professional hospitalists often participate in teaching opportunities within the hospital. This may include training medical school students and residents directly or organizing the academic training program for hospital staff and students.
Although they may spend most of their time caring for patients, hospitalists tend to have short-term relationships with their patients that only last the duration of the patient’s hospital stay, as opposed to primary care physicians who develop long-term patient relationships. In addition, they participate in non-patient activities that focus on the efficiency, quality and safety of patient care within the hospital. They often lead committees and initiatives that improve efficiency, focus on quality improvement (QI), promote infection control, and foster teamwork between hospital departments (ACP, 2017).
A hospitalist may be employed by a medical institution or by a large group practice who coordinates care for their patients who are hospitalized. There are a few specialties among hospitalists. For example, some hospitalists may elect to work primarily overnight (“nocturnists”) or may gain experience or undergo further training to enable them to care for critically ill individuals (sometimes referred to as “intensivists”) (ACP, 2017). Other hospitalists focus on research activities, such as treatments for various diseases or creating models for qualify and safety.
The History of Hospital Medicine
The history of hospital medicine does not begin in ancient times, although that is where the first concept of medicine in general began. Only in the past 30 to 40 years has the field of hospital medicine emerged as a recognized medical field, along with its specialties and sub-specialties. Robert Wachter and Lee Goldman introduced the field of hospital medicine and hospitalists and provided a general definition for the profession and its importance to medical care in the United States.
The Introduction of Hospitalists
The term “hospitalist” was first used in a publication in 1996 and was defined as a specialist in inpatient medicine who is responsible for managing the care of hospitalized patients in the same way that primary care physicians are responsible for managing the care of outpatients (Wachter and Goldman, 1996). The general public was confused as to why the profession of hospitalist would exist or be needed. In 1999, Lindenhauer et al (1999) further defined a hospitalist as physicians who assume the care of hospitalized patients in place of the patient’s primary care provider. Basically, a hospitalist is an on-site primary care doctor for hospitalized patients.
Later in 1999, Wachter (1999) clarified yet again the definition of a hospitalist. He wrote that a physician in this field spends at least 25% of their time serving as the physician-of-record for inpatients, during which time the primary care provider is absent, then returning the patient to the primary care provider at the time they are discharged from the hospital. While this was a complex definition, it clarified the specific role of the hospitalist.
Although a hospitalist provides direct care to their patients, they may also have other duties that include research activities or leadership positions. Depending on the organization of the hospital they work in, a practicing hospitalist may not spend the majority of their time performing patient care. There was some disagreement between members of the same profession as to the appropriate definition, and whether the 25% minimum for patient care was relevant. At the time, a hospitalist could be a physician who spend 90% of their time on direct patient care, or they could be a research physician who spends 90% of their time researching hospital medicine.
The First Dictionary Definition
In 2005, the term “hospitalist” was first published in a dictionary. The 2005 update of the Eleventh edition of Merriam-Webster’s Collegiate Dictionary defines a hospitalist as a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians (Pantilat, 2006). Many professional hospitalists dislike this limited definition of their medical field.
Practicing hospitalists have their own definition. Our society has an official definition of hospitalists: “Physicians whose primary professional focus is the general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to hospital medicine.” (Pantilat, 2006).
The National Association of Inpatient Physicians (NAIP) was established as a national organization dedicated to hospital medicine in 1999. Currently, the NAIP has approximately 1800 members and continues to grow at a rapid pace, with surveys conducted by the NAIP identifying no fewer than 4500 hospitalists nationally (Marinella, 2002). In fact, most adult general hospitals with a bed capacity of 200 or more have a hospitalist system implemented or are in the process of launching such a program (Marinella, 2002).
The Economic Factor
There was an economic reasoning for this transition of continuous in-hospital care. This was due to Medicare reimbursements that were on a fixed-payment system for hospitals, whereas primary care physicians were charging per day or per visit. The hospitals could not pay for the primary care physicians daily visits and standard two-week inpatient recommendations. Hospitals then turned to doctors and physicians within their own hospital to provide the same care the primary care physicians were.
The hospitalist movement produced data suggesting that the presence of hospitalists could improve the quality of care without straying from the hospital's financial and professional interests – now recognized as more than an economic utility, hospitalist programs began to grow in number and thrive (White, 2008). The result of the transition to hospitalists improved the quality of care while at the same time reducing the costs of the care provided.
A Growing Field
Hospital medicine is the fastest growing medical specialty in American medical history, now boasting more than 20,000 hospitalists (White, 2008). The hospitalist we know today emerged in response to the need to replace primary care physicians, who treated their patients in all care settings, with physicians who could focus solely on care of patients while they were in the hospital (White, 2008).
The diversity of specialists within the hospitalist field does present some challenges. There is a need to develop education and training programs that are comprehensive and applicable to all hospital settings. Patient safety, leadership, palliative care, and quality improvement are just a sample of the issues that pertain to all hospitalists (Pantilat, 2006). There is also a rise in separation between hospitalists who perform surgery and those who do not.
Hospital medicine
Hospital medicine is a medical specialty dedicated to the delivery of comprehensive medical care to hospitalized patients. In addition to their expertise in managing the clinical problems of acutely ill, hospitalized patients, hospital medicine practitioners work to enhance the performance of hospitals and healthcare systems overall.
The discipline of hospital medicine is a specialized medical field that focuses on patient care. Hospitalized patients tend to have serious medical illnesses, and hospitalists provide continuity of care and collaboration with the patient’s primary care physician and other specialists in order to provide comprehensive care.
The discipline of hospital medicine grew out of the increasing complexity of patients requiring hospital care and the need for dedicated clinicians to oversee their management (ACP, 2017). The traditional method of hospital care presented a challenge because the physicians caring for hospitalized patients, they were also caring for emergency patients as well. This led to a lack of coordination and intensity of in-patient care. By focusing on in-patient care, hospitalists acquire specialized knowledge of various illnesses and diseases and are able to provide more efficient and effective care.
Another aspect of hospital medicine is internal medicine, which is a specialized field that focuses on adult medical issues as presenting in a hospital setting. Although not all hospitalists are required to be internists, the nature of internal medicine training uniquely prepares internists for hospital medicine practice (ACP, 2017). Many hospitalists are trained in general internal medicine or an internal medicine specialty field. The American Board of Internal Medicine offers a specific certification called Focused Practice in Hospital Medicine for established internists who limit their practice to hospital medicine, and this is separate from basic internal medicine certification (ACP, 2017).
Hospital medicine is still an evolving field, which allows for variable models and practices within the profession. For example, work shifts and rotations may vary between hospitals. In one location, you may work one or two weeks straight and then receive the same amount of time off. In another, you may work 2 or 3 days straight and have the same amount of time off. The goal is to provide continuous, focused medical care to hospitalized patients and at the same time, allow for decompression and recovery for the hospitalist, as the long shifts and hours are very demanding. Although the schedule may seem hectic and demanding, hospitalists work as part of a team and they typically enjoy great flexibility with their scheduling.
How to Become a Hospitalist
There is a wide range of medical backgrounds and specialties a hospitalist may have. In addition to the internal medicines, family doctors and pediatricians, a growing number of "specialty" hospitalists practice psychiatry, obstetrics, orthopedics, and general surgery exclusively within the realms of the hospital.
Extensive education and training is required to become a licensed hospitalist. To legally practice in this field, an aspiring hospitalist will need to complete an undergraduate degree program, medical school, residency, and pass an exam to become licensed by the state they choose to practice in. Although it is not required, board certification may also be obtained. Be prepared for over a decade of education before you can practice medicine as a hospitalist, although this is similar to other medical professions.
Undergraduate Degree
There is no requirement for the type of undergraduate degree, but coursework in biology, chemistry and physics must be completed to qualify for medical school. It is also recommended to have a high GPA, as medical school is extremely competitive. Volunteering in a clinical setting is also recommended to stand out in your medical school application. Prior to completing the undergraduate degree, you will need to take the Medical College Admissions Test (MCAT) exam.
Medical School
Medical school programs are typically 4-5 years in duration, depending on the degree you decide to pursue. A Doctor of Medicine (M.D.) or a Doctor of Osteopathic Medicine (D.O.) degree is offered, and the D.O degree usually requires an additional year of training.
The first two years of medical consists mainly of classroom coursework that include anatomy, physiology, pharmacology, pathology, biochemistry, human behavior, medical ethics and medical law. The last two years focus primarily on training in supervised laboratory and clinical settings, such as hospital rotations. In a hospital rotation, a medical student rotates through various medical departments to gain a comprehensive understanding of medical practices.
Residency and Fellowship Training
When medical school is completed successfully, students will begin their residency training programs, which can last anywhere from 3 to 8 years. Residency training provides students with additional experience in a specialized medical field. As mentioned previously, many hospitalists specialize in internal medicine, family medicine or pediatrics. Some residency programs have created dedicated training for hospital medicine.
A fellowship is not required to become a licensed hospitalist, but it is an optional 1 to 2-year program that allows the fellow to focus on a sub-specialty field, such as general internal medicine or geriatric medicine. Available fellowships can be found through the Society of Hospital Medicine. Most fellowships include clinical and research opportunities.
Licensing and Certification
A hospitalist must be licensed in the state they choose to practice in. Each state has their own licensing requirements, although some accept the United States Medical Licensing Examination (USMLE) or the Comprehensive Osteopathic Medical Licensing Exam (COMLE), which are national licensing exams for M.D.’s and D.O.’s.
Certification is optional, although it does signify a high level of proficiency in hospital medicine or a related specialty. There is no official certification organization for hospitalists. Practicing hospitalists often acquire certification in their specialty, such as internal or family medicine. If they choose, a hospitalist may become certified through the American Board of Family Medicine (ABFM) or the American Board of Internal Medicine (ABIM).
Other Skills
Successful hospitalists need to be well-rounded and have other skills in addition to their medical knowledge and training. Leadership and organizational skills are required to manage and coordinate all aspects of a patient’s care and implement quality improvement initiatives within the organization (Career, 2017). Communication skills are needed to explain complex medical information in terms the patient, their families and other medical professionals understand. Problem-solving skills, empathy and attention to detail are also skills a hospitalist will benefit from.
The Future of Hospital Medicine
According to Marinella (2002), the hospitalist movement in American health care is enjoying immense popularity and continues to grow at a rapid pace. Currently, most hospitalists are general internists, with board certification in internal medicine. There is no official certification organization or board for hospital medicine or hospitalists. Three relatively new specialties—emergency medicine, critical care medicine, and family practice—all originated from trends in medical practice that filled a specific void; subsequently, all of these disciplines became areas of board certification and currently enjoy security as specialties (Marinella, 2002).
Hospital medicine is an extremely demanding field. Long hours and irregular shifts are standard in this profession, because that is in the best interest of the patient. Moreover, in addition to the intense mental stimulation hospital medicine demands, the additional issues of discharge planning, pressure from insurance companies and health maintenance organizations, and declining reimbursement all contribute to potential burnout (Marinella, 2002).
Although hospital medicine is a new medical field, the high demand indicates it will continue to grow and develop in the future. This career is challenging and demanding, but it does come with its benefits. Many hospitalists take great pride in providing high quality patient care and improving their patient’s quality of life. In addition, the median annual salary for a hospitalist is $217,267, with a range between $191,060-$246,135.
References
Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996; 335:514-517.
Lindenauer PK, Pantilat SZ, Katz PP, et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130(4Pt2):343-349.
Wachter RM. An introduction to the hospitalist model. Ann Intern Med. 1999;130(4Pt2):338-342.
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