What is a Hospitalist?
I vividly remember my first EPIC training day. The instructor asked me what my position was and I said “I am a hospitalist.” As I became conscious of blank stares and quizzical expressions, a bold soul stepped forth and enquired “you are a what?” I explained as best as I could with my limited 1 week experience. Today, with 2 years of experience, I am somewhat better equipped to answer that question. I am certain the task of spreading the word about what a hospitalist is continues to be germane, as I continue to encounter the same blank stares and quizzical expressions I did two years ago when discussing my position.
My personal definition of a hospitalist is: A generalist who manages patients admitted to the hospital in concert with his or her subspecialist colleagues and transitions them back to their primary care physicians. The term hospitalist was coined by Drs Wachter and Goldman in a 1996 article in the New England Journal of Medicine (NEJM).1 The origin of the field is broadly attributed to the two fairly independent factors: resident work hour regulations and the economics of medicine. The former is self evident. By decreasing the number of hours residents can work, the Accreditation Council for Graduate Medical Education (ACGME) pushed hospitals to substitute a relatively cheap pool of resident labor with a more expensive fix: in house physicians (hospitalists) who would admit and manage patients. The latter is a direct fall out of the need to maintain solvent medical practices, be it primary care practices or large hospitals. Starting in 1983, Medicare (followed by private insurers) started reimbursing hospitals based upon diagnoses (DRG system) rather than length of stay. In order to stay afloat, hospitals started frantically cutting length of stay and raising their admission threshold. This meant that relatively fewer patients of any particular primary care physician (PCP) would be admitted to the hospital at any given time. PCPs began to find that it was not viable financially to take care of hospitalized patients. It seemed fiscally more prudent to see larger volumes in the clinic and rely on inpatient physicians to see hospitalized patients. These physicians (hospitalists) are in turn able to see higher volumes in house. The field that started out as filler for manpower is beginning to transition itself into a sine qua non of efficient inpatient care. Hospitalist programs are bringing about reductions in inpatient length of stay and treatment costs of hospitalized patients. Fortunately, this reduction does not come at the cost of effective care as most quality measures have either stayed stable or have shown modest improvements under the hospitalist system. In addition, hospitalists are perfectly positioned to take a lead in designing patient quality improvement programs and improving care transitions.
The current state of hospital medicine is robust. There are 30,000 hospitalists in the USA practicing in more than 3,000 large hospitals and more than 50% of all community hospitals. Traditionally, the field has been dominated by internal medicine graduates. In recent times, other specialties are beginning to make their presence felt. Society of Hospital Medicine, State of Hospital Medicine Survey reveals that 89% of graduates in the field are trained in Internal Medicine, while 5.5%, 3.7% and 1.2% are graduates of pediatrics, family practice and combined medicine-pediatrics programs respectively.
The Medical College of Wisconsin hospitalist program has evolved according to the needs of the system. It now fills a unique niche by being one of the largest sections in the hospital that provides clinical care, resident teaching and inter-departmental care transition. Hospitalists at Froedtert wear many hats: we staff general medical wards (both on resident and non-resident teams), facilitate patient triage and admission (by virtue of our role as an admitting medical officer) and provide in house 24 hour direct patient care and resident supervision. The section also plays a role in co-managing patients admitted to other specialties. The section is fortunate to have 6 physician extenders (physician assistants and nurse practitioners) who ably augment hospitalist MDs in their day to day work.
The future of Hospital Medicine is exciting. Fellowship training in Hospital Medicine is now available. If the field continues to evolve along the lines of Emergency Medicine and Critical Care, board certification in Hospital Medicine may soon be a fact. Hospitalist programs now extend beyond the traditional pail of Internal Medicine and into the fields of pediatrics, neurology and even surgery. It would be fascinating to watch how the field responds to the various conundrums that would inevitably arise as this phenomenal growth continues over the next few years.
Article written by:
Ankur Segon MD MPH
Section of Hospital Medicine Medical Director
Division of General Internal Medicine
Vipulkumar Rana, MD
FMLH Section of Hospital Medicine
Division of General Internal Medicine
1. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996 Aug 15; 335(7): 514-517.
2. State of hospital medicine survey. Society of Hospital Medicine. Available from: www.hospitalmedicine.org.