Hospital medicine

Hospital medicine in the United States is the discipline concerned with the medical care of acutely ill hospitalized patients. Physicians whose primary professional focus is hospital medicine are called hospitalists; this type of medical practice has extended beyond the US into Canada.

The term hospitalist was first coined by Robert Wachter and Lee Goldman in a 1996 New England Journal of Medicine article.^[1] The scope of hospital medicine includes acute patient care, teaching, research, and executive leadership related to the delivery of hospital-based care. Hospital medicine, like emergency medicine, is a specialty organized around a site of care (the hospital), rather than an organ (like cardiology), a disease (like oncology), or a patient’s age (like pediatrics).^[2] A similar field, acute medicine, has recently developed in the United Kingdom.^[3]

Training

Hospitalists are physicians with a Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree.^[4] While it was commonly believed that any residency program with a heavy inpatient component provided good hospitalist training, studies have found that general residency training is inadequate because common hospitalist problems like neurology, hospice and palliative care, consultative medicine, and quality improvement tend to be glossed over. To address this, residency programs are starting to develop hospitalist tracks with more tailored education. Several universities have also started fellowship programs specifically geared toward hospital medicine.

According to the State of Hospital Medicine Survey by the Medical Group Management Association and the Society of Hospital Medicine, 89.60% of hospitalists specialize in general internal medicine, 5.5% in a pediatrics subspecialty, 3.7% in family practice and 1.2% in internal medicine pediatrics.^[5] Data from the survey also reported that 53.5% of hospitalists are employed by hospitals/integrated delivery system and 25.3% are employed by independent hospitalists groups.

According to recent data, there are more than 50,000 hospitalists practicing in approximately 75% of U.S. hospitals, including all highly ranked academic medical centers.^[6]

Canada

In Canada, there are currently no official residency programs specializing in hospital medicine. Nevertheless, some universities, such as McGill University in Montreal, have come up with family medicine enhanced skills programs focused on hospital medicine. This program, which is available to practicing physicians and family medicine residents, has a duration of six or twelve months. The main goal behind the program is to prepare medical doctors with training in family practice to assume shared care roles with other specialists, such as cardiologists, neurologists, and nephrologists, in a hospital setting. Moreover, the program prepares family physicians by giving them a set of skills required for caring for their complicated hospitalized patients.^[7][8]

History

Hospital medicine is a relatively new phenomenon in American medicine and as such is the fastest growing specialty in the history of medicine. Almost unheard of a generation ago, this type of practice arose from three powerful shifts in medical practice:

• Nearly all states, as well as the national residency accreditation organizations, the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA), have established limitations on house staff duty hours, the number of hours that interns and residents can work. Many hospitalists are coming to perform the same tasks formerly performed by residents; although this is usually referred to as a House Officer rather than a hospitalist. The fundamental difference between a hospitalist and a house officer is that the hospitalist is the attending physician of a patient while that patient is hospitalized. The house officer admits the patient for another attending physician and cares for that patient until the attending physician can see the patient.
• Most primary care physicians are experiencing a shrinking role in hospital care. Many primary care physicians find they can generate more revenue in the office during the hour or more they would have spent on inpatient rounds, including traveling to and from the hospital.

In addition to patient care duties, hospitalists are often involved in developing and managing aspects of hospital operations such as inpatient flow and quality improvement. The formation of hospitalist training tracks in residency programs has been driven in part by the need to educate future hospitalists about business and operational aspects of medicine, as these topics are not covered in traditional residencies.

Certification

As a relatively new specialty, only recently has certification for specialty experience and training for hospital medicine been offered. The American Board of Hospital Medicine (ABHM), a Member Board of the American Board of Physician Specialties (ABPS), was founded in 2009. The ABHM was North America’s first board of certification devoted exclusively to hospital medicine. In September 2009, the American Board of Internal Medicine (ABIM) created a program that provides general internists practicing in hospital settings the opportunity to maintain Internal Medicine Certification with a Focused Practice in Hospital Medicine (FPHM).

Quality initiatives

Research shows that hospitalists reduce the length of stay, treatment costs and improve the overall efficiency of care for hospitalized patients.^[9] Hospitalists are leaders on several quality improvement initiatives in key areas including transitions of care, co-management of patients, reducing hospital acquired diseases and optimizing the care of patients.

Employment

The number of available hospitalists positions grew exponentially from 2006 to 2010 but has since then leveled off.^[10] However, the job market still remained very active with some hospitals maintaining permanent openings for capable hospitalists. Salaries are generally very competitive, averaging almost $230,000 per year for adult hospitalists.^[11] Hospitalists who are willing to work night shifts only (nocturnist) are compensated higher than their day shift peers.^[12]

Related terminology

Though hospital medicine is a young field, there have been attempts at further division of labor in the field.
A nocturnist is a hospitalist who typically covers the twelve-hour shift at night and admits patients as well as receives calls about already admitted patients.
A proceduralist is generally defined as a hospitalist who primarily does procedures in the hospital such as central line insertion, lumbar puncture, and paracentesis.
A neurohospitalist cares for hospitalized patients with or at risk for neurological problems.^[13]
A surgicalist is a surgeon who specializes and focuses on surgical care in the hospital setting.^[14]

The following are other commonly used monikers:
An admitologist or admitter is a hospitalist who only admits patients and does not round on the already admitted ones, or discharge the admitted patients.
A rounder is a hospitalist who only sees the already admitted patients.^[15]

See also

• Society of Hospital Medicine
• Obstetric hospitalist

References

Further reading

• "The Hospitalist Movement — Time to Move On", New England Journal of Medicine
• "Study ties hospitalist care to shorter patient stays", American Medical News by the American Medical Association
• "What Is a Hospitalist? A Guide for Family Caregivers", free consumer guide available in four languages

External links

• American Board of Hospital Medicine
• Society of Hospital Medicine
• American Board of Internal Medicine