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Clinical Privileges

From: The Hospitalist, June 2008

Is there a standard percentage of time for inpatient care that is used to define a hospitalist?

by Dr. Hospitalist

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Clinical Privileges

Question: Is there a standard percentage of time for inpatient care that is used to define a hospitalist? (i.e., 25% of time in inpatient activities = expert in hospital medicine). Our hospitalist section is drafting a clinical privilege form, and I have been searching for a national standard.

Heather Toth, MD, Hospital Medicine, Department of Pediatrics, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee

I will caution you as you draft your clinical privilege form that whether you are a hospitalist or not is a different issue than whether you are qualified or not to provide a specific type of clinical care.

Dr. Hospitalist responds: You and others may be aware of a little secret in hospital medicine: hospitalists have been around in this country for decades.

Even though Drs. Robert Wachter and Lee Goldman coined the term “hospitalist” in the New England Journal of Medicine in 1996, hospitalists have been working our nation’s hospitals for a long, long time.

Don’t get me wrong—I am not diminishing their roles in establishing the field of hospital medicine. What I am saying is that hospitalists were around before 1996, but nobody had defined their role. and nobody knew what to call them.

Drs. Wachter and Goldman did not only name the profession, they also gave it credibility. Prior to the mid-’90s, I get the sense most medical professionals viewed hospitalists as second-rate doctors. These hospital doctors were doing the jobs most respectable doctors didn’t want to do or didn’t have to do.

Trying to define the amount of inpatient care one must perform to be called a hospitalist might not be the easiest or best way to define the role.
Trying to define the amount of inpatient care one must perform to be called a hospitalist might not be the easiest or best way to define the role.

Those jobs included caring for critically ill patients when other doctors were unavailable or didn’t have the time to see their patients. This could be at 2 p.m. or 2 a.m. in most hospitals. Drs. Wachter and Goldman were, and are, respected academic physicians. In their seminal article, they essentially called out these hospital doctors and lauded their roles in the hospital. Moreover, they anticipated growth in this field of medicine. In some ways, they were saying, “I’m OK and you’re OK. It’s OK to be a hospitalist.”

Well, the rest is history; whereas we had about 2,000 hospitalists in the mid-’90s, we now have an estimated 20,000 hospitalists in the country.

It seems nowadays, many doctors are calling themselves hospitalists. How many times have you heard a doctor say, “I was a hospitalist before the field existed?” I wonder whether we really had so many hospital doctors back then.

Or, is it an issue of how one defines “hospitalist”? Some doctors may be making claims about being a hospitalist because it is now acceptable to be a hospitalist. Whereas 15 years ago, hospitalists were looking in at the establishment; in some parts of the country, hospitalists have become the establishment.

My brother was a member of his high school basketball team, which was ranked No. 1 in the state. Ignore the fact that as a scrub he never came close to stepping onto the court during a game. He still made sure people knew he was a player on the championship team. Everyone wants to be part of a winner.

There may be other reasons to call oneself a hospitalist. Many view hospitalists as specialists in inpatient care. Before long, hospitals may grant privileges to hospitalists that they may not grant to other types of doctors. We have seen this before.

At one time, there was virtually no such thing as a “closed” ICU in hospitals.

Evidence suggested patients received better care when intensivists cared for ICU patients. Today, it is rare to find an academic medical center without a closed ICU, and many community hospitals have adopted a similar model.

Whether doctors are calling themselves “hospitalists” because it is the cool thing to do now or whether it is a matter of turf, you bring up a good question: “How much inpatient work does one have to do to be called a hospitalist?” Drs. Wachter and Goldman certainly didn’t specifically address this issue in their article, and neither has SHM.

SHM’s definition of a hospitalist is: “Hospitalists are 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.”

This definition of a hospitalist is about as good as any I have heard. It should be noted this definition makes no mention of training. One can be an internist, family physician, pediatrician, obstetrician, or general surgeon and be a hospitalist.

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Do you have a problem or concern that you’d like Dr. Hospitalist to address? E-mail your questions to drhospit@wiley.com.

With this definition, it does mean, however, you can take care of patients one to two months out of the year and still be considered a “hospitalist” as long as your non-clinical work (teaching, research, and leadership roles) is related to hospital medicine.

I will caution you however as you draft your clinical privilege form that whether you are a hospitalist or not is a different issue than whether you are qualified or not to provide a specific type of clinical care.

Hospitalists are individuals with different knowledge bases and skills sets. You can work clinically as a hospitalist 12 months a year, but if you have never put in a central line, your hospital should not grant you privileges to put in central lines until you have demonstrated some minimal level of competency.

I suspect you are not alone. There are many doctors and institutions around the country that are or will be struggling with the same issues you are facing. TH


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