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What Is a Hospitalist?


The next Annual Meeting is near. This means that the year, serving as your President, has nearly come to an end. As a result, this will be my last column. It is a good time for reflection.

First, I must thank the thousands of hospitalists who have joined SHM, filled out surveys, and attended meetings (either nationally or locally). You see, SHM’s data on hospitalists—where they are, what they do, and numbers in practice—is the source of information people outside the profession are using to understand and make decisions about our growing specialty. There is strength in numbers and your participation at every level infuses the energy necessary for us to continue the journey of becoming a legitimate specialty. Thank you.

As an organization, we have made significant progress toward our mission of making quality and safety core to what it means to practice hospital medicine. We have joined a number of other organizations, associations, and foundations to create various initiatives aimed at improving the quality and safety of care delivered in our hospitals. Specific areas of focus to date have been in the care of geriatric, diabetic, cardiac, and critically ill patients. We have also begun to address key preventative strategies such as antibiotic resistance and thromboembolic disease prophylaxis. These national partnerships SHM has formed with such organizations as the American College of Chest Physicians, American Association of Critical Care Nurses, American Hospital Association, Hartford Foundation, American College of Cardiology, Institute of Health Care Improvement, Joint Commission, and many others, demonstrate the breadth of teamwork that is necessary to care for patients across the continuum. Hospitalists are a crucial part of that team as more and more of our nation’s patients are cared for by hospitalists during their acute illnesses.

It has been an amazing year of watching this organization grow and mature. But what do I worry about as I leave my post? What is the kernel of concern that I must ensure is passed on with this next “transition of care” of our organization? It is that which defines us. I mentioned in my speech at lunch last year that we (the Society of Hospital Medicine) would fail if what hospitalists became known as were simply those pediatricians or internists who spent more time than their peers in the hospital. I don’t know about you, but at least once each month someone will approach me and say “I spend 25% of my time seeing patients in the hospital—So I must be a hospitalist!” (Quoting the original work of Drs. Robert Wachter and Lee Goldman in their 1996 New England Journal of Medicine article.) Well, as time has passed and the field has clearly evolved with more than 10,000 hospitalists practicing, the definition has clearly evolved.

But is our defi nition of what we do still based on time in the hospital? Or is it a more substantial definition? Is it about one’s professional focus? Is it about where one’s passion for medicine lies? What one wakes up in the middle of the night worrying about? What is a hospitalist?

The definition set forth by the Society of Hospital Medicine (adopted in the spring of 2000) is the following: Hospitalists are doctors whose primary professional focus is the general medical care of hospitalized patients. Their activities may include patient care, teaching, research, and leadership related to hospital care. Hospital 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).

It seems silly to be asking this question of what defines us after writing about the burgeoning specialty. But as was pointed out in February’s JGIM issue, “varied employment relationships create diverse practice structures, priorities and roles.” Our practices have each grown so quickly out of local market pressures and individual hospital needs that we have evolved in slightly different directions. This is a natural consequence of such rapid growth. Just like any other specialty, practice structures and employment models will differ across the country. But I would challenge us to ensure that our higher priorities do not differ.

The American health care system needs an entire army of physicians and other providers to give whole heartedly and completely of their professional time, creativity, and energy to the hospital… to fix current system problems. It is no different than the cardiologists of today spending their energy and time discovering at the molecular level what causes ventricular dysfunction and then translating that knowledge to bedside care. Hospitalists, are specialists of in hospital medicine, and must do for the hospital what cardiologists do to the heart. We must study and learn what causes the health care delivered by the hospital to fail. Then we must translate that knowledge to the care of all patients in the hospital by improving the systems of care delivery.

According to Dr. Charles Mayo, “The definition of a specialist as one who ‘knows more and more about less and less. Its truth makes essential that the specialist, to do efficient work, must have some association with others who, taken altogether, represent the whole of which the specialty is only a part.” Our generalist colleagues care about the hospital as much as we do but do not necessarily have the time to concentrate specifically on hospital systems. There are so many other things that require their attention at the same time, but we need them to be there.

So we are only a part of what is needed to deliver the best care to all patients. But we have become a critical part of that team in the hospital. It is the hospitalists who, through their chosen focus on one aspect of medicine, will need to give the energy, creativity, and time to improving our systems of health care delivery in the hospital and across key transitions of care. Regardless of where we practice or how our practice is structured, our higher calling as a specialty is to determine the root causes of what ails the hospitals of this country. Then, as a specialty we must discover new mechanisms that would provide care at the level of quality called for by our patients. If we as hospitalists are truly specialists… If we are experts at delivering hospital based care… Then we have a vested interest in addressing these higher priorities. The improvements in health care that will be achieved, because a group of providers have dedicated their careers to making the hospital a better place for our patients, will ultimately make the definition of a hospitalist quite clear.

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