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What Is a Hospitalist?


 

When I meet new people, I’m commonly asked, “So what do you do?” The first answer is easy: “I’m a doctor.” It’s the follow-up question that’s tricky: “What kind of doctor?”

“I’m a hospitalist,” I say.

“What’s that?”

I imagine that each of us faces similar questions almost daily from friends, family, patients, or strangers we meet. This tells me people are still learning who we are and what we are. I also imagine each of us has developed a standard way of answering that second question.

I like to say that a hospitalist is “a doctor who is an expert in taking care of people in the hospital.” Though not necessarily comprehensive, my definition usually does the job in casual conversation. In many ways I find this explanation easier than when I tried to describe myself as an “internist,” for which I never developed an easy definition. My favorite one-liner for internist was “pediatrician for adults,” but even that prompted blank stares or polite nods.

Early Definitions of Hospitalists

My definition certainly works in casual conversation. But the question gets to the heart of who we are, what we do, and what our field is about. Our ability to define these issues is critical to clarifying what hospitalists and hospital medicine are about.

It is interesting to look at early definitions of hospitalists. The first time the word hospitalist was published in 1996, hospitalists were defined as “specialists in inpatient medicine ... who will be responsible for managing the care of hospitalized patients in the same way that primary care physicians are responsible for managing the care of outpatients.”1

At the beginning there was a need to compare what hospitalists do, or will do, to something that was already known. The concept was so new that it needed an analogy to be explained. Even in 1999, a paper published in Annals of Internal Medicine defined hospitalists as “physicians who assume the care of hospitalized patients in place of the patients’ primary care provider.”2

Three years after the term was first coined, hospitalists were still being defined in relationship to other physicians. Another paper in Annals of Internal Medicine in 1999 defined a hospitalist as “a physician who spends at least 25% of his or her time serving as the physician-of-record for inpatients, during which time he or she accepts ‘hand-offs’ of hospitalized patients from primary care providers, returning patients to their primary care providers at the time of hospital discharge.”3 Of course that definition was quite a mouthful when explaining what you do to, say, your mother. But there were two important issues wrapped up in that definition.

The first was recognizing that some hospitalists were primarily engaged in research or leadership positions and did not provide a great deal of direct patient care, yet clearly defined themselves as hospitalists. The second was that we were still defined by our relationship to the primary care physician role. Our field was too new to be defined on its own and had to be explained in terms of the existing paradigm.

What became clear was that hospitalists should not be defined by the amount of inpatient care we provided but by our professional focus. For many hospitalists, the thought of caring for hospitalized patients only 25% of the time seemed ridiculous. To others involved in leadership or research who focused exclusively on hospital medicine yet did little patient care the definition seemed too restrictive.

In the end, any definition of hospitalists that depended on time could not encompass the wide range of roles and responsibilities that hospitalists held. Finally, a few months ago, hospitalist was included in the dictionary for the first time. 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.” Although I am delighted to see hospitalist in the dictionary, this definition is too limited to be useful or accurate. It is certainly true that the presence of hospitalists means other physicians can come to the hospital less, but that is far from what hospitalists or hospital medicine are about.

In just 10 years we have moved from having hospitalists defined in relationship to other physicians to having other physicians defined in relationship to hospitalists. This evolution is good for our field as we emerge from being the new kids on the block to being part of the existing paradigm.

SHM Definition of Hospitalists

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.”

I wish the dictionary had used this definition because it gets to the heart of what hospitalists are and defines us in a positive way, on our own terms, and not in relation to other physicians. This definition embraces the broad range of professional activities that hospitalists perform. Our definition even allows for hospitalists to engage in nonhospital-based activities such as outpatient care. The key to this definition is the emphasis of our professional focus being the care of hospitalized patients.

The Big Tent

What the SHM definition of hospitalists recognizes is the great diversity of physicians who serve as hospitalists and the wide variety of roles we all play in the service of caring for hospitalized patients. Both MDs and DOs serve as hospitalists, and they do so as internists, family physicians, and pediatricians. That all these physicians can come together in the same professional organization speaks to the importance of the unifying goal of caring for hospitalized patients that defines what each of us does.

Further, hospitalists can be involved exclusively in patient care, research, teaching, or leadership or in a combination of these roles. Once again the common principle is the focus on the care of hospitalized patients. In fact our society and field are better, more robust, more innovative, and more responsive to the needs of patients because we represent such a broad range of physicians in so many roles.

Our coming together in one organization creates a “big tent” for hospital medicine and allows for cross-fertilization of ideas. However, like any big tent, the strength of our diversity also creates challenges. For example, from an educational standpoint, we need to design programs and materials that meet the needs of all hospitalists. We have found that we share much, regardless of the setting in which we practice, the age of our patients, or the type of work we do. Patient safety, leadership, palliative care, and quality improvement are just a sample of the issues that pertain to all hospitalists.

Additionally, understanding these issues and addressing them takes people who are experts in patient care, teaching, research, and leadership—precisely the job descriptions found within the SHM. I am proud that SHM is one of the only professional societies to include internists, family physicians, and pediatricians from community practice, academia, and industry. Our big tent even extends beyond physicians to include nurse practitioners, physician assistants, pharmacists, nurses, and others who enrich our society and strengthen our field. In fact, our name—the Society of Hospital Medicine—was deliberately chosen to reflect the big tent. We specifically rejected a name that focused on the word hospitalist—not because we are not proud of it, but because we wanted all of those who work to improve the care of hospitalized patients to feel welcome in our society and to join in our mission.

Hospitalist Takes Hold

The phenomenon we now see is the emergence of “surgical” and “OB” hospitalists who care for hospitalized patients who otherwise do not have access to such physicians. Whether these physicians will assume the role of improving the system to provide better care to all inpatients or serve solely as technicians who work a shift and go home remains to be seen.

What is clear, however, is that in just 10 short years we have moved from having hospitalists defined in relationship to other physicians to having other physicians defined in relationship to hospitalists. This evolution is good for our field as we emerge from being the new kids on the block to being part of the existing paradigm.

Hope for the Future

The evolved definition of hospitalist reflects the maturing of our field and leaves me optimistic and hopeful for the future of hospitalists and hospital medicine. I hope that the dictionary will adopt our definition of hospitalist. I hope that one day hospitalist will be as well-known a word as pediatrician. I hope that as our field matures we never lose our enthusiasm and energy. And finally, I hope that our field stays unified and that the SHM continues to represent the broad range of physicians who work as hospitalists. Our field will be stronger and our achievements greater when we stand together, recognizing all that we share in common as hospitalists and respectful of the diversity that adds richness to our field. TH

SHM President Dr. Pantilat is an associate professor of clinical medicine at the University of California at San Francisco.

References

  1. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996;335:514-517.
  2. 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.
  3. Wachter RM. An introduction to the hospitalist model. Ann Intern Med. 1999;130(4Pt2):338-342.

Letters

The Power of Words

I enjoyed reading the December issue of The Hospitalist. I am somewhat concerned, though, about Dr. Pantilat’s continual assumption that all hospitalists are internists, which is far from accurate and alienates those of us with different board certifications.

For example, he notes that “any process of certification for hospitalists has huge implications for all physicians practicing internal medicine.” True, but certification has huge implications for all of us, including pediatricians and family physicians who are hospitalists. At these early stages of the specialty wording is important, and Dr. Pantilat needs to choose his phrases carefully. Many family medicine docs are choosing careers in hospital medicine. It would be a shame if family medicine hospitalists had to break away and form their own society.

—Robert A. Brockmann, MD, MSc, Englewood, Colo.

You are exactly right: The strength of hospital medicine and SHM is based on our “big tent” that embraces physicians who work as hospitalists (internists, family physicians, and pediatricians) in all settings—community practice, academia, and industry. Reflecting this diversity, SHM has a pediatrics committee and a family medicine committee to address the unique issues that arise for hospitalists in these specialties.

Regarding certification of hospitalists, the SHM Board of Directors decided to address certification for internists first because the majority of hospitalists and SHM members are internists. Our plan is to apply the approach for internists in family medicine and pediatrics to achieve equivalent certification processes for all physicians who practice hospital medicine.

The future of the SHM is predicated on the contributions of all physicians and other healthcare providers who care for hospitalized patients and work to improve that care. Our field and organization are strongest when we work together and use our unique perspectives and expertise to advance hospital medicine. Thanks for reminding us of the richness of our field.

—Steven Pantilat, MD, President, SHM

Communication breakdown?

I was disappointed that in the Dec. 2005 issue of The Hospitalist, you covered both the issues of malpractice (“A Malpractice Primer,” p. 1) and poor communication (“Say What?” p. 20). Yet other than a single mention in the latter article, no one connected the relationship between the two.

The Harvard study has shown that patients don’t sue physicians who practice medicine poorly more frequently than those who practice good medicine and, with regard to payouts or financial judgments, the correlation is to disability rather than negligence.1,2

Two more recent articles have shown that physicians who have higher patient satisfaction and a low complaint rate are sued less frequently.3,4 In our institution the most important component to overall patient satisfaction with the hospitalization relating to the physicians is how well the physician kept the patient informed. This, as your publication and others have noted, is a core function of the hospitalists. TH

—David B. Edwards, MD, FACP, Mesa, Ariz.

References

  1. 1. Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991;325:245-251.
  2. 2. Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. NEJM. 1996;335:1963-1967.
  3. 3. Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002;287:2951-2957.
  4. 4. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;108:1126-1133.

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