As the field of hospital medicine grows, some hospitalists are gravitating toward subspecialty services. In recent years we’ve witnessed a proliferation of ‘ists’: There are now surgicalists, laborists, psychiatric hospitalists—even hepa-hospitalists.
The numbers of “hyphenate hospitalists” are not tracked by SHM, but the subspecialization trend highlights raises questions about hospital medicine’s evolution. Among the issues:
- What does this growth of hospitalist subspecialists foreshadow about the strength of the hospitalist movement?
- Does subspecialization always convey positive changes for the hospitalist?
- Do physicians risk trade-offs when their hospital medicine practices are rooted solely in one subspecialty?
- What about retaining the opportunity to see and treat a variety of patients and conditions—presumably one of the initial attractions of a career in internal medicine and family medicine?
The founder of hospital medicine, a noted pediatric hospitalist, the chair of the SHM’s membership committee, and a former hepa-hospitalist recently shared their experiences and views on these issues.
Hospital medicine pioneer Robert M. Wachter, MD, has observed at his and other hospitals the increasing dependence on hospitalists’ services.
“Hospitalists have traditionally done more than just take care of medical patients,” says Dr. Wachter, professor and chief of the division of hospital medicine, associate chairman, department of medicine, chief of the medical service at the University of California San Francisco (UCSF), and author of the upcoming blog “Wachter’s World.” “They’ve always done medical consultations and helped to take care of sick patients with surgical, gynecological, and psychiatric issues.” But now, he says, “The demand for hospitalist services is almost limitless.”
At UCSF, he reports, hospitalists now manage the medical problems of patients on the complex heart failure service, the bone marrow transplant service, and the neurosurgical and orthopedic services. Dr. Wachter views the trend of using hospitalists in a variety of subspecialty services as “one of the most exciting developments for the field—it is taking the field to a whole new level of importance and growth.” That’s because it signals recognition that the concept of hospital medicine has value “for virtually every patient sick enough to be in the building,” he says.
Ambiguity of Terms
Not only are hospitalists increasingly present in subspecialty services, but some specialist services are reorganizing according to the hospitalist model. This may create complexities regarding hospital medicine’s core identity, according to Dr. Wachter.
For instance, at UCSF, there are generalist surgeons who have organized a hospitalist service, providing on-call responsiveness, triage for specialized surgical problems, and a breadth of care and coordination typical of the hospital medicine model. Separately, there are also internal medicine hospitalists who serve on the surgery service. “I think there is going to be some ambiguity about roles until we clean up the language,” remarks Dr. Wachter. For instance: “Is the hospitalist on the surgery service still a generalist who takes on the role of subspecialist by caring for a more specialized population? And, what do you call the specialist surgeon who takes on a more hospitalist role?”
Shaun Frost, MD, FACP, chair of SHM’s Membership Committee and regional medical director for Cogent Healthcare in St. Paul, Minn., considers whether the inclusion of various subspecialists fits with the SHM’s definition of hospitalists. “If you’re looking strictly at ‘definition,’ SHM considers a hospitalist to be a physician whose primary professional focus is the general medical care of hospitalized patients,” he says. “As hospitalist subspecialists are likely engaging in the management of hypertension, diabetes, chronic lung and cardiac disease, etc., I see no reason to believe that they would not fit the definition of a hospitalist.”
Best Use of Skills?
Although Drs. Wachter and Frost see inclusion of hospitalists on subspecialty services as a positive trend, others warn that hospitalists should be wary about the reasons for their enlistment.
Lauren M. Friedly, MD, a hospitalist at Marin General Hospital in Greenbrae, Calif., believes subspecialty hospitalist jobs are “ultimately untenable for solid, well-trained, dedicated hospitalists.” She developed this view after a frustrating two years on a liver transplant service—where she found she “wasn’t able to practice medicine in a way that was comfortable.”
Dr. Friedly explains that she chose to be a hospitalist because of her experience as a medical student at UCSF and as a resident at California Pacific Medical Center—watching and learning from the originators of the movement, such as Dr. Wachter and Masa Yukimoto, MD, former chief resident. All the reasons she chose hospital medicine—the pace, acuity of patients, ability to revisit patients and ruminate about their problems, and the opportunity to improve the quality of a patient’s in-hospital care by adhering to a “first do no harm” philosophy—were stymied when she became a hepa-hospitalist.
“The problems that can potentially exist in any subspecialty hospitalist group are magnified a hundredfold in a liver transplant program,” she explains. “There were philosophical differences in our approach to medical care of inpatients, and the hospitalists were, in some ways, considered the bottom of the food chain.
“Because of our position relative to the hepatologists and transplant surgeons, we were not provided the autonomy nor the resources with which to accomplish any of these things. For example, decreasing length of stay by discharging patients efficiently, which to a well-trained hospitalist may mean less risk of exposure to nosocomial infections and iatrogenic complications, was not necessarily valued by the transplant surgeons and hepatologists. Less is often more for a well-trained hospitalist, but this sentiment is in direct conflict with the maximalist approach used in transplant medicine.”
Satisfying in the Long Run?
Perhaps the most important question about subspecialization for the hospitalist is whether joining a subspecialist service is a good fit. Dr. Frost believes it’s important to consider whether a career in a subspecialty service would be satisfying in the long run. “For many of us,” he explains, “one main reason we chose to pursue careers in general internal medicine, general pediatrics, or family practice is that we enjoy variety. Personally, for example, I know that I would quickly become bored with solely focusing on one organ system or one special patient population. Therefore, I believe that there is probably a limited group of folks who would enjoy exclusively restricting the scope of their hospital medicine practice to a specific subspecialty area.”
Still, Dr. Friedly admits she will miss the challenges of dealing with complex pathology. On the liver transplant service, for instance, she cared for patients with complex gastrointestinal issues, including cancers. But, due to her time on that specialized service, she now finds herself having to refresh her more general internal medicine skills.
The Pediatrics Picture
The hospitalist model is increasingly common in pediatrics, where costs per patient and length of stay have been lowered when using the hospital medicine model to restructure academic pediatric inpatient services, and hospitalists have contributed to improved survival in pediatric intensive care units.1-2
In part because of lower patient volumes on pediatric hospitalist services, the trend toward subspecialization is not as evident in pediatric hospital medicine as it is in adult hospital medicine, according to Sanford M. Melzer, MD, senior vice president of strategic planning and business development at Seattle Children’s Hospital and Regional Medical Center, and a member of the American Academy of Pediatrics’ Committee for Hospital Care. However, with shortages of physicians in key specialty areas, that may be changing.
Dr. Melzer, who has been a clinical pediatric hospitalist for 20 years and has published research on the financial aspects of pediatric hospitalist programs, reports that his service is beginning to field requests for hospitalists from specialty programs to provide staffing—just as adult hospital medicine programs have noticed.3 For example, the oncology service at Seattle Children’s Hospital has started to explore using pediatric hospitalists to help manage its pediatric cancer unit, which treats 225 new diagnoses of childhood cancer annually.
In part because oncology treatment at Seattle Children’s tends to be “heavily protocolized,” Dr. Melzer believes pediatric hospitalists can provide quality inpatient care as inpatient generalists, in terms of palliative care and symptom management, if included on that service.
The other area in which pediatric hospitalists may provide “specialty” care is in neonatology, where shortages of specialists or costs of coverage result in hospitalists covering the delivery room or the neonatal intensive care unit (NICU).
Pediatric hospitalists, as generalists, typically provide care for many different types of illnesses and conditions. “This is one of the attractive features of the job for pediatricians choosing this career track,” Dr. Melzer says. “An increasing degree of specialization may make these positions somewhat less interesting, and may highlight discrepancies between hospitalist and specialist salaries.” On the other hand, he says, “Continued shortages in specialty areas in pediatrics will continue to drive the trends toward increased deployment of generalists in these services.”
One model employed in children’s hospitals is to utilize more physician extenders, such as nurse practitioners and physician assistants, to provide the needed coverage. How pediatric hospitalists will fit into this evolving care model is not clear, notes Dr. Melzer.
To avoid the possible pitfalls hospitalists can encounter with subspecialist services will require innovative solutions, Dr. Friedly believes.
“Ultimately, I think the only way that it will be sustainable [as a long-term career choice] for any individual hospitalist to take a position within a subspecialty program will be to help create or to be part of the initial vision,” Dr. Friedly says. “Or, an already-established hospitalist group could approach the subspecialist and ask, ‘How can we help you deliver the highest quality standard of care to your patients while they’re here in the hospital?’ ”
As of July 1, the UCSF neurosurgery service has embraced the addition of core internal medicine hospitalists who help to manage the medical problems of the [typical census of] 60 neurosurgery patients. So far, Dr. Wachter reports, the hospitalists are enjoying their stint on the neurosurgery service. “They’re learning a lot because these patients have very unusual and specialized problems,’’ he says. “It only took three minutes for them to realize that they were making a difference because some of the patients are very sick and have many medical problems. The surgeons don’t focus on or keep up with medical management, and even if they did, they are in the OR all day long.”
Rotating hospitalists to specialty and subspecialty services for 25% of their time in the hospital, as the UCSF Neurosurgery hospitalists do, might be one way to preserve the traditional general medical model to which many internal medicine hospitalists still gravitate. “This could be an interesting, specialized niche practice, but would not be the bulk of what they do,” says Dr. Wachter.
Dr. Frost agrees that the key to addressing the challenge of subspecialization lies in building this type of work into the context of a larger hospital medicine program. “Rotating all members of a hospital medicine group through a subspecialty experience for a portion of their overall time may be the way to go,” he notes.
Dr. Friedly cautions that certain subspecialist services, such as liver transplant, may not embrace the multidisciplinary hospital medicine model, so it remains to be seen if the effort can evolve to be truly collaborative. Her advice to younger residents just entering hospital medicine? “Hospitalist medicine has unlimited possibilities as a career choice, especially if you enjoyed being an internal medicine resident. Be careful, however, to avoid a setting where you risk losing your hard-earned skills while also being treated like a ‘perma-resident.’ Starting out in a more traditional hospitalist program to learn solid hospitalist ‘tricks of the trade,’ then transitioning to a subspecialty program where you can offer your skills, rather than the other way around, may be the more sustainable, long-term option.” TH
Gretchen Henkel is a frequent contributor to The Hospitalist.
- Ogershok PR, Li X, Palmer HC, et al. Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.” Clin Pediatr. 2001 Dec.;40(12): 653-660.
- Tenner PA, Dibrell H, Taylor RP. Improved survival with hospitalists in a pediatric intensive care unit.” Crit Care Med. 2003 Mar;31(3):847-852.
- Melzer SM, Molteni, RA, Marcuse EK, et al. Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis. Pediatrics. 2001 Jul;108(1);79-84.