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?”