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What Is a Laborist?


 

One of the interesting things about hospital medicine is our diversity. It is an evolutionary construct and can be both a strength and a concern as we all try to create and define our new specialty.

Most hospitalists are trained as general internists. This wasn’t always so. As recently as 1997 almost 50% of hospitalists were internal medical subspecialists. The thinking at that time was that because infectious disease docs, pulmonologists, intensivists, and others were already in the hospital seeing ill patients, why couldn’t they just also be hospitalists?

Well, it turned out they wanted to be infectious disease specialists and pulmonologists and they soon found out that being a hospitalist is somewhat different than these other specialties.

Now hospital medicine is a popular career path for those finishing a general internal medicine residency, as well as for those who are finding a career as a hospitalist preferable to their original choice as in traditional internal medicine. (See “Trendwatch: The Specialization of Hospital Medicine,” p. 27.)

Whether we are talking about the differences between academic hospital medicine or that practiced in community hospitals, or the uniqueness of a small group of hospitalists at only one hospital or a large multistate group of hospitalists in 10 states with 400 hospitalists, we are all part of hospital medicine.

PEDIATRICIANS AND FAMILY PRACTICE

At the same time, even though only 3% of hospitalists are family practitioners, more than 90% of hospitalists in Canada come out of family practice training. Increasingly, young graduates of family practice residency programs are choosing to become hospitalists.

And let’s not forget the pediatricians. Pediatricians comprise about 9% of all hospitalists, and more than 200 pediatric hospitalists got together for the largest pediatric hospital medicine meeting ever in Denver at the end of July. (See the “Pediatric Special Section,” p. 33.) It was an impressive community of pediatric hospitalists. Most children’s hospitals and many community hospitals now have pediatric hospital medicine groups. Most of the pediatric inpatient care in this country is now provided by hospitalists and pediatric subspecialists.

In fact, those who have taken training in med-peds are finding that a career as a hospitalist is a nice fit, and they are welcomed by those who care for children and adults in the hospital.

But hospital medicine is not only about physician caregivers. More than 5% of hospitalists in this country are nonphysician providers, either nurse practitioners or physician assistants. As the demand for hospitalists rapidly increases many hospital medicine groups find that adding nurse practitioners or physician assistants helps them to complete the workforce they need to have in place to meet their clinical and administrative demands.

And hospital medicine includes pharmacists, case managers, and administrators to round out the inpatient team. Each of these professions is developing “hospital medicine specialists” looking for skills and experiences to allow them to help facilitate the work of the hospitalists and to use a team approach to achieve the rapidly expanded expectations of hospital medicine groups.

EDUCATION AND CERTIFICATION ISSUES

This growing conglomeration of healthcare professionals in one specialty presents unique issues. Some of these come in the form of diverse and expanding educational needs. The patient wants to be assured that no matter where the individual hospitalist started his or her training, the hospitalist will bring to the bedside the appropriate skills for their acute medical problems. This leads to having SHM develop courses in critical care skills, perioperative medicine, leadership, and the like.

Yet even though the endpoint may need to be similar for all hospitalists, it takes a fine touch and significant customization to craft educational materials when many hospitalists may start from a different base point.

When it comes to potential credentialing in hospital medicine, there is not a clear path to create a certification in hospital medicine. The solution for the 80% of hospitalists trained in internal medicine may very well be through the American Board of Internal Medicine (ABIM), but the pediatric and family practice solution will need to involve the American Board of Pediatrics (ABP) and the American Board of Family Medicine (ABFP), respectively. And this doesn’t even begin to address the credentialing needs of the nonphysicians.

Further, as SHM looks to represent all of the diverse elements that form the fabric of hospital medicine, we need to be in touch with the American College of Physicians, the American Academy of Pediatrics, the American Academy of Family Physicians, the Society of General Internal Medicine, the Ambulatory Pediatric Association, the American Association of Critical Care Nurses, the American Society of Health System Pharmacists, the American

Academy of Physicians Assistants, the American Academy of Nurse Practitioners, and many other important substantial medical professional societies; members of each believe that their organization relates to a segment of hospital medicine.

DIVERSITY CREATES NEW SOLUTIONS

The good part of this diversity is that as SHM helps to build this new specialty we are able to include so many unique vantage points. This strategy of inclusion allows for new ideas to percolate to the surface and leads to innovation and creativity. In fashioning the hospital of the future, “old think” must not rule the day. One way to change the outcome is to change those who are at the table.

If hospital medicine is to be part of the process of creating a hospital that is patient-centered, relies on measurable quality improvement, and delivers care by teams of healthcare professionals, then we need to open the tent and let in different perspectives. In SHM’s ongoing quality improvement efforts in heart failure and glycemic control, this is our approach—with meaningful input from hospitalists, subspecialists, nurses, pharmacists, and many other stakeholders in hospital medicine. This will lead to a different and—let’s hope—better outcome.

LABORISTS AND SURGICALISTS

And there are more wrinkles in the hospitalist world all the time. Recently USA Today wrote a story about “laborists” as hospitals try to solve access to obstetrical services by having contracted laborists on site 24/7. Some hospitals have to be creative when their community surgeons aren’t available for trauma care and some hospitals have contracted with orthopedists and general surgeons as “surgicalists.”

Are these the latest additions to the roll call of hospital medicine or just a footnote or an asterisk? Time and the marketplace will tell.

Besides the basic training for hospitalists there are many variations determined by site of practice and employment model. Whether we are talking about the differences between academic

hospital medicine or that practiced in community hospitals, or the uniqueness of a small group of hospitalists at only one hospital or a large multistate group of hospitalists in 10 states with 400 hospitalists, we are all part of hospital medicine.

In the end, hospital medicine is defined more by its common goals and its common values regardless of initial training or mode of practice. At this time in healthcare, many are looking for healthcare professionals to have the skills and the energy to create the hospital

of the future that will be a better place to work and to get the best care. SHM is committed to harnessing the diversity of our specialty to do our part to create a better future. With your help, we can get there. TH

Dr. Wellikson has been the CEO of SHM since 2000.

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