By Jack D. McCue, MD Dr McCue is Clinical Professor of Medicine, University of California, San Francisco.

The inevitability of hospitalist medicine as a career for internists was apparent to many of us in medical education more than a decade ago. Although the birth of hospitalist medicine in internal medicine is usually dated to the mid-1990s, it is fair to say that it was an etymologic birth—the beginning of the use of the term "hospitalist" rather than the origin of the concept of practicing medicine predominantly in an in-patient acute care setting. Dividing medical care into hospital and outpatient practice was a courageous idea at the time, however. The emphasis in medical education and medical care was on continuity: hospitalist medicine was a serious challenge to the nearly unchallengeable belief that the primary care physician was the best person to care for the patient in nearly any location—office, hospital, intensive care unit, home, or long-term care facility. Although "continuity" remains a potent buzzword in medical education,¹ in the reality of contemporary patient care, continuity has become an attenuated, if not quaint, idea. Technology is the continuity of the future—not primary care physicians.

As a word, "hospitalist" leaves a lot to be desired. For example, the pressure to have some sort of formal board recognition² would be helped if there were an organ (an "ology" like cardiology), a defined marker such as age, an "iatrics" like geriatrics or pediatrics, or a recognized body of knowledge with accompanying hardware, like cardiopulmonary support for critical care medicine (but that may be a bit of a stretch). It is hard to get around the fact that a hospital is a place. And hospitalists are internists (nearly always) who practice in that place. But as we all know well, without some type of exam or certification, third-party payers do not recognize one physician as different from any other similarly trained physician.

The distinction between profession and career is based, according to the Oxford English Dictionary (the great squelcher of arguments), on the existence of specialized knowledge of a subject, field, or science, and is usually applied to occupations that involve prolonged academic training and a formal qualification. For the time being, hospital medicine is a career, not a profession, and will probably remain one. Having your own textbooks and a journal may help, but I cannot convince myself that there is a definable hospitalology or hospitaliatrics. The chance the august American Board of Internal Medicine (ABIM) will create a certificate of added qualifications as it did for geriatrics, or another subspecialty as it did for critical care medicine seems remote, at least for the near future. It does not really matter, however (except perhaps for annoying the poor hospitalists who, like geriatricians 2 decades ago, get tired of having people ask them what they do). The fact is that hospitalists are here to stay, and that is a good thing.

There are 2 basic models of hospitalists: One is the older, private practice model of a large group of internists who rotate hospital care in blocks of time among members of their group (eg, every fourth month Dr X takes care of our group's patients in the hospital[s] where they have been admitted), or a group of internists who devote a disproportionate amount of time to in-patient care, because they have arranged with other primary care physicians to take care of all their hospitalized patients. The more relevant model today, however, is the one in which hospitalist groups are composed of internists who are employed by a hospital or by a hospitalist company—some of which contract with scores of hospitals in many states. Members of the group practice predominantly or, more often now exclusively, in a single hospital.

What's the Attraction?

Originally, hospitalists tended to be male and recent residency graduates with a propensity to work too hard and burn out.3 The demographics and probably physician turnover have been rapidly changing, as physicians have become more interested in the peculiar concept of "a better lifestyle." The nearly bottomless demand for hospitalists to this point has also led to more competitive salaries for hospitalists compared with primary care physicians, and opportunities for a salaried job without the risk and investment entailed in setting up a private practice. A regular paycheck and no new debt are especially attractive to recent graduates who typically have a significant educational debt.

There has been a peculiar and perhaps unanticipated spin-off of the growing demand for hospitalists over the past decade, with their presumably better lifestyle and higher salaries. They are recruited largely from the pool of general internists who a decade ago would have been office-based primary care physicians. Until the demand—which is generally projected to level off at 20,000 hospitalists in a few years—wanes, I believe we can expect primary care general internal medicine to compete rather poorly for our newly graduated internists.⁴

What Do Hospitalists Do?

Basically, what medical residents do on hospital rotations.^5,6 The actual content of a hospitalist's job is determined less by training than by the needs of the hospital in which he or she practices; a hospitalist who works in several hospitals could have very different job responsibilities in each of them. About 70% of their patient care is indirect (communications, paperwork, and follow-up) and only about 20% is face-to-face.⁵ Although this study was done at a university hospital, there is no reason to think that it does not represent the workday of the community-based hospitalist. And although most hospitalists may disagree with me, I am unconvinced by Wachter's² conclusion that the content of hospital practice meets the ABIM's criteria for "focused recognition through its maintenance of certification program."

Is It Worth It for the Hospital?

Hospital CEOs certainly think so, and they are not an easy group to schmooze.⁷ The literature has consistently shown that hospitalists increase efficiency by reducing length of stay by about 10% to 20% and reducing cost per case by about $800,⁸ and more recent studies have borne that out. The effect on quality has not been consistent, and the skeptic would conclude that differences in quality relate as much to how good your attending physicians were in the first place as to how good the hospitalists who replace them are. All else being equal, patients would rather have their primary care physician take care of them in the hospital, but they generally don't mind having hospitalists if they are assured of good communication between the hospitalist and their primary care physician.⁹

The Future?

I think we are seeing it. The fast pace of office practice is not going to slow, and the demands for efficiency in our expensive hospitals will not abate. Mandatory programs are not welcomed by doctors, however, and there remains great concern that by giving up hospital practice, general internists will lose skills and professional standing (legitimate concerns, I believe). Still, the positive effects of reducing the burden of after-hours call, eliminating responsibility for caring for the growing multitude of acutely ill unassigned patients, and reducing disruptions in office practice by removing a major source (ie, calls from the hospital) have consistently resulted in a reduced hassle factor and a greater efficiency in primary care office practice.

Whether profession or career, hospitalist medicine appears to have evolved into a good job that is appreciated by hospitals and primary care physicians (and tolerated by patients). The irony may be that the improved lifestyle of the beleaguered primary care internist that results from collaborating with hospitalists could attract some burned-out hospitalists back to office practice.

References

1. Hirsh DA, Ogur B, Thibault GE, et al. "Continuity" as an organizing principle for clinical education reform. N Engl J Med. 2007;356:858-866.
2. Wachter RM. What will board certification be and mean for hospitalists? J Hosp Med. 2007;2:102-104.
3. Hoff TH, Whitcomb WF, Williams K, et al. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161:851-858.
4. McCue J. Rural primary care: has the canary stopped singing? Intern Med World Report. 2007;22(2):19.
5. O'Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1:88-93.
6. Glasheen JJ, Epstein KR, Siegal E, et al. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167:727-728.
7. Exline JL, Topping S, Baxter C. CEO's perceptions of hospitalists: diffusion of the strategy. Hosp Top. 2004;82:18-24.
8. Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis. Med Care Res Rev. 2005;62:379-406.
9. Hruby M, Pantilat SZ, Lo B. How do patients view the role of the primary care physician in inpatient care? Am J Med. 2001;111(11B):21S-25S.