The hospitalist field presents rapidly growing opportunities, evidenced by expectations that hospitalists will outnumber cardiologists in the near future. Although early growth was driven largely by financial pressures on hospitals, more recent catalysts include the need to improve quality and safety and to comply with resident duty-hour restrictions. In addition to traditional clinical responsibilities, hospitalists will increasingly embrace additional clinical and nonclinical roles in the coming years and will serve as change agents, hospital leaders, and experts in quality improvement activities and in research initiatives on improving the delivery of inpatient care. Residency program graduates and practicing physicians can obtain the skills and training to prepare themselves for these roles and varied career tracks.

Over the past decade, major transformations in the delivery of inpatient care have made for an exciting and rapidly changing atmosphere for hospitals, physicians, and patients. Before that time, a hospitalized patient’s primary care provider would likely have assumed responsibility for his or her care. The physician would have visited in the morning before clinic hours and perhaps again at the end of the day. There were similar models in academic settings, where supervising attending physicians might have been available only in the morning and then returned to an outpatient practice, procedure suite, or research laboratory in the afternoon.

Ten years ago, one of us (Dr Wachter) coined the term “hospitalist” to describe the new breed of physician who would serve as an inpatient specialist, assuming responsibility for a patient’s care at the time of admission, managing the patient’s hospitalization, and then facilitating the transition of the patient’s care back to the primary care physician after discharge.¹ Today, there are approximately 12,000 practicing hospitalists. This number is likely to expand to at least 30,000 over the next decade, which would make it a larger specialty than cardiology. These figures are from the Society of Hospital Medicine (SHM), a professional organization established in 1997 that now represents nearly 5000 hospitalist members.² With this growth, and with early research demonstrating the financial and clinical benefits of hospitalists to patients and the healthcare system,³ hospitalists are now assuming increasingly diverse roles in clinical and in nonclinical areas.

In this review, we briefly discuss the history of the hospitalist movement and the supporting evidence behind its growth, the emerging roles for hospitalists, and the future of the specialty. We also provide guidance for those interested in pursuing a hospitalist career, including some “pearls” about where to start.

The Hospitalist Movement: History and Success
Current drivers of the hospitalist movement differ in many regards from those of the past. Initially, financial pressures faced by hospitals led many to embrace hospitalists as a potentially powerful solution. In the 1990s, the growth of managed care and capitation raised the threshold for hospitalization. Accordingly, patients who were admitted to a hospital were more acutely ill, a shift that increased the premium for inpatient expertise and availability. As the American healthcare came to recognize the importance of the “system” in improving efficiency, there was a growing need for physicians who could orchestrate a patient’s hospitalization while simultaneously focusing on improving the system that allowed patients to move through it effectively. These beginnings of the hospitalist field set the stage for its subsequent growth.

Although early motivation for this growth revolved largely around financial exigencies, this relatively narrow motivation eventually gave way to a more complex set of drivers. First, the expansion of the hospitalist field coincided with a new focus on improving the safety and quality of the delivery of the American healthcare, catalyzed by the publication of 2 influential reports from the Institute of Medicine.^4,5 In turn, this push to improve care placed a variety of pressures on hospitals, which included everything from increased regulatory mandates for safety⁶ to public report cards⁷ and pay-for-performance initiatives.⁸ These pressures forced hospitals to engage physicians in addressing these changes, particularly in the inpatient arena.

In teaching hospitals, a second important driving force was the residency duty-hour restrictions mandated by the Accreditation Council for Graduate Medical Education (ACGME).⁹ The 80-hour workweek forced hospitals to search for alternative providers and systems for patient care. Equally important, the new work-hour limits placed a premium on improving patient hand-offs, as well as on teaching and supervision. In most cases, the resulting decrease in patient continuity for residents required greater continuity and attention from supervising attending physicians, a shift from attendings’ traditional roles as primarily teachers, rather than clinical supervisors. Today, hospitalists in teaching hospitals direct and coordinate patient care more actively than in years past, a role valued by institutions, residency programs, and patients.

Despite the seemingly fluid development of the hospitalist movement, the efficacy of hospitalists has long been debated. Advocates argue that the new model improves efficiency and quality, whereas critics raise concerns about the negative impacts on patient continuity and patient satisfaction when they are cared for by hospitalists instead of their primary care physician.

Early studies documented an average decrease in length of hospital stay and costs of 15%, with no detrimental effects on hospital quality or patient satisfaction.³ A more recent review of 21 studies evaluating the merits of hospitalists concluded that hospitalists lowered the total costs of patient care, primarily as a result of shorter hospital stays.¹⁰ Finally, several studies have shown that medical students and residents consider hospitalists to be better teachers than nonhospitalist attending physicians.^11-14

Thus, overall, the literature supports the economic and educational benefits of hospitalists, while showing no adverse effects—and possibly some improvements—in quality. Although many organizational factors contribute to site-to-site variations, even many skeptics have come to believe that the model is likely to enhance efficiency and perhaps quality as well.

Hospitalist Programs and Roles
The hospitalist road map (Figure) offers many opportunities to choose a fork for a given career path. Although many hospitalist programs share similar organizational structures, each has a different flavor, and prospective hospitalists have a wide range from which to choose. Traditionally, one of the first selection criteria involves teaching versus nonteaching settings, with their attendant differences in group structure, call requirements, need for shift work, and salary. Teaching programs offer hospitalists educational opportunities, supervising responsibilities, academic requirements (eg, research or scholarly work), and an environment that is constantly balancing educational goals with service needs. With growing pressure on training programs to comply with residency duty-hour limits, hospitalists are being asked to take on more responsibilities, which often include the creation of nonteaching services within teaching hospitals. This need has spurred a remarkable growth of hospitalist programs in teaching institutions over the past few years.

Nonteaching hospitalist programs—although not participating to the same degree in educational missions (but many “nonteaching” academic hospitalists instruct medical students and perform other teaching roles)—are also taking on increasingly diverse roles. These include the development of new or improved clinical services (eg, palliative care and medical consultation), involvement in continuing medical education, commitment to quality improvement and patient safety efforts, and engagement with institution-based operational initiatives (eg, patient flow, bed control management).

Adoption of information technology (IT) systems, including computerized physician order entry and electronic medical records, is another rapidly growing area and one in which hospitalists are certain to play a critical role. The IT revolution in healthcare is still in its nascent stage, and physician involvement will be key at each step of the process—a process known best by those who practice and understand the nuances of inpatient care delivery.

Present Challenges and the Future
Despite the growing opportunities in the field of hospitalist medicine, it is important to understand existing challenges. A more complete review of these challenges has been published,¹⁵ but 2 in particular are worth discussing. The first is the financial viability of hospitalist groups, since most rely on significant financial support from their institutions (or organizations). Although billing effectively certainly represents an important aspect of optimizing clinical revenues, hospitalists provide services that cannot be adequately compensated by traditional fee-for-service systems. Creating bed capacity, engaging in quality improvement activities, spending time to coordinate a patient’s care to prevent readmission and prolonged hospital stays—all these are vital functions for hospitals and all are fulfilled by hospitalists and not “covered services.” As a result, many hospital leaders view hospitalists as an investment rather than a cost. But this financial dependence creates somewhat more uncertainty than in fields where professional fee revenues are sufficient to generate market-level salaries.

One of the likely trends that will help justify the “business case” for hospitalists is tying compensation to quality and safety measures (eg, improving rates of pneumococcal vaccine administration), administrative measures (eg, length of stay, discharge time of day, readmission rates), or other measures driven by a particular hospital’s needs. In addition, hospitalists’ value will be measured by the expanding roles and services they provide, many of which directly or indirectly enhance the financial performance and patient care outcomes at an institution.

The second challenge, which certainly relates to the first, is the possibility of hospitalist burnout. Many skeptics suggest that a hospitalist career is suitable only for young physicians. They have a difficult time envisioning a mid- or late-career hospitalist. There is little evidence of burnout thus far. A study published in 2001 found that 13% of hospitalists met the criteria for “burnout” and another 25% were at risk for burnout—rates that compare favorably with other medical specialties.¹⁶ At the time this study was published, the authors had speculated that the relative novelty of the hospitalist specialty may, in part, be responsible for the relatively low burnout rates.

One of the factors that could contribute to hospitalist burnout is a mismatch between optimal staffing and patient volumes. A hospitalist caring for too many patients may generate more clinical revenue, but at the cost of prolonged patient hospitalization, since the hospitalist cannot take the steps to facilitate a timely discharge under such circumstances. Another potential contributor to hospitalist burnout is the ever-increasing expectations of employers, hospitals, consultants, primary care physicians, and payors—which one of us (Dr Wachter) recently dubbed, “Life as a Swiss Army Knife.”¹⁷ These expectations, though validating the need for hospitalists, also increase risk for burnout if not managed carefully and proactively.

Given the successful evolution of the hospitalist model, the next logical step would be to create a distinct hospital medicine subspecialty, with its own board certification. In the past 30 years, emergency medicine and critical care medicine have both emerged as models for similar “site-specific” generalist specialties whose practices are defined by their location. Hospital medicine already convenes for large annual meetings, has its own textbook¹⁸ and journals (the Journal of Hospital Medicine, launched in early 2006, and The Hospitalist), and its own thriving specialty society, SHM, which recently developed the core competencies of hospitalists,¹⁹ drawing on a survey of its members that demonstrated how hospitalists’ work encompasses clinical care and a set of skills (care coordination, end-of-life care, and communication) that are not emphasized in traditional medical training.²⁰ It is likely that specific residency tracks that focus on hospitalists’ clinical and nonclinical competencies will emerge.²¹ Some form of board certification is currently being actively contemplated.

Is a Hospitalist Career for You?
A hospitalist career represents the interface between managing critically ill patients and doing so from a generalist perspective, with a strong emphasis on coordinating a patient’s care and directing improvements in the healthcare system. In contrast to the continuity relationships that define their primary care colleagues’ professional lives, hospitalists form intense and important relationships with patients and their families over the course of a hospital stay. They also enjoy collaborative relationships with their subspecialty colleagues, hospital staff (eg, nurses, case managers), and administrators and, in teaching hospitals, with fellows, residents, and medical students.

How Do I Become a Hospitalist?
During residency training
The scenario is a familiar one: you are sitting with your fellow residents early in your second or third year, contemplating the proverbial “What are you going to do after residency?” question. Many of your colleagues have already completed fellowship applications, others have confirmed the need to “take a year off and figure it out,” and the remaining ones plan to move to their geographic location of choice and then “find a job.” If you are considering a career in hospital medicine, this decision should not be made by default. Rather, you should take advantage of ways to learn more about the field during residency training.

Whether you train in internal medicine, pediatrics, or family medicine, you share the common thread of having gone through a “generalist” training experience. If you have found that you truly enjoy being a generalist but prefer doing so in the hospital environment, you are practically a hospitalist already. If possible, aspiring hospitalists should request work with a faculty hospitalist during an inpatient ward month in their residency years. Ask the hospitalist these questions: “How do you like your job? What do you do in your nonclinical time? Do you have the respect of your colleagues and hospital personnel? Any downsides to the career?” If your training program does not involve hospitalists, an elective that would allow this exposure might be helpful. As an alternative, you might also consider an elective that provides project-oriented experience working with a hospitalist on a quality-improvement effort.

Regardless of the hospitalist model at your home institution, we do recommend asking hospitalists of all types about their jobs and roles, whether they work in academic, community, or county settings (former graduates of your training program are always a nice target). One way to do this efficiently is to attend a regional or national SHM meeting. In one meeting you will learn about the issues facing hospitalists nationally; network with others, both in training and in practice; and, quite likely, will hear of job opportunities. Furthermore, you will most likely appreciate the enthusiasm and energy of this rapidly growing and evolving field.

In addition to annual conferences, SHM maintains a website with a career resource center and publications.² These resources can help the aspiring hospitalist learn more about the field and shape personal interests during residency and beyond.

Looking for your first job
The graduating resident interested in pursuing a hospitalist career need only pick up any major medical journal to see the vast number of available jobs. A review of 4 journals found that the proportion of employment advertisements for hospitalists increased from 1% in 1996 to 12% in 2004.²² In addition to positions at individual institutions, several regional and national hospitalist staffing companies assist in the recruiting and matching of interested graduates with positions across the country. But even though landing a hospitalist position is relatively easy, it is critical to find a job that fits your personal interests and geographic desires, and that maximizes the potential for sustainable career satisfaction.

What should you ask when researching or interviewing for hospitalist jobs? Good questions include: “How many shifts per month? How many hours per shift? How many nights and weekends per month? How many consecutive days will I work (eg, 7 on/7 off model versus other systems of scheduling)?” And, “What is the typical patient load for each hospitalist?” This type of framework will allow you to comparison shop among positions.

In terms of salary, it is important to understand the nuances of your future pay. In some models you are employed by a group, practice, or hospital, with an expectation to work a defined number of shifts for a stated salary. In other models you may get paid per shift, with a minimum number required to qualify for benefits. Other groups will offer additional compensation for each procedure and each new admission, and still others may offer incentive programs for bonuses (eg, individual and group-based incentives). On the surface, a $165,000 salary may seem more attractive than a $150,000 salary, but if the latter comes with incentives or a schedule and patient load that better suits your desires, we discourage your decision making to rely on simply, “Who will pay me more.” Also consider the possibility of salary growth. For example, academic jobs typically start at relatively low salaries but tend to have good benefits and relatively consistent raises with seniority. You want to build a career, not a quick recipe for burnout.

Finally, one of the most important questions to ask hospitalists you meet (particularly in academic settings) is, “What was your job when you started, and how is it different now?” The answer to this question will provide tremendous insight into how a hospitalist group has grown, and how hospitalists have assumed new roles or have altered their jobs because of new responsibilities (including child rearing). Furthermore, understanding the evolution of the group as well as the individual positions can help determine whether the group is well managed and is likely to succeed over time.

Role for additional training
Although many residency graduates are perfectly qualified to pursue a hospitalist career immediately, some may consider additional training. Fellowships are particularly important for aspiring academic hospitalists seeking to develop a research niche or nonclinical expertise. For individuals who are seeking a nonclinical niche or to hone their clinical and teaching skills, a chief residency or clinical fellowship experience can help build expertise and confidence before the first hospitalist position.

A growing number of hospitalist fellowship programs offer specific clinical, teaching, and research skills and training. An earlier review outlined the 16 available hospitalist fellowship programs.²³ Furthermore, those interested in healthcare policy, organizational behavior and change, quality improvement, informatics, and other areas in which hospitalists interface with their organizations can obtain helpful skills through dedicated course work, workshops, and seminars. This may include a general medicine fellowship, and/or a master’s degree in public health, clinical epidemiology, health services research, public policy, or business administration. All these options may also be done as part of a fellowship, while on the job, or as a sabbatical of sorts. Finally, you can increasingly seek out concentrated skills training through workshops organized by academic medical centers, SHM,² or other healthcare organizations (eg, the Institute for Healthcare Improvement at www.ihi.org).

Unlike traditional specialty fellowships, which attract residents immediately after training, many of the training options mentioned can remain attractive even after beginning a hospitalist career. You could begin with a primarily clinical focus and then seek additional training to develop new skills. Hospitalists are already emerging as leaders in their respective institutions, and this kind of additional training will be vital to those who wish to assume these varied research, quality, and management roles.

Conclusion
Graduates of residency programs will enjoy the continued growth of the field as well as the expansion of the roles available for hospitalists in clinical and in nonclinical settings. The combination of national initiatives focused on improving the quality and safety of inpatient care with ongoing changes in the way we educate and train future residents will provide hospitalists with prominent change-agent roles, both locally and nationally. We believe this will make hospitalist careers increasingly appealing to energetic, committed, and bright graduates across the country.

Self-assessment test
1. How many hospitalists are currently practicing in the United States?
A. 3000
B. 6000
C. 12,000
D. 30,000

2. Which of the following facts likely did NOT contribute to the growth of the hospitalist field?
A. Change in payment for inpatient services
B. Managed care
C. The Institute of Medicine report on building a safer healthcare system
D. Resident work-hour limits

3. All the following statements about hospitalists are true, except:
A. They are a distinct subspecialty with their own board certification
B. They help decrease the length of hospitalizations
C. Burnout rates compare favorably with those of other specialties
D. They help lower patient care costs without sacrificing patient satisfaction

4. Hospitalists’ salary may be structured around all the following conditions, except:
A. Working a predefined number of shifts each month
B. Direct payments from referring primary care providers
C. Additional compensation for each procedure
D. Additional compensation for each new admission

5. How many hospitalist fellowship programs are currently available?
A. 4
B. 8
C. 16
D. 24

(Answers at end of reference list)

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 Society for Hospital Medicine. About SHM. Available at www.hospitalmedicine.org. Accessed October 31, 2006.

3. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002; 287:487-494.

4. Institute of Medicine, Committee on Quality of Health Care in America. Kohn L, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

5. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

6. Wachter RM. The end of the beginning: patient safety five years after ‘To Err Is Human.’ Health Aff (Millwood). 2004; (suppl web exclusives):W4-534–W4-545.

7. Williams SC, Schmaltz SP, Morton DJ, et al. Quality of care in US hospitals as reflected by standardized measures, 2002-2004. N Engl J Med. 2005; 353:255-264.

8. Thrall JH. The emerging role of pay-for-performance contracting for health care services. Radiology. 2004; 233:637-640.

9. Weinstein DF. Duty hours for resident physicians”--”tough choices for teaching hospitals. N Engl J Med. 2002; 347:1275-1278.

10. 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.

11. Hunter AJ, Desai SS, Harrison RA, et al. Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations. Acad Med. 2004; 79:78-82.

12. Landrigan CP, Muret-Wagstaff S, Chiang VW, et al. Effect of a pediatric hospitalist system on housestaff education and experience. Arch Pediatr Adolesc Med. 2002; 156:877-883.

13. Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med. 2004; 164: 1866-1871.

14. Kripalani S, Pope AC, Rask K, et al. Hospitalists as teachers. J Gen Intern Med. 2004; 19:8-15.

15. Wachter RM. Hospitalists in the United States”--”mission accomplished or work in progress? N Engl J Med. 2004; 350:1935-1936.

16. 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.

17. Wachter RM. The Hospitalist Movement 10 Years Later: Life as a Swiss Army Knife [Webcast video editorial]. Available at www.medscape.com/viewarticle/540918. Accessed October 27, 2006.

18. Wachter RM, Goldman L, Hollander H. Hospital Medicine. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005.

19. Pistoria MJ, Amin AN, Dressler DD, et al, eds. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1(suppl 1):S2-S95.

20. Plauth WH III, Pantilat SZ, Wachter RM, et al. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247-254.

21. Hauer KE, Flanders SA, Wachter RM. Training future hospitalists. West J Med. 1999; 171:367-370.

22. Auerbach AD, Chlouber R, Singler J, et al. Trends in market demand for internal medicine 1999 to 2004: an analysis of physician job advertisements. J Gen Intern Med. 2006; 21:1079-1085.

23. Ranji SR, Rosenman DJ, Amin AN, et al. Hospital medicine fellowships: works in progress [online extra]. Am J Med. 2006; 119: 72.e1-72.e7.

Answers: 1. C; 2. A; 3. A; 4. B; 5. C.