UO > Feature > Hospital Medicine: The Next Great Specialty?

If you happened to blink, you may not have noticed that a new medical specialty has exploded onto the United States health-care scene. “Exploded” is probably the most apt description of the way hospital medicine has grown from concept to full-blown specialty in a matter of just a few years. Although some physicians were placing an emphasis in their practices on hospitalized patients, the word “hospitalist” wasn’t used until a New England Journal of Medicine article in 1996. Today, an Internet search for “hospitalist” returns more than 69,000 entries.

Since the practice of hospital, or inpatient, medicine concentrates on the general medical care of hospitalized patients, it departs from the framework of most specialties because it is organized around a site of care. Hospital-based physicians have long practiced in Europe and Canada, but now there are an estimated 8,000 hospitalists in the United States. The Society of Hospital Medicine (SHM) projects the ranks will reach 30,000 by the end of the decade.

Cliff Hall, MD, the director of the inpatient care service program at Good Samaritan Regional Medical Center in Corvallis, Oregon, has seen the evolution of hospital medicine and welcomes it.

An internist since completing his residency in 1972, Hall was in private practice for 29 years. He retired in 2001 only to be asked four months later to help Good Samaritan set up its hospitalist program.

“I was trained in pulmonary disease and critical care, so a good portion of my career had been with critically ill hospital patients,” Hall says. When he first came out of retirement, he worked part time, but, “It became apparent that for credibility and communication, I needed to do clinical as well as administrative work.” So, he became a hospitalist himself, and the first patients were admitted to the hospitalist program in 2002. There are now five full-time hospitalists on staff, plus a few part-timers, and Hall has been able to cut back to less than a full schedule.

Hospitalists usually work on a shift-based or call-based staffing model, or a combination of the two. Some programs are staffed 24 hours by hospitalists, and in others internists or residents cover the night shift, with hospitalists on call. Some hospitalists work block schedules, with one week on, the next week off. At Good Samaritan, hospitalist coverage is 24 hours, with three overlapping shifts, and the physicians work up to seven consecutive days.

“We have three physicians working every 24 hours,” Hall says. “One works 12 hours, one 10 hours and one eight hours, and they overlap. When we set this up, we knew that the majority of physicians in private practice may work from 48 to 96 hours continuously, including on-call work, and we felt strongly that we would never allow that. We never wanted anyone to work longer than 12 straight hours.”

A typical day for the day-shift hospitalist at Good Samaritan begins at 7 a.m. with a meeting to discuss patient cases with the overnight staffer, who stays two more hours to assist in the transition. For the next 10 hours, until 5 p.m., the day hospitalist might see a total of 10 to 15 patients, including two or three new admissions and two to four discharges. She might have one or two internal medicine consults for surgical colleagues. The most common patient conditions the hospitalist will see include heart attack, stroke, congestive heart failure, and pneumonia.

The second shift hospitalist comes in at 2 p.m., with three hours of overlap, and works until 10 p.m. The night person comes in at 9 p.m. and works until 9 a.m. If all is quiet, he may get a few hours of sleep in the hospital. “The overlap is good for communication, good for continuity,” says Hall. “Patient care is our highest priority.”

The scheduling appeals especially to young physicians who place a premium on having more balance between their professional and family responsibilities. Most hospitalists at Good Samaritan are in their late 30s. The average age nationwide is 37.

Hall says the great majority of patients appreciate having a doctor available at all times. “We have a great group of hospitalists. They’re pleasant, well-trained, the patients love them.” But every so often, a patient is disgruntled that his primary physician “‘isn’t here when I need him,’” says Hall.

“But you know, with the average hospital stay three to three and a half days and primary care doctors only on call several nights a week, the patient is not likely to be admitted by his or her doctor anyway. Medicine has changed,” Hall says. “Continuity of care by the primary care physician is almost a myth. Discontinuity of care is always a factor, but you can overcome it with good communication.”

There are several different employment arrangements for inpatient physicians. They can be hospital employees, work for a large or small private practice medical group, a multi-specialty group, or in an academic setting.

According to the SHM’s 2004 Compensation and Productivity Survey of 300 hospital medicine group leaders and administrators representing 2,131 hospitalists, there are several compensation models being used by hospital medicine programs. A mix of straight salary, productivity bonus, and incentives is the most popular method, at 47 percent of those surveyed. Compensation based on salary alone is used by 41 percent and 12 percent use a model of straight productivity and incentives. Hospitalists employed by hospitals tend to be more likely to receive straight salary.

The survey, which was released in April, showed a median total compensation for a hospitalist of $155,000. Those working for multi-state hospitalist-only groups have a median compensation of $169,000, while academic hospitalists earn a median income of $135,000.

Most hospitalists are trained in general internal medicine. A small percentage of the physicians are trained in an internal medicine subspecialty, usually pulmonology or critical care, and some are family practice doctors. A few are pediatricians. Currently, there is no board certification for hospital medicine, but there is some movement toward recognition as a subspecialty.

Hospitals, medical groups, and managed care plans have all jumped on the inpatient medicine bandwagon, though some more enthusiastically than others. Virtually all of the nation’s leading medical centers have developed hospital medicine programs, and many managed care companies have preferred provider agreements with hospital medicine physicians or groups. They promote the arrangements to primary care physicians, who are then free to decide whether to refer patients to the hospitalists.

A variety of factors in the health-care industry are driving the trend to use hospitalists. As primary care physicians will attest, more care is being handled on an outpatient basis, so only the most complex and acutely ill patients get hospitalized.

“When I started my practice 30 years ago,” says the 61-year-old Hall, “I typically had six to eight patients in the hospital at any given time. Now, you might only have one or two, and they’re much sicker.”

According to a study by the Advisory Board, a health-care industry research and analysis company based in Washington, DC, the typical primary care doctor is unlikely to see any one condition requiring hospitalization more than three times per year. The theory goes that hospitalists, who handle acute disorders routinely, therefore bring a greater degree of expertise and are more able to recognize and diagnose unusual disorders and respond rapidly to changes in patients’ conditions. Primary care physicians can benefit from the arrangement because they have more time to focus on outpatient care with the majority of their patients.

Repeating the all-important mantra of lower costs, SHM says care by hospitalists can reduce hospital stays by more than 30 percent and hospital costs by as much as 20 percent. The Advisory Board cites data that shorter stays and lower costs per case occur across every geographic region when hospitalists are used.

This makes sense to Hall. “It used to be there were two decision points in the day—morning rounds and evening rounds. With hospitalists on site, there are multiple decision points all day long. Test results can be reviewed sooner and decisions made. Everything gets done quicker.”

Continuity of care is another advantage cited by SHM, noting that hospitalists help improve the communication in “shift handoffs” between day and evening nurses and coordinate the care provided by the many professionals involved with each patient.

Mary Jo Gorman, MD spent 10 years in critical care medicine before becoming a hospitalist in 1997. She says the work itself initially drew her to the specialty, and she thinks most hospitalists have similar feelings. “It’s more fast-paced and you can see patients improve rapidly,” says Gorman. “They come in extremely sick, you help them get better, and they leave. It appeals to a lot of people.”

Gorman wasn’t content simply to be a practicing physician. She put her business skills to work when she was a critical care practitioner, or intensivist, and started a hospital-based critical care group in St. Louis in 1991. The group’s practice grew rapidly and Gorman began looking for another entrepreneurial pursuit. She became interested in hospital medicine and started a hospitalist group, also in St. Louis.

In 1999, that group merged with IPC - The Hospitalist Company, which is based in North Hollywood, California. IPC is now the largest independent hospitalist company in the country with 300 full-time employee physicians in 10 markets. Today, Gorman is the chief medical officer for IPC and has recently had to give up her practice because of administrative responsibilities. She is also on the board of the SHM.

Gorman says the average salary of hospitalists who work for IPC is $178,380, which includes a base salary and a productivity plan. Productivity is based upon the number of patient encounters and the revenue per encounter. She said IPC has a strong resident recruitment program and hires local physicians as needed, adding that many times physicians choose to become hospitalists because they are looking for a change. IPC physicians work primarily on a call-based staffing basis.

She predicts the number of hospitalists will continue to grow for three main reasons: economic, quality of care, and demographics. “It is more economical for outpatient primary care physicians to let someone else see the one or two patients they might have in the hospital,” says Gorman. “Then there is the issue of patient care. We need to re-engineer what is going on in hospitals. It is important that a physician lead efforts to improve patient care and outcomes. Third is the aging population, which is also becoming more obese. There is going to be a demand for more health-care services, including hospitalization.”

Sylvia McKean, MD, the medical director of the Brigham and Women’s Hospital/Faulkner Hospitalist Program in Boston, is a physician who has settled on hospital medicine after sampling a variety of specialties throughout her career.

“I really like the care of inpatients,” she says. “I think people who do this simply like taking care of patients in the hospital.” Her program’s 16 hospitalists serve two hospitals: Brigham and Women’s is a tertiary-care facility and Faulkner is a community teaching hospital.

McKean sees a distinct career advantage in the skill portability of hospitalists. “Much like an emergency room physician, you don’t have to worry about leaving patients behind. It is much harder professionally to leave patients that you have been seeing for five or 10 years. Hospitalists can move from hospital to hospital without losing a patient panel.” She added that hospitalists are in demand at “hospitals everywhere in the country,” including her own program.