Hospitalists on the Move
Published: Dec 12, 2012
Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
Hospital medicine is helping to redesign health care. In synch with accountable care organizations (ACOs), this specialty plays an important role in coordinating customized patient care from admission to discharge. Now recognized by the ABIM through its Focused Practice in Hospital Medicine program, being a hospitalist is no longer just for those in early career transition from residency to private practice. With opportunities to develop treatment protocols, plan institutional financial and global health initiatives, as well as be in demand throughout the United States with flexible work schedules, hospital medicine is a career choice for those wanting to practice in a fast-paced acute-care setting and achieve work-family balance.
— John A. Fromson, M.D.
Health reform and hospitals' changing needs spur continued evolution — and new career opportunities — in this fast-growing physician sector
By Bonnie Darves, a Seattle-based freelance health care writer
The career trajectory that Julia Wright, MD, has accomplished in just six years makes “upwardly mobile” sound like an understatement. She has served as chief of the hospital medicine division at the University of Wisconsin, was tapped as senior medical officer for a leading national hospitalist company and, in short order, given the post of regional medical director. Then two years ago, she became business unit president for Cogent HMG, the country’s largest private hospitalist company.
In many ways, Dr. Wright exemplifies the fast-track evolution of the field that she has chosen for her career. “If you like change, hospital medicine is a good career choice because hospitalists have been in the forefront of change since the beginning,” said Dr. Wright. She alludes to the field’s 15-year history and its meteoric growth from a smattering of internists in the mid-1990s who cared for primary care physicians’ hospitalized patients in the hospital, to approximately 34,000 hospitalists working in more than 70 percent of U.S. hospitals in 2012.
Perhaps the most significant change in the last decade has been the clear shift in hospital medicine from being primarily a way station between residency and fellowship, or a short-term pursuit for physicians seeking their ideal practice opportunity, to a viable first-choice career. The field’s important position in medicine has been further validated in recent years by the American Board of Internal Medicine’s creation of the Focused Practice in Hospital Medicine program, which sets standards for the specific knowledge and skills of internists who practice exclusively in the hospital (see "Focused Practice Designation Recognizes Hospitalists’ Skill Set, Experience" section below).
“It’s been very fulfilling to see — and to be part of — this evolution and maturation, and to watch hospitalists moving into leadership positions in their institutions,” Dr. Wright said.
That’s not to suggest that there are quieter times ahead for the field. Although hospital medicine has continually adapted to meet hospitals’ needs higher quality, more efficient care of medical inpatients, and, increasingly, specialist colleagues’ needs for co-management of surgical and intensive care-unit patients, another chapter is unfolding. As health reform and market forces place new demands on hospitals, hospitalists are positioned to take their care model to a new level. They soon will play a leading role — and may even become the key force, some industry watchers maintain — in reshaping how care is delivered in hospitals.
“Young physicians interested in hospital medicine must embrace the fact that an important part of the job today is working on the systems aspects of care, to improve care processes,” said Shaun Frost, MD, president of the Society of Hospital Medicine and associate medical director for Care Delivery Systems at HealthPartners Health Plan in Minneapolis, Minnesota. “Hospital medicine has always seen itself as a specialty whose role is to help hospitals deliver better care. But with health care reform evolving, hospitalists will have an even larger role in organizing care delivery.”
In particular, hospitalists will be charged with identifying new ways to streamline care and reduce costs, and they’ll become a key resource, Dr. Frost maintains, for orchestrating patient transitions throughout the care continuum — from pre-admission to the post-discharge phase. “As hospitals move toward [structures] such as accountable care organizations (ACOs), health systems are being forced to think outside the box,” he said, “and they’re asking hospitalists to help. What that means is that a hospitalist’s job description, particularly in an ACO, may include directing or restructuring those care transitions.”
Hospitals tap hospitalists to help lead change
John Combes, MD, senior vice president of the American Hospital Association, sees hospitalists as key players in the transitions ahead as hospitals adjust to mandates from the government and demands of the marketplace. “Given the health reform environment and the way things are changing in care delivery, we are looking to hospitalists to help us improve efficiency and move toward value-based care,” Dr. Combes said. “I think that there is a tremendous career path ahead for physicians who choose hospital medicine, especially for those who understand the flaws of the current system.”
In many hospitals, administrators already are actively engaging hospitalists to design interventions to prevent or reduce readmissions, Dr. Combes explained. At the earlier end of the spectrum, he added, hospitals are eyeing hospitalists to help develop customized care planning for patients at high risk for developing complications during their hospitalization.
“Hospitalists are in a good position to lead these types of initiatives, and I think that the young physicians who are experienced or interested in these areas will find many opportunities to move into leadership roles,” Dr. Combes said, “because the division between the clinical side and the administrative side is going to erode.”
Dr. Wright concurs, based on her experience. She predicts that the forces affecting hospitals will lead to rapidly expanding roles for hospitalists and, in tandem, new career opportunities. Over the next five to 10 years, hospitalists increasingly will move beyond simply providing direct patient care, she explains, to standardizing care throughout the hospital and developing institution-wide protocols. “We will see hospitalists not only integrating systems of care within their hospitals but also working in the pre- and post-discharge areas with physicians who are providing care in those settings,” she said. “I think we’ll also see hospitalists becoming more involved in high-level financial issues at their hospitals.”
In the hospital setting, hospitalists are increasingly working collaboratively with their specialist counterparts to improve the care of certain vulnerable populations, such as patients with psychiatric illness or addiction disorders. And that is creating new career paths for hospitalists who seek to broaden their clinical practice focus. Hospitalist David Frenz, MD, medical director of addiction medicine at HealthEast Care System in St. Paul, Minnesota, predicts that hospitals will recognize the value of more tightly integrating hospital medicine and behavioral health or psychiatry services to improve outcomes and reduce costs.
“There will be many opportunities for hospitalists coming into the field to help hospitals and physicians move beyond these silos to provide better-coordinated care,” said Dr. Frenz, whose program was a forerunner in integrating hospitalists in behavioral health services.
In many areas of the country, hospitalists have been steadily moving into these hybrid roles. Health plans are recognizing, for example, that the hospitalist skill set is a valuable asset in efforts to ensure appropriate utilization of inpatient medical services, and are hiring hospitalists to assist in related initiatives. Hospitalists also are being tapped to assist with population-health improvement programs targeting the chronic diseases that frequently lead to readmissions.
In a nascent development, hospitalists are participating in global health initiatives as well. As illustration of the latter trend, the University of California-San Francisco now offers a global health hospital medicine fellowship; and Northwestern University in Chicago operates a designated global health hospitalist program.
The appeal: Many career paths, much flexibility
For physicians who are primarily interested in direct patient care, and who enjoy the particular challenges and rewards of practicing in the fast-paced acute-care setting, the hospitalist field continues to offers the benefits that have made it so popular. These include a wide variety of positions in every geographic region and in hospitals of all sizes. The other perennial draw is the potential for flexible work schedules that enable time for family activities and frequent travel.
Hospitalists can choose to work in intensive time blocks, and then take off several days in a row, or can work in the now common seven days on, seven off (every other week) schedule. In many hospitals, more traditional schedules — weekdays only, or five-consecutive-day blocks — are available. Hospitalists also can practice primarily as nocturnists, or as locum tenens if they wish to combine medicine and travel.
“There are so many iterations and types of schedules now that I tell residents that they should be able to pretty much craft their own schedule, especially in a large program,” said Darlene Tad-y, MD, associate program director for internal medicine at the University of Colorado in Denver and director of the hospitalist training program. “It’s a rewarding and satisfying career, especially now that so many new opportunities are emerging for hospitalists.”
Dr. Tad-y, who co-chairs the Society of Hospital Medicine (SHM) Physicians in Training Committee, said that despite these opportunities, she often finds herself countering the misconception among residents and medical students that being a hospitalist is a strictly clinical job. “I explain that there are many avenues for focusing on quality improvement work, and that the opportunities in academic medicine for hospitalists are broadening as well,” she explained. “Many program clerkship directors are now hospitalists, for example.”
Katherine Chretien, MD, is among them. An associate professor of medicine at George Washington University, she is chief of the hospitalist section at the Veterans Affairs Medical Center in Washington, D.C., and also serves as the medicine clerkship director. The combination of responsibilities has made for “a very satisfying career so far,” Dr. Chretien said, and at the same time enables considerable variety because of her exposure to the myriad initiatives underway at the VA.
“We’re looking at many of the same themes as community hospitals and academic centers — such as utilization, costs and quality of care,” Dr. Chretien explained. “We even have hospitalists here who specialize in QI projects, because we’re the natural players in that area.”
Dr. Chretien, in her personal life, exemplifies the growing trend toward combining hospital medicine with other pursuits. In 2008, she started the Mothers in Medicine blog as a forum for sharing her own frustrations about the difficulty of obtaining work-life balance. (She has three children.) The blog has been not only rewarding but also far more popular than she expected; the site tallies between 25,000 and 30,000 page views a month.
“We have contributors from all over the world, and from all of the specialties,” Dr. Chretien said. Her “sideline” also has led to other writing opportunities, including a humor column and, more recently, a spot on the USA Today board of contributors.
Academic hospitalist roles evolving, too
For physicians who enjoy teaching and clinical practice as hospitalists, the opportunities are expanding rapidly, in both academic centers and large community hospitals. In many academic centers, as the distinction between teaching and non-teaching hospitalist services diminishes, even hospitalists who haven’t elected academic careers from the outset may find opportunities to teach part time or occasionally.
As hospital medicine evolves, many hospitalists are carving out interesting niches in the academic setting, according to Vineet Arora, MD, associate program director in internal medicine at the University of Chicago and a longtime hospitalist.
“I think one of the most important material changes we have seen is that hospital medicine has developed its own research and educational agenda and platform,” said Dr. Arora, who co-chairs SHM’s Physicians in Training Committee with Dr. Tad-y. “Trainees who are attracted to hospital medicine are often attracted by the opportunity to make systems improvements, in addition to the mentors they encounter.” The field’s expanding non-clinical opportunities are emerging as another drawing card. Hospitalists are increasingly become involved in informatics, quality improvement, and medical education, and partner with administration in a variety of areas, Dr. Arora explains.
“We’re seeing a lot of creative hybrid hospitalist positions emerging now — ones that combine hospital medicine with an advocacy or public policy role, or with business,” Dr. Arora said. “That’s attractive to young physicians who want to explore a range of options.”
Leadership opportunities abound
Hospitalists, who have become the mainstay in many hospitals because of their constant presence, are rapidly moving into leadership roles, Dr. Frost points out. Today, it’s not uncommon to find hospitalists serving as chief of staff or VP of medical affairs, or leading key hospital committees or health system quality improvement initiatives. And incrementally, they are moving into administrative leadership and governmental positions as well. “We’re seeing hospitalists become chief medical officers and hospital CEOs, and assume top leadership roles in health systems,” he said, noting that the Centers for Medicare and Medicaid Services recently named hospitalist Patrick Conway, MD, as its chief medical officer.
These recent developments, and the evolution of hospital medicine as a desirable career and hospitalists as an indispensable component of inpatient care delivery, are particularly gratifying to John R. Nelson, MD, co-founder of the hospitalist movement. “It’s been fascinating, actually, to watch how the field has developed and to have been involved in all of this,” said Dr. Nelson, who started the hospitalist program at Overlake Hospital in Bellevue, Washington, where he still practices, and is co-founder of Nelson Flores Hospital Medicine Consultants.
“It’s also very cool to see so many other specialties — neurology, general surgery, gastroenterology, and obstetrics, for example — adopting the hospitalist model,” he said. “That’s been one of the big surprises for me, to watch the movement gain momentum outside of hospital medicine.”
Focused Practice Designation Recognizes Hospitalists’ Skill Set, Experience
In response to both the growth of the hospitalist sector and requests from hospital medicine leaders to create a pathway for recognizing inpatient physicians’ competence, the American Board of Internal Medicine (ABIM) in 2009 created the Focused Practice in Hospital Medicine Maintenance of Certification (MOC) program.
The program involves an intensive pre-qualification process — including at least three years of direct patient care in the hospital, or a combination of patient care and systems quality improvement work--and rigorous self-evaluation of medical knowledge and practice performance. To earn the designation, physicians must pass the ABIM Hospital Medicine Maintenance of Certification examination.
“The intent of the program is to recognize the particular skill set of hospitalists in this new and emerging discipline in internal medicine, and to provide hospitalists a means of demonstrating their competence through a robust program of assessment,” said Eric Holmboe, MD, chief medical officer and senior vice president of the American Board of Internal Medicine.
As of November 2012, nearly 500 physicians had enrolled in the program, and 268 had earned the FPHM designation. Based on survey results, the time commitment for obtaining FPHM certification is similar to that required for the MOC program.
For additional information on the program, go to http://www.abim.org/specialty/hospital-medicine.aspx.