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Hospitalist

John R. Nelson, MD
Co-President,
Society of Hospital Medicine

The term "hospitalist" was first coined in 1996 in an article in the New England Journal of Medicine. Some doctors have been in hospitalist practice since the 70's or 80's, but there has been an explosive growth of this type of practice since the mid 1990's. In fact, very few doctors who finished training in 1996 were aware of this career option, but by the summer of 1998 it had become a very popular career choice. There were an estimated 300 to 400 doctors practicing as hospitalists in 1995, and by late1998 this number had grown to over 3,000. It appears that the rapid growth will continue for the next few years.

In 1998, the demand for hospitalists exceeded the supply of doctors to fill the positions. This desirable situation for those thinking about becoming a hospitalist will probably continue for another year or so, but there may be a glut of hospitalists by the turn of the century.

Some of the most commonly cited reasons for choosing hospitalist practice are as follows:

• the opportunity to focus on inpatient care - many find it more rewarding and stimulating than ambulatory care
• many hospitalists feel like their training provided better preparation for inpatient care than ambulatory care
• hospitalist practice is a simpler business to manage than outpatient private practice
• a hospitalist can be busy on the first day of work and doesn't need to spend months or years building a practice, as can be the case for office-based practice
• greater flexibility in scheduling, e.g., many hospitalists don't follow a typical Monday to Friday schedule

For many, the most significant drawback to hospitalist practice is that it must be a 24 hours a day, 7 days a week enterprise. That creates some challenges in scheduling, and can result in a schedule that requires working more nights and weekends than in outpatient-based practice. But usually this is offset by more weekdays off. It can be similar to the lifestyle of emergency medicine practice in that regard.

Doctors from a variety of training backgrounds are choosing hospitalist practice. In a 1997 survey of hospitalists, 89% came from an internal medicine background. Roughly 6% were trained in family practice and 5% in pediatrics. Of the 89% with an internal medicine background, the majority were general internists, but about 20% were boarded in critical care and 11% in pulmonary medicine. What training is best for a hospitalist will vary depending on the particular practice setting, but most practices look for general internists or pulmonary/critical trained doctors.

Hospitalist incomes vary widely. Typically, it is similar or slightly higher than a doctor with the same training working in a traditional (inpatient and outpatient) practice in the same market. Of course some salary variation is due to different workloads and number of patients seen, but there are other important variables. Because hospitalist practice is a relatively new phenomenon, there is not a large body of data about average salaries. Thus, for a new practice there is a great deal of negotiating room when discussing compensation. A prospective hospitalist with good negotiating skills might be able to do very well.

There are a number of common models for hospitalist practice. They differ primarily in who employs the hospitalist. In order of approximate prevalence, hospitalists are employed by (most to least common):

• hospitals
• managed care organizations
• local medical groups, usually large multispecialty groups
• geographically diverse, for-profit, hospitalist companies
• academic hospitalist practice
• self-employed

Each arrangement has its potential advantages and disadvantages, and no one is clearly better than another. It would be a good idea to do significant "comparison shopping" before signing a contract.

How does one go about finding the right hospitalist practice? Follow conventional job search strategies, including conversations with colleagues, faculty, and friends; and peruse the classified advertisements in medical journals and news publications. Many publications have developed a specific section for hospitalist positions. And be sure to visit various Web sites, many of which have an increasing amount of hospitalist-specific content.

Remember also that it may be possible to start a new hospitalist practice rather than joining an existing one. It is possible to start your own private practice and contract with parties such as hospitals, managed care organizations, or medical groups. Starting a practice from scratch does require a good deal of planning and attention to many organizational details, but still may be easier than starting an office-based practice since there is often no need to rent office space, buy furniture and supplies, and hire a number of employees. Those who have started their own practice, or have been the first to sign an employment agreement with some other entity, usually have a great opportunity to shape the practice as they see fit, and often do better financially.

The Society of Hospital Medicine (SHM) is the medical society for hospitalists. It is an active and rapidly growing organization and a good source of information about hospitalist practice. The Hospitalist newsletter is published regularly and has a classified advertisement in each issue. Membership is open to physicians interested in hospitalist practice, and dues are discounted for those in training. The SHM web site (www.hospitalmedicine.org) is a good source of additional information about hospitalist practice and maintains a list of job opportunities for hospitalists.

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