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Hospitalists a growing alternative to office practice

For internists looking for nontraditional career paths, inpatient-only medicine is one of several choices

From the January 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Christine Wiebe

Janet Grayson, MD, knew there was a problem. After all her years of training, she wasn't happy practicing medicine. She felt her residency had not prepared her for office practice, and she didn't like caring for "the worried well" whose problems seemed never-ending.

Meanwhile, the large group practice she belonged to outside Minneapolis was studying how to improve physicians' work schedules, which included having individuals manage the practice's hospitalized patients. When the group decided to hire full-time hospital doctors to ease their inpatient duties, Dr. Grayson took one of the jobs.

The change meant longer hours and more stress for about the same pay, but Dr. Grayson had found her niche. "I was finally doing what I was trained to do," she said. "It was like the weight of the world had been lifted from my shoulders."

Dr. Grayson is part of a growing cadre of internists called "hospitalists," physicians who devote most of their professional time to inpatient care. She also represents a growing number of internists who are looking for—and finding—alternatives to traditional office-based practice.

According to experts, there has never been a better time for internists looking for new career options, even within the field of general medicine. While most new generalists still stick with private practice, which alone offers a myriad of choices, others are discovering special niches. The trend is being driven by physicians' desire for more predictable hours, and by the desire to master a smaller portion of the daunting body of knowledge in general medicine.

Niches open to internists include full-time nursing home positions, military practice and work at correctional facilities. Some new internists also work initially as locum tenens, taking short-term assignments through placement agencies so they can "try out" jobs before settling on one.

Promising path?

But one of the fastest growing, most promising new career paths for internists is that of the hospitalist. About 1,500 internists are working as hospitalists, according to John R. Nelson, ACP Member, a hospitalist in Gainesville, Fla. and a founder of the new National Association of Inpatient Physicians. (For more information on this group, call 352-333-5113, or see story on page 2.) With 10 years of experience in the field, Dr. Nelson may be the closest thing to a veteran hospitalist. Even he has difficulty defining the job, though, because such varied models exist across the country.

Most hospitalists work as employees of a hospital or group practice, although some are self-employed or work as partners in a group practice. Some work strictly in the hospital, while others have more hybrid jobs that include rotations in outpatient care. Some work at teaching hospitals and supervise residents and students, while others work at community hospitals and have no teaching duties.

Typically, hospitalists' income is comparable to internists' in traditional practices, said Dr. Nelson, who has been conducting an informal survey on the topic. The exception, he said, may be the first hospitalists in a given market, who may be able to command higher salaries.

A handful of residency programs already offer special training tracks in inpatient medicine, and more are studying that option. Ironically, traditional training programs that have been criticized for having housestaff spend too much time in the hospital now find themselves ideally suited to produce hospitalists.

According to Robert M. Wachter, FACP, who helped coin the term "hospitalist," the hospitalist track has been an important development for the specialty of internal medicine. "In the past, many trainees who liked acute care went on to subspecialty training," he said, whereas those interested in general medicine usually went into primary care. "The hospitalist job has created an intersection that never existed before."

The job market for hospitalists is currently wide open, but Dr. Wachter, associate chair of the department of medicine at the University of California, San Francisco (UCSF), predicted that it may begin to narrow in just a few years. At UCSF, for instance, only eight applicants competed for two hospitalist jobs two years ago; last year, a similar opening generated 100 applications.

Staying out of the hospital

On the flip side, the growing number of hospitalists is allowing some physicians to focus almost exclusively on outpatient care, particularly at practices that contract with hospitals to care for their inpatients.

Working as an outpatient-only physician offers physicians the freedom to concentrate in the office without being called away to the hospital, said Hobie Collins, a consultant with the Medical Group Management Association in Englewood, Colo. He noted that outpatient-only physicians are expected to see more patients in lieu of their hospital duties, which can be just as demanding as trips to the hospital. Experts also say that physicians who give up hospital care eventually could lose those skills, whereas most hospitalists could still return to an office practice.

For those reasons, the outpatient-only option may be best suited to residents who put more value on lifestyle than on a complex practice, said Kirk Mathews from Cjeka & Company, a physician-recruiting firm. Without hospital duties, office-based physicians have more predictable hours, which may be more conducive to family life, he said. That makes some of those jobs "plum" positions that are more competitive than traditional practice options.

Other options

Even with the growth of hospitalists, there is still demand for young internists in nearly all kinds of practice settings. Nursing homes, for instance, often look for someone with geriatric training, but they may consider a general internist with a demonstrated interest, Mr. Matthews said.

But the overwhelming message from experts is that new internists are not limited by traditional practice options. A variety of other paths exist that may be more suited to their interests and abilities.

Christine Wiebe of Providence, Utah, writes frequently on issues related to medical residency.


If you want to be a hospitalist...

SAN FRANCISCO—At a conference on the emerging role of hospitalists in American health care last month, speakers said that residents interested in hospitalist jobs need to be adept at all the procedures they are likely to do in the hospital, from managing ventilators to putting in central lines. But there are also other important skills that budding hospitalists should focus on. They include the following:

  • Quality. Because hospitalists are likely to be responsible for quality improvement activities, learn how to develop and implement guidelines and clinical pathways, as well as measure quality and outcomes measurement.
  • Communication. Hospitalists have to be "killer communicators," said Lee Newcomer, FACP, chief medical officer at United Health Care in Minneapolis. Learn to talk clearly, frequently and naturally with patients, their families, referring primary care doctors and other hospital staff.
  • Computing. Hone your medical computing and informatics knowledge. Up-to-date skills are essential because hospitalists will be at the heart of making electronic medical records work.
  • Outpatient skills. Also keep up to date on outpatient skills not only to help primary care physicians, but also, according to Dr. Newcomer, to direct patients to appropriate post-hospital care.

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