Shaun Frost, MD, FACP, chair of SHM’s Membership Committee and regional medical director for Cogent Healthcare in St. Paul, Minn., considers whether the inclusion of various subspecialists fits with the SHM’s definition of hospitalists. “If you’re looking strictly at ‘definition,’ SHM considers a hospitalist to be a physician whose primary professional focus is the general medical care of hospitalized patients,” he says. “As hospitalist subspecialists are likely engaging in the management of hypertension, diabetes, chronic lung and cardiac disease, etc., I see no reason to believe that they would not fit the definition of a hospitalist.”
Best Use of Skills?
Although Drs. Wachter and Frost see inclusion of hospitalists on subspecialty services as a positive trend, others warn that hospitalists should be wary about the reasons for their enlistment.
Lauren M. Friedly, MD, a hospitalist at Marin General Hospital in Greenbrae, Calif., believes subspecialty hospitalist jobs are “ultimately untenable for solid, well-trained, dedicated hospitalists.” She developed this view after a frustrating two years on a liver transplant service—where she found she “wasn’t able to practice medicine in a way that was comfortable.”
Dr. Friedly explains that she chose to be a hospitalist because of her experience as a medical student at UCSF and as a resident at California Pacific Medical Center—watching and learning from the originators of the movement, such as Dr. Wachter and Masa Yukimoto, MD, former chief resident. All the reasons she chose hospital medicine—the pace, acuity of patients, ability to revisit patients and ruminate about their problems, and the opportunity to improve the quality of a patient’s in-hospital care by adhering to a “first do no harm” philosophy—were stymied when she became a hepa-hospitalist.
“The problems that can potentially exist in any subspecialty hospitalist group are magnified a hundredfold in a liver transplant program,” she explains. “There were philosophical differences in our approach to medical care of inpatients, and the hospitalists were, in some ways, considered the bottom of the food chain.
“Because of our position relative to the hepatologists and transplant surgeons, we were not provided the autonomy nor the resources with which to accomplish any of these things. For example, decreasing length of stay by discharging patients efficiently, which to a well-trained hospitalist may mean less risk of exposure to nosocomial infections and iatrogenic complications, was not necessarily valued by the transplant surgeons and hepatologists. Less is often more for a well-trained hospitalist, but this sentiment is in direct conflict with the maximalist approach used in transplant medicine.”
Satisfying in the Long Run?
Perhaps the most important question about subspecialization for the hospitalist is whether joining a subspecialist service is a good fit. Dr. Frost believes it’s important to consider whether a career in a subspecialty service would be satisfying in the long run. “For many of us,” he explains, “one main reason we chose to pursue careers in general internal medicine, general pediatrics, or family practice is that we enjoy variety. Personally, for example, I know that I would quickly become bored with solely focusing on one organ system or one special patient population. Therefore, I believe that there is probably a limited group of folks who would enjoy exclusively restricting the scope of their hospital medicine practice to a specific subspecialty area.”
Still, Dr. Friedly admits she will miss the challenges of dealing with complex pathology. On the liver transplant service, for instance, she cared for patients with complex gastrointestinal issues, including cancers. But, due to her time on that specialized service, she now finds herself having to refresh her more general internal medicine skills.