The hospitalist is a relatively new medical job title which was introduced in the United States of America and later spread to Canada, Australia, New Zealand and more recently to the Middle East. It is now the USA's fastest growing medical speciality. But many doctors are still confused about what the hospitalist actually does and whether a hospitalist job could be right for them. This article provides an overview of this increasingly common physician role and the job search process.

What is Hospital Medicine?

In 1977 the specialty of hospital medicine emerged in the United States of America (USA)and was first defined by the University of Chicago as "the field of internal medicine which concentrates on the practice of care for hospitalised patients." Traditionally in patient medical care was managed by the patient's primary care family physician supplemented by attending internists who were self employed fee for service physicians working from their own practices. This arrangement had a weakness. The bulk of the family physician's work was focused on the treatment of out patients in the community and the additional burden of caring for patients during hospital stays, which could be lengthy, posed an untenable strain.

Additionally, increasing pressure on healthcare systems to optimise value by providing the best quality care for the lowest possible cost spurred the re-engineering of models of care and the development of hospital medicine as a distinct branch of general internal medicine with in-patient care provided by salaried physicians working in conjunction with nurses, specialists, and physician assistants. This new cadre of inpatient clinicians were known as hospitalists, and were a creation of necessity.

Definition of the Hospitalist

As the field of hospital medicine expanded, the term "hospitalist" was used as the job title of its medical practitioners and in 1996,

the New England Journal of Medicine created a formal definition of the hospitalist as "a physician whose primary professional focus is the general medical care of hospitalised patients with activities including patient care, teaching, research, and leadership related to The Society of Hospital Medicine (SHM), the professional association of hospitalists."

The hospitalist model began with the assumption that having a single inpatient generalist responsible for overseeing hospital care would improve value. When studies showed that the use of hospitalists did decrease costs, largely through decreased length of hospital stay, medical centres agreed to subsidise their salaries, creating the economic engine that drove growth in this new model of care.

Other factors which contributed to the demand for hospitalists were the willingness of family physicians to relinquish the care of their hospital patients, the hospital workforce gap created by restrictions to resident physicians’ duty hours since 2003 and the  absence of additional licensing or training requirements beyond residency required for hospitalist jobs. This guaranteed the immediate availability of a large labour pool, and graduating residents, many practicing family physicians, and trainees with a generalist bent, who might have pursued primary care in the past, flocked to hospitalist work.

Since 1996, the number of hospitalists has grown rapidly and there are over 50,000 hospitalists in the United States, making it the fastest-growing medical specialty in the country. As an indication of the growth of the speciality, here are some figures:

• 2000: Fewer than 1,000 hospitalists
• 2012: Just under 30,000 hospitalists
• 2019: Over 44,000 hospitalists
• 2020: More than 60,000 hospitalists 
  

Following this explosive growth a new title of nocturnist was implemented for hospitalists who work exclusively at night.

Scope of Practice of the Hospitalist - The Job Description

In the USA, hospitalists work in more than 80% of hospitals with over 200 beds and increasingly in smaller and rural hospitals as well. Their responsibilities encompass almost every section of the hospital, including the emergency department, general medical department, surgical postoperative field, blood bank, and obstetrics. The flexibility of a hospitalist’s job description allows the physician to bridge the gaps in hospital organisation.

Today, a patient admitted to a  hospital in the USA is highly likely to receive care from a hospitalist, the fastest growing medical profession in modern history. Hospitalists have also expanded their scope of practice beyond caring for adult general medical patients. They are increasingly comanaging surgical patients and taking ownership of hospital care in specialties ranging from neurology to obstetrics. Hospitalists are no longer restricted to the hospital: the model of a site-based generalist coordinating the care of complex patients is now employed in some nursing and long-term care facilities, and in rehabilitation centres.

The hospitalist's duties may be grouped into three categories:

Clinical

Hospitalists provide inpatient care in a variety of settings, including medical wards, paediatric wards, emergency rooms, intensive care units, and rehabilitation centers. They assess patients, formulate treatment plans and manage and coordinate patient care throughout treatment.  Hospitalists receive patient referrals from primary care providers (PCPs), emergency physicians, and/or subspecialists, and provide consultations to patients admitted to orthopaedic, surgical, and rehabilitation services. They manage and treat a significant range of complex and comorbid disease conditions and their scope of practice is increasing. Paediatric hospitalists are now performing the same role in children's wards as hospitalists in general medicine. 

The rapid expansion of hospitalists has advanced the aims of reducing hospital costs while preserving or improving quality of care. Hospitalist care is associated with shorter hospital stays, lower cost per stay, and the same or improved quality metrics and outcomes (eg readmission, mortality).

Medical Education and Research

In addition to clinical work, hospitalists have academic roles which cover the majority of training services in hospitals including the training, mentorship and supervision of resident medical officers. They also form an important part of medical research teams at local, state, and national levels.

For resident medical officers, hospitalists provide unified oversight for an entire group of patients. Prior to the era of hospitalists, things were less coordinated. Hospital based residents were either trying to connect with office based family physicians about hospital patients or were effectively cobbling together recommendations made by various inpatient subspecialists. In a teaching environment, residents and students increasingly have dedicated inpatient supervisors available day and night, and report a better educational experience as a result.

Hospital operations

Hospitalists are often involved in developing and managing aspects of hospital operations, such as quality improvement and inpatient flow. As leaders, hospitalists invigorate all facets of the health-care system with the goals of reducing hospital stays and patient re-admissions, reducing costs of healthcare and enhancing the patient experience of the healthcare system. Initiatives pioneered by hospitalists include:

• shortening the duration of hospital admissions
• effective management of patient transfer from hospital to home or another post- acute healthcare facility
• reduction in post discharge hospital re-admission
• establishment of post-discharge clinics in health centres for vital post-discharge health assessments, prescriptions, and wound care.
• scheduling for patient assessment and management within 3 days of hospital discharge
• evaluation of readmissions or dissection of readmission to identify the reason behind readmission.
  

Medical Training of Hospitalists

After internship or pre-vocational training, junior doctors intending to become hospitalists enter residency programs in internal medicine most commonly, or family medicine or paediatrics. Upon completion of residency, no further qualifications, or training is required and doctors can apply for hospitalist jobs. 

Whilst residents in internal / general medicine and paediatrics have extensive experience with hospital patients, family medicine residents focus predominantly on outpatient care over inpatient care, so many chose to do a Hospitalist Fellowship to help them manage complexities dealt by hospitalists, although they are not mandatory for hospitalist jobs.

In Australia and New Zealand, postgraduate medical training in internal general medicine and paediatrics is overseen by the Royal Australasian College of Physicians (RACP). The Royal Australian College of General Practitioners manages training in general practice. There are 4 stages to medical education at undergraduate and postgraduate levels.

The Internal Medicine Society of Australia and New Zealand represents the needs of doctors working in Internal Medicine (also known as General Medicine or General and Acute Care Medicine) across Australia, Aotearoa New Zealand and the Pacific, of which there are medical and trainee specialists in hospitals and private practice. IMSANZ membership is open to all consultant physicians with an interest in the specialty, and basic and advanced physician trainees practising in general medicine, acute medicine or chronic disease.

Hospitalist Salaries and Compensation

Hospitalists are salaried physicians with few opportunities for fee for service practice. The average hospitalist salary in the United States is around $336,000 per year, with a range of $216,000–$403,000. However, salaries can vary depending on a number of factors, including: 

• Location: The highest paying cities for hospitalists include Bangor, ME, Terre Haute, IN, and Springfield, MA. The lowest paying region is the Northeast. 
• Practice environment: Hospitalists working in academic hospitals earn more than those working in non-academic hospitals. 
• Gender: Male hospitalists earn about 4% more than female hospitalists. 

Other factors that can affect a hospitalist's salary include: 

• Additional pay, such as cash bonuses, commissions, tips, or profit sharing 
• Side gigs, such as locums, moonlighting, urgent care, expert witness work, or medical surveys.

In Australia and New Zealand, hospitalists are paid in accordance with the salary scales of other salaried medical specialists.

The Advantages of Being a Hospitalist

Working as a hospitalist has become an increasingly popular career choice for physicians interested in a flexible, well-paying medical career. Here are some of the benefits of being a hospitalist to consider:

Job Opportunities Abound for Hospitalists

Hospitalists have some of the highest expected growth rates amongst all the medical specialties and by 2030, the hospitalist profession is expected to grow by 26% in the USA and perhaps by more in other countries where the speciality is just beginning to take off. 

Hospitalists Receive Great Pay

Working as a hospitalist is financially lucrative and generous salaries are often supplemented by bonuses and other financial incentives plus opportunities for work as locums.

Hospitalists Have Scheduling Flexibility

Many doctors chose to work as a hospitalist because of the scheduling flexibility. Shifts average 10-12 hours per day and can be arranged to maximise time off with shifts and leave arranged in blocks. Some hospitalists work as little as 15 shifts per month with extensive time off to pursue other interests.

Hospitalists Have High Job Satisfaction

Hospitalists report high levels of job satisfaction attributing this to the ability to schedule work flexibly and practise medicine with high levels of clinical autonomy. Reported burnout rates are lower than in other medical specialities.

The Challenges of Hospitalist Jobs

Although hospitalists have achieved unprecedented growth and tremendous successes very quickly, there are new challenges to address. The pressure for value, the key rationale for hospitalists initially, has now reached even higher levels with governments attempting to restrict spending on healthcare.

The Pressure to Sustain Value

In the modern incarnation of value-based purchasing, success is about far more than cost reduction: there are initiatives to publicly report and provide differential payment on the basis of patients’ experiences, quality, safety, access and efficiency. Because hospitalists practise in the most expensive segment of the healthcare system, they are perfectly positioned to improve value, and must sustain success in such work.

The Coordination of Care with Family Physicians and Specialists

The co-ordination of care between hospitalists, other specialists and family physicians remains an established challenge. In theory, hospitalists have the potential to be the main managers of the inpatient setting, accountable for coordinating appropriate transitions of care between in-hospital levels of care and different platforms of care delivery, from the post-acute facility to the clinic to the community. However, the results of studies of that coordinating role have been disappointing. Studies have shown that direct communication between hospitalists and family physicians occurred less than 20% of the time, and discharge summaries were available at only a third of follow-up visits, often adversely affecting the quality of care.

The substantial rise in electronic health record systems since 2009 provides the infrastructure for streamlined communication, including immediate visibility of discharge summaries to family physicians within integrated systems and automatic delivery to outside providers. However hospitalists continue to face the challenges created by an absence of standards for discharge summaries, lagging ability to transfer data between electronic health record (EHR) systems, and unclear responsibilities for care transitions.

Impact on Medical Education and Resident Medical Officer Training

Although the overall educational experience of resident medical officers has been improved by hospitalists, the perfect balance between autonomy and around the clock supervision remains elusive. Hospitalist involvement and oversight are a positive response to the challenges imposed by duty hour restrictions of residents but residents report less involvement in patient care and decreasing autonomy impairing their ability to act as independent medical practitioners.

Lack of Time for Academic Advancement

Academic advancement is a challenge for the hospitalists who practise in academic settings. Time for scholarship, such as research and publication, competes with clinical education, quality improvement, and non-teaching patient care. More than half of adult academic hospitalists’ work is spent on clinical activity including direct delivery of care, which leaves little time for academic pursuits.

The Future of Hospitalists

Healthcare systems around the world are under financial pressures to lower the costs of patient care and design new models of service delivery. Of all the changes taking place, there are two emerging areas as ripe for significant hospitalist contribution.

The Digital Health Movement: Data Science and Medical Informatics

The digital health movement increasingly links patients with healthcare providers and will continue to facilitate more assessment and care in the community, further reserving care in hospitals and clinics for the sickest patients. Hospitalists are already deeply involved in the growing fields of data science and medical informatics and are thus poised to use improvements in EHRs to help ensure that hospital care is cost-effective and seamlessly integrated with outpatient and community modalities.

The Hospitalist as Integrator and Coordinator

At this time of unprecedented change in healthcare, hospitalists will need to be defined less by the building in which they care for patients, and more by their stewardship of key resources and their role in integrating systems of care. The hospitalist can play the role of coordinator and integrator to ensure appropriate matching of patients to the hospital level of care and the coordination of post-discharge care. New models might even allow some hospitalists to follow the most complex and fragile patients into the outpatient setting in an effort to minimize readmission and provide better continuity of care.

The Hospitalist as Revolutionary

The short history of the hospitalist is a movement born out of reengineering the system and openness to change. The future of hospitalists will depend on the continued ability to reimagine the care model and workforce, to measure outcomes rigorously, and to support care delivery systems that work. The pressure to maximise value will only increase with time. Hospitalists have already improved value in healthcare, and with the spirit of reinvention they might just do it again.

For further information about hospitalist jobs in the international healthcare sector, please contact us or search currently advertised jobs.

Additional Resources

While you continue your medical job search, Odyssey Recruitment provides useful resources to keep your career moving in the right direction. Begin the application process now, and then learn more about how we can help you.

• Medical Jobs by Specialty: Explore medical jobs around the world and learn about the various options and remuneration packages
• Medical Licensing: Check out the licensing requirements for each jurisdiction and how we help you
• Medical Job Search Tips: Use the content here to learn everything you need to know about optimal searches for medical in different geographical locations and the physician recruitment process.