Career resources content posted on NEJM CareerCenter is produced by freelance health care writers as an advertising service of NEJM Group, a division of the Massachusetts Medical Society and should not be construed as coming from, or representing the views of, the New England Journal of Medicine, NEJM Group, or the Massachusetts Medical Society
Hospital medicine has made a lot of headway for a relatively new physician specialty. In just over 25 years, hospitalists have integrated themselves into virtually every aspect of care delivery in hospitals and health systems. From their beginnings as in-hospital internists and family medicine physicians managing the inpatient care of community primary care physicians’ patients, a vital role that persists today, hospitalists are now serving in top leadership positions, commandeering quality improvement initiatives, and developing facility-wide protocols. They’re also comanaging specialists’ patients and delving deep into hospital operations and IT infrastructures to help facilitate systems improvements.
For young physicians contemplating where they’ll hang their stethoscopes, that broad swath of practice possibilities is a large part of the specialty’s appeal, according to Rohit Uppal, MD, MBA, chief clinical officer for TeamHealth Hospitalist Services in Orlando, Florida. “The lure of hospitalist practice is that physicians are exposed to aspects of medicine that they might not encounter elsewhere and also have the opportunity to learn leadership skills on the job,” Dr. Rohal said. “There’s really no other specialty that exposes you to the breadth of medicine.”
For example, hospitalists may work with colleagues in the ER and critical care, cardiology, neurology, orthopedics, and, in limited cases, trauma specialists, Dr. Rohal said. In a newer role, serve as physician advisers assessing the status of and optimal care setting for an even broader range of patients.
Increasingly, Dr. Rohal said, hospitalists are also integrally involved in managing transitions of care and the systems issues that challenge hospitals. Hospitalists are moving into informatics, quality improvement (QI), care management, telehealth, and services utilization. “The possibilities, in terms of career paths for hospitalists, are robust — and growing. Hospitalists were already being viewed as leaders in the hospital before the pandemic hit. Their impressive performance during COVID-19 cemented that,” said Dr. Rohal, whose company employs approximately 3,000 hospitalists at 200 U.S. sites.
Jerome C. Siy, MD, a past president of the Society of Hospital Medicine and division medical director of hospital-based specialties for HealthPartners in Minneapolis, Minnesota, agrees that hospitalists’ role in helping hospitals navigate the pandemic has revealed even more ways, particularly in telehealth, that hospital medicine physicians’ expertise might bring value.
Today, Dr. Siy said, hospitalists are being tapped for key roles in operations — improving electronic health records (EHRs) and consulting on informatics innovations. “We’re even seeing hospitalists getting involved in emerging areas such as predictive analytics, patient risk scoring, population health, and nascent hospital-at-home programs,” he said.
“As an early-career hospitalist, you have to invest in growing your knowledge base and carving out time to do committee work if you want to pursue a leadership role. There are new skill sets to learn, and that takes time.”
–Jerome C. Siy, MD, HealthPartners
Per Danielsson, MD, a hospitalist who has helped hospitals pilot hospital-at-home (HAH) programs, which seek to provide hospital-level care for older patients who may be at risk for functional decline or other problems associated with long inpatient stays if they remain in the hospital. He views the model as a win-win for hospitals and the hospitalists who clinically manage such patients. Hospitalists bring valuable experience to HAH programs because of their extensive expertise in triaging acutely ill patients, working in multidisciplinary teams, and, recently, delivering telemedicine. In a June 2019 article in the Journal of Hospital Medicine, Dr. Danielsson predicted that HAH hospitalists might one day become a subspecialty of their own.
In a field that continues to grow steadily, and at a time when hospitals are amenable to placing talented hospitalists in just about any administrative role they’re interested in, there’s no shortage of both traditional practice opportunities and jobs that combine clinical and administrative work. Today, an estimated 50,000 hospitalists practice in the United States, and the specialty experienced a 50 percent growth rate between 2012 and 2019, according to a study published in Journal of Hospital Medicine in August 2022.
What early-career hospitalists are seeking
Even if the sky is the limit in terms of the myriad ways that hospitalists might configure their clinical careers or combine clinical and administrative work, young physicians considering — or newly entering — the field choose the specialty for its schedule flexibility and its perceived ability to deliver acceptable work/life balance. Ijeoma Carol Nwelue, MD, hospitalist medical director for Baylor Scott & White Health in Fort Worth, Texas, said that even early-career hospitalists aren’t shy about articulating their wish lists.
“Young physicians really want that work/life balance, so schedules are a big issue for them,” she said. “Hospitalists really want their work planned around their life, and they’re expecting not to have to grind it out every day. They want specific fixed hours, but they also want some schedule flexibility when they need it.”
Most hospitalist organizations are attempting to deliver on both fronts. Still, the predominate schedule in the specialty is seven on/seven off (often called a “7/7”) — hospitalists work seven days or nights in a row, followed by seven off — can be a bit of a grind when hospitalists are in the “on” mode, several sources acknowledged. As such, some groups are exploring ways to shorten shifts or otherwise reconfigure schedules. So far, no new standard has emerged.
Young physicians are also looking for ways to serve the community at large. They’re increasingly articulating that desire when they interview for positions, observed Dr. Nwelue, now a veteran of the field. “That’s something we’ve been seeing a lot in recent years — young physicians wanting dedicated time for community outreach, for opportunities to care for or teach patients outside of the hospital setting,” she said. “It’s a common request of this new generation.”
Hospitalists want to teach, too
Also high on the wish list for many young hospitalists are formal or informal teaching opportunities. Although hospitalists in academic medicine have such opportunities as a matter of course, many of those practicing in other settings such as community hospitals also want to spend some time teaching students, residents, or even other colleagues, several sources mentioned. Fortunately, some of the hybrid community hospital/academic institution partnerships that have emerged in the past decade are giving hospitalists a chance to do some teaching and research work in addition to their clinical duties.
In the academic realm, some programs are seeking more expedient pathways for early-career hospitalists move into medical education more quickly — with the objective of providing that career satisfier sooner that it might occur traditionally in competitive academic environments. The University of Chicago, for instance, has pioneered an innovative Passport to Clinical Teaching program, which offers early-career hospitalists access to medical-education opportunities that they can pursue on their own time and can coordinate with their clinical responsibilities.
“A lot of young hospitalists really want to teach and to learn how to become mentors, but it’s challenging because their schedules are heavy clinically. And there is substantial competition for available teaching time in academic environments,” said Elizabeth A. Murphy, MD, assistant professor and director of clinical service development in the University of Chicago’s Section of Hospital Medicine. “What we’ve done is create structured content on becoming a better teacher that hospitalists can access on their own time.”
More limited teaching opportunities are available as a series of Passport rotations in various domains, that cohort members complete within about a year, Dr. Murphy noted. Participants typically spend time at external community hospitals that operate smaller residency programs or host medical students and can use extra hands. Cohort members also learn how to develop continuing medical education (CME) offerings, work in community health clinics, and engage in scholarly activities, among other offerings.
J.P. “John” Murray, MD, a young University of Chicago hospitalist who now directs the hospitalist consult service, maintains that his Passport program participation effectively jumpstarted his career. “I really appreciated the fact that the Passport program is geared toward young hospitalists. It provides lots of opportunities to get involved with residents and medical students, that you might not have otherwise,” Dr. Murray said. “It provides a framework and exposure. It keeps you sharp, and it provides a way to show leadership that you’re very interested in teaching.”
The program started in 2020 and has been well received, Dr. Murphy said. Some of the learners in the initial cohort have received teaching awards or moved into formal teaching roles. “Many hospitalists come into academic medicine because of their favorable training experiences and because they want to be part of what academic medicine does,” Dr. Murphy said. “This offers early-career hospitalists a way to do that, and it gives us a way to harness the mentoring talent we have.”
Telehealth and other practice options
Not surprisingly, because of their varied exposure to many aspects of care delivery and the skills they gained navigating the pandemic, hospitalists have been pivotal in helping hospitals develop and expand telehealth services, to reach both home-bound patients and those in underserved areas. Dr. Siy noted that hospitalists at his organization provide telehealth services at night to outlying hospitals and some reserve a portion of their clinical time to work in rural hospitals.
Dr. Nwelue reported that her organization is piloting a hospitalist-managed telehealth service aimed at managing lower-acuity patients — such as those with infections that require IV antibiotics — who can be safely cared for at home with nursing intervention and hospitalist management. Likewise, in pediatrics, a field that has struggled with capacity as dedicated pediatrics units have shrunk or disappeared, pediatric hospitalists are using telemedicine to expand their reach into rural and smaller hospitals. In particular, pediatric hospitalists are helping such facilities care for lower-acuity young patients that present to their emergency departments.
In recent years, another brand of hospitalist has emerged — transitionalists. These hospitalists focus on the intersection of inpatient care and so-called step-down units. Transitionalists practice either part-time or full-time in post-acute settings such as inpatient rehabilitation facilities, long-term acute-care hospitals, or skilled nursing facilities. In such roles, hospitalists often serve as medical directors.
In another recent development, hospitalists are being tapped as in-house consultants. They’re helping hospitals reduce unnecessary services utilization, assess medical-necessity issues, and streamline post-discharge care continuity. Because hospitalists develop in-depth familiarity with specialists’ practice patterns, test ordering, and patient lengths of stay, hospitals are discovering that hospitalist input pays dividends in both reducing costs and improving care.
Inside hospitals and health systems, organizations are realizing that young tech-savvy hospitalists can also be instrumental in helping them vexing issues. Hospitalists are being tapped to help resolve workflow, IT, and EHR issues that cause inefficiencies — or clinician frustration. “This is an ideal role for early-career hospitalists who have an interest and some expertise in healthcare technology,” said Dr. Siy. “There’s a real demand for such skills.”
One of the big draws in the early years of hospital medicine was that hospitalists working “7/7” schedules could use some of the off-week time to moonlight at local hospitals, perhaps to pay off education debt more rapidly. Although moonlighting isn’t as common as it once was in the field, some hospitalists recognize that they can use their off time to learn new clinical or business skills or even start new ventures.
Mitchell Durante, DO, and Anthony King, DO, hospitalists at BJC Healthcare Christian Hospital in St. Louis, Missouri, recently decided to take advantage of their “7/7” schedule flexibility to start a manipulative medicine clinic that’s open during their off weeks. “It took us a few years to get this up and running, but we’re excited about starting our own business,” Dr. Durante said. “That’s one of the good things about hospital medicine — it gives you the flexibility to do something like this.”
Some hospitalists are also utilizing their newly developed telemedicine skills with their flexibility to carve out opportunities to provide remote care and consultations from home. Others are developing new products or apps, launching podcasts, or serving an independent medical reviewers.
The other ‘ists’—growth of specialty hospitalists is slow, but steady
In the past 15 years, several specialties have made strides in developing inpatient-only services based on the hospitalist model as specialists wrestle with the growing challenges of simultaneously managing a combined outpatient/inpatient practice.
The mainstays of the specialty hospitalist movement remain orthopedics, trauma, anesthesiology, OB/GYN, general surgery, and gastroenterology. But psychiatry and neurology are both increasingly embracing the hospitalist model. In a pioneering venture, the University of California San Francisco has started a Neurohospitalist Division that utilizes a structure similar to the traditional medicine hospitalist model.
Although it’s not uncommon now to see hospitalists as medical directors, chief medical officers, and health-system committee chairs, young hospitalists should understand that both a learning curve and a willingness to devote extra time to small-scale initiatives are prerequisites for obtaining leadership roles, Dr. Siy noted. “As an early-career hospitalist, you have to invest in growing your knowledge base and carving out time to do committee work if you want to pursue a leadership role. There are new skill sets to learn, and that takes time,” he said.
Organizations are trying to accommodate hospitalists’ desires to move into leadership roles without waiting a decade or longer. TeamHealth, for example, operates a designated leadership track for interested hospitalists. And it’s a popular option, according to Dr. Uppal. In addition, the Society of Hospital Medicine’s Leadership Academy offers a wide range of courses that enable hospitalists to obtain leadership and management skills.
“The possibilities, in terms of career paths for hospitalists, are robust — and growing. Hospitalists were already being viewed as leaders in the hospital before the pandemic hit. Their impressive performance during COVID-19 cemented that.”
–Rohit Uppal, MD, TeamHealth Hospital Medicine
For Jessica Porter, MD, a TeamHealth hospitalist medical director at Memorial Hospital Miramar in Hollywood, Florida, the opportunity to lead came early — soon after she completed residency in 2016. She jumped at the chance. “I’d always been interested in leadership, and in contributing, because, well, someone did the same for me. It was a steep learning curve, but I managed it and found I really enjoyed the administrative work,” said Dr. Porter.
Today, although Dr. Porter maintains a full clinical schedule, she manages to fit in most of her administrative duties during her “on” weeks, and receives a stipend for her leadership work. Those duties include managing operations and coaching physicians, representing hospitalists’ interests at hospital management meetings and, as needed, boosting morale. “It’s very gratifying work, and I think it’s important to have a seat at the table when [organizational] decisions are being made,” she said.
Dr. Porter advises young hospitalists who are interested in leadership to look for committee and task force openings, engage in quality improvement initiatives and, above all, express their interest in leadership roles. “If you don’t ask, you don’t get it — whether it’s a raise or a leadership opportunity,” she said.