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Treating the whole hospital

August 2009

Kudos to Dr. Ford for his excellent editorial in the most recent Today’s Hospitalist magazine, which cogently argued that hospitalists are not internists. Far from being a slight of our colleagues, the editorial was an acknowledgement that our profession has carved out a new, important niche for practicing medicine within a hospital.

This got me thinking about the word “hospitalist” and what it means to be one. Of course, any discourse into the etiology of that word begins with Dr. Wachter. I’d be very curious to know how he conceptualized the word when he had his eureka moment all those years ago.

My curiosity–and admittedly, this is completely an academic exercise–arises from the fact that most medical professions derive their name from the organ on which they concentrate. I work on hearts, therefore I am a cardiologist; I study the lung, so I must be a pulmonologist, and so on. Clearly, my analogy is not perfect. So if you were naive about the types of medical subspecialties, when told you would be seen by an intensivist, you might quite reasonably request the perfectionist instead.

But with hospitalists, the logic that my doctor must have a unique set of knowledge based on a specific organ clearly does not apply. Dr. Ford makes an important point by stating the obvious: We in fact treat the hospital, not just the patients we see within it.

How so? You name it. Just about every care coordination project is now being driven by a hospitalist. Same holds true for quality metrics, core measures, patient satisfaction, nursing satisfaction, and on and on.

This is not to say that these projects didn’t exist before, but no one had any real, vested skin in the game related to those projects’ outcomes. This is certainly not true for hospitalists who, by the very nature of their jobs, are interwoven in the fabric of the hospital. And there is no doubt this trend will continue, especially given the fact that many of the top administrative positions will soon be filled by hospitalists.

Of course, we shouldn’t lose sight of the fact that our call for independent recognition is not without reasoned dissent and even potential conflict of interest. While an internist can still practice in an emergency department, good luck to any internist looking for an ED job in all but the most rural areas. Many of us would argue that turning emergency medicine over to ED doctors has improved the delivery of emergency care, but increasing barriers to entry in medicine is just like the effects of increasing entry barriers to in any industry. Those barriers restrict competition and can serve to increase costs.

To no one’s surprise, health care does not function like a classic free market. Still, restricted competition will likely provide upward pressure on hospitalist salaries. So while I agree that a separate hospitalist boarding is long overdue, we should not be blind to the fact that separate boarding will likely serve our financial self-interests.

By itself, this shouldn’t stifle our call for separate specialty status. But it should at least give us reason to proceed with caution. Like it or not, if board certification in hospitalist medicine becomes the norm, traditional internists who seek to practice in the hospital may well be looking to rural America for a job.

Coming full circle, we were taught in medical school to treat not just the disease but the whole patient. The development of hospitalist medicine has perhaps made even this time-tested maxim outdated when it comes to hospitalized patients.

It is no longer good enough to treat the whole patient. Instead, we must treat all that ails the whole hospital. If for no other reason than this one, it is time for our own and separate board certification.