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Hospital medicine: the new minor leagues?

April 2008

Has hospitalist medicine become the minor leagues of specialty medicine? There are plenty of ways to interpret this question, but my major concern is this: What does it mean when our field is increasingly populated by doctors who are in the pre-fellowship period of their careers? More and more, I find that my best applicants are looking for one-year positions prior to jumping into other fields, which range from cardiology to rheumatology.

I can certainly understand the appeal for pre-specialty physicians of working a year as a hospitalist. When I was a resident, I thought it was premature to be applying for a fellowship early in my second year, when I–and a lot of my colleagues–hadn’t really gravitated yet to one subspecialty.

Working as a hospitalist is a good way to strengthen a curriculum vitae, particularly if you can complete research initiated while in residency. And, for cash-strapped physicians staring at $100,000 or more of debt, a year or two making “real” money goes a long way to alleviate student-loan anxiety.

But all of this begs the question: How is a program affected when its staff consists of talented but transient hospitalists? And is a one-year tour of duty a good model for hospital medicine?

I recall reading a paper a few years back that drew the following conclusion: It takes two years for a hospitalist to become fully efficient. For a rookie hospitalist, efficiency means learning how to strike that all-important balance between doing a thorough workup and knowing when it is OK, for the sake of financial viability, to triage some of the diagnostic workup to the outpatient arena.

Learning this balance is more of an art than a science, and it takes time and experience. On top of that, I’d say that it takes at least six months before a hospitalist feels comfortable in an unfamiliar environment, from creating a sense of collegiality among consultants and nurses to learning a new IT system. All of this adds up to high price that programs have to pay if they continually lose hospitalists, just as these individuals begin to master their craft.

Another concern: Transient hospitalists create an image problem for career hospitalists, non-hospitalist physicians and nurses alike. Seasoned hospitalists cannot help but wonder what it means to be a hospitalist if more and more of their colleagues are simply filling a gap between fellowships, as a way station before a “real” job.

Non-hospitalists, in the face of here-today-gone-tomorrow attendings, will surely begin to question the vitality of the specialty. That’s particularly true when the exodus seems to indicate that top doctors choose to do specialty training, while others grow up to be hospitalists.

Here’s another concern I’ve heard: Migrant hospitalists may be more likely to accept working conditions that career hospitalists know will lead ultimately to dissatisfaction and burnout. A friend recently interviewed at a program where physicians cover Sundays as a 24-hour in-house shift. The one-year hospitalists in the group actually favored that arrangement, but most of us would find it intolerable. A final and related concern: One-year hospitalists may be “cheap” labor. Administrators whose eyes are glued to the P&L balance sheet may not be able to appreciate the many benefits that experienced–and deservedly more expensive–hospitalists offer.

Ultimately, this conversation about transient hospitalists may be academic. Because there simply are not enough hospitalists to go around, I suspect that transient hospitalists will continue to be the norm, not the exception.

And then again, you never know. Originally, I thought I would do a pulmonary fellowship after a year or two of being a hospitalist. Eight years later, I am very happy that I never did.