At a meeting about a job in a Tacoma hospital, Dr. Per Danielsson's interviewer mentioned another position -- one that would allow him to exclusively care for the type of critically ill hospital patients he preferred, and offer him more flexible hours and higher pay.
"I stopped the interview and said, 'I want to talk to the person in charge of that job,' " Danielsson said. "One month later I started as a hospitalist. I just didn't know I was one at the time."
That's because the profession was just taking off and the term wasn't officially coined until the fall of 1996, months after Danielsson started his new job.
Dr. Robert Wachter, a professor and physician at the University of California-San Francisco, wrote an article in the New England Journal of Medicine in 1996 about the emerging role of what he called "hospitalists" -- a new breed of doctor whose main responsibility is caring for hospital patients from the time they're admitted until their discharge, then returning them to their regular physician.
Most Seattle hospitals and clinics began hospitalist programs around 2000, including Swedish Medical Center, the University of Washington, Virginia Mason Medical Center, Evergreen Medical Center, the Polyclinic and Overlake Medical Center. Called the fastest-growing medical specialty in the country by the Society of Hospital Medicine, the estimated number of hospitalists is projected to grow to about 30,000 by 2010 -- from 20,000 in 2008.
They are board certified in internal or family medicine, and the job is just as intense and difficult as any other physician's, hospitalists say.
But the lure often lies in the job's perks. Better pay and more flexible hours make the 100-hour workweeks of a resident or those pursuing a specialty seem unreasonable. A normal hospitalist schedule is seven days on -- usually 12-hour shifts -- and seven days off. They usually work all holidays, but knowing when they are off helps in planning time.
"When I was a resident at Boston City Hospital, I came home early one Saturday and my 3-year-old daughter said 'Daddy came to visit us,' " Danielsson said.
"That line sums up residency" -- and why he enjoys his hospitalist schedule, he said.
Instead of a primary care physician who spends most of his time treating outpatients, a physician who is always in the hospital takes care of critical patients.
"Say a person is really sick with pneumonia: a clinic-based physician may have seen one patient like this per year where a hospitalist may see 20 to 25 in a year," said Danielsson, now the medical director of the Adult Hospitalist Program at Swedish, which has 29 hospitalists. "Our team has a 24-hour presence and we're skilled at all levels."
The position came about as patients' hospital stays became shorter and more intense, and medical organizations pushed to reduce medical errors and deaths, and increase patient safety. Restrictions on the often 100-hour-plus workweeks of residents shifted the day-to-day care to specialists in inpatient care.
"As absurd as those hours may seem, it is restrictive and places a premium on hospitalists" to carry the rest of the workload, said Dr. Paul Sutton, assistant chief of the medical service at the UW Medical Center.
Sutton said he helped begin the eight-person hospitalist program at the UW Medical Center in 2001 so he could teach in a hospital setting. Before that, he spent the majority of his time teaching and treating outpatients.
But as fast as the profession is growing, its future may be uncertain.
Wachter wondered in a 2004 New England Journal of Medicine article whether hospitalists were still a work in progress, raising issues such as physician burnout and funding for hospitalist programs -- what he calls "the field's greatest challenge."
Sutton and Wachter both point to lower reimbursement rates for hospitalists who diagnose and treat patients but don't regularly perform the complex (and higher reimbursed) procedures other specialists do. The gap in salary paid, and what is reimbursed, might not sustain some programs, Sutton said.
"Right now in Seattle, salaries are higher in hospital medicine compared to residents, but whether that will continue, I don't know," he said. "Ten years ago there was a push for primary care physicians and salaries were up and that didn't last."
But others believe hospitalists are here to stay. Dr. John Rosenthal, one of 15 hospitalists at Evergreen Medical Center in Kirkland and former director of its program, said inevitably it will become its own specialty. Evergreen plans to hire five more hospitalists by fall.
The profession is exploding and there's no looking back, Danielsson said.
"I view hospitalization as episodic care," Danielsson said. "Most people wouldn't object to seeing a specialist when something is wrong and we're specialists in hospital medicine."
ABOUT HOSPITALISTS
According to the New England Journal of Medicine, hospitalists are one of the fastest-growing medical specialties.
Hospitalists usually work solely within hospitals, caring for patients from the time they are admitted to the time they are discharged.
Hospitalists work in many areas of the hospital from the ICU and CCU to the ER and medical surgical units. Their primary role is the direct management of inpatients, and in many cases, inpatient physicians now perform most of the tasks once handled by patients' primary care physicians. As the field has evolved, a growing number of hospitalists have begun assuming a care-coordinator's role including the patient's care, discharge planning and patient/family communications.
What benefits can hospitalists offer? Hospitalists work in the hospital every day and are therefore more accessible for hospitalized patients than primary care physicians who spend the majority of their day in a clinic or office.
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