Problem
Jennifer has a mixture that is 4 cups cinnamon and 1 cup sugar, and she wants it to be 3 parts cinnamon to 1 part sugar...
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Caroline Olson wants to be a generalist. Instead of mastering a single organ or disease, the fourth-year medical student at the University of California-San Francisco gets excited about "the whole patient." While she's at it, Olson wants to improve hospitals, too, preventing medical errors, keeping costs down, and raising the quality of care. And she's looking at a medical specialty that will allow her to do both: hospitalist.
After a three-year residency in internal medicine, she'll be stationed on a hospital floor to treat acutely ill patients from the moment they're admitted to the day they're discharged.
The term hospitalist was introduced by Olson's mentor, Robert Wachter, in a 1996 article he cowrote for the New England Journal of Medicine. "Before we existed, the [hospitalized] patient was managed by a roving band of specialists, focusing like a laser on a particular part of their body," says Wachter, now chief of the medical service at UCSF Medical Center. But there was a problem: No single person had "ownership" of the patient.
This meant that specialists sometimes worked without reference to the larger picture. William Atchley Jr., hospitalist and medical director for the division of hospital medicine at Sentara CarePlex Hospital in Hampton, Va., shows just how complicated such cases can be: In treating a patient with end-stage kidney failure, an epidural abscess (an infection at the spot where a catheter is used to inject drugs into the spine), and acute gastrointestinal bleeding, he consulted with specialists in neurosurgery, infectious disease, nephrology, and gastroenterology. As the patient's condition worsened, Atchley helped arrange palliative and hospice care.
Because hospitalists watch patients so closely, they see where the coordination of treatment runs smoothly and where it doesn't. So when Atchley is not treating patients, he works on improving the way his team handles them. "We take research and apply it to the hospital," he says. Figuring out how best to control diabetes, prevent blood clots, and manage pneumonia for inpatients tops the list of challenges for most hospitals, he says.
Hospitalists are in demand. Research suggests that having them on staff results in shorter patient stays and more efficient, more cost-effective care. And there is plenty of room for growth. "We will not fill up the specialty for the next 10 years," says Laurence Wellikson, chief executive officer of the Society of Hospital Medicine.
Controlled chaos
Hospital-based medicine requires dexterity; improvements in outpatient care mean people who need inpatient care are often very sick. "The medicine from that standpoint can be a lot more complex; it's a little more emotionally charged," says Casey Drake, a pediatric hospitalist at Children's Medical Center of Dallas. For her, the demands are offset by the freedom that a hospitalist's set schedule brings. "It allows me to be really intense and challenged yet not just spend all my time being a doctor," she says. When she had an office practice as a general pediatrician, she often shuttled between office appointments and hospitalized children: "I couldn't control the chaos." Now she knows another hospitalist from her team is always on site, monitoring patients when she's not there.
Pay is also a draw. The average starting salary for a hospitalist is $164,000, in line with pediatric oncology or sports medicine. Unlike in other specialties, there's no mandatory hospitalist training or board certification, although the American Board of Internal Medicine is working to recognize the specialty. Right now, the majority of hospitalists-75 percent-are trained in internal medicine, with 11 percent in pediatrics and 3 percent in family medicine, according to the Society of Hospital Medicine.
The emergence of hospitalists over the past 10 years has been driven largely by hospitals themselves: "It's a natural phenomenon," says Ray Curry, executive associate dean at Northwestern University's Feinberg School of Medicine. Primary-care physicians have fewer patients in the hospital than they did 20 years ago, giving them less familiarity with acute illnesses; hospitalists evolved to provide the inpatient care. "It hasn't required too much retooling at the medical student or residency levels," says Curry.
Indeed, most medical students will get face time with hospitalists as part of their third- and fourth-year rotations because the profession is increasingly popular in teaching hospitals, says Wachter. Another way to get exposure is to find a working hospitalist as a mentor, says Olson, who wasn't aware that hospitalists even existed until after her third year, when an adviser suggested she talk to Wachter.
A few hospitalist-specific rotations are starting to become available. In Dallas, for example, the University of Texas Southwestern's Department of Pediatrics offers a pediatric "externship" for third-year medical students at Children's Medical Center. Externs take overnight call and, with guidance, drive the care of patients.
Intending hospitalists need not think their career trajectory is limited to the patient's bedside; experts believe they're positioned to improve inpatient care in general. "Not only do you have to be a well-trained physician clinically; you have to understand all the processes required to move a patient through," says Ron Greeno, chief medical officer at Cogent Healthcare, a company that creates hospitalist programs for client hospitals. The Society of Hospital Medicine's Laurence Wellikson is also optimistic: He believes today's young hospitalists will become tomorrow's hospital directors, chief executive officers, chief medical officers, and chief quality officers.
At UCSF, Olson sees one major requirement: "You have to love both sides of things-both the patients and the setting that patients are in."
Smart Choices
EMERGENCY MEDICINE. "It got a shot in the arm in the post-terrorism era," says S. Ray Mitchell, dean for medical education at Georgetown. Grey's Anatomy and ER didn't hurt either, he says. ANESTHESIOLOGY and CRITICAL CARE are also showing a spike in interest. "You work hard, but there are fixed hours and reimbursement is good," says Jean Robillard, dean of the University of Iowa's Carver College of Medicine.
Insider Tip
Feel drawn to service overseas? Thanks to a $20 million grant from the Bill and Melinda Gates Foundation, the UNIVERSITY OF WASHINGTON School of Medicine and School of Public Health plan a new Department of Global Health, with a joint degree expected to start in fall 2008. The UNIVERSITY OF CALIFORNIA-SAN FRANCISCO and UC-BERKELEY currently offer a track in caring for the urban underserved and seek to expand to other campuses. In the longer term, the University of California system plans a new medical school at the Riverside campus.
Average student debt at the end of med school: $119,131 (public institutions); $149,460 (private)
In 2006, more than 15,000 medical school seniors bid for their residencies; nearly 85% got one of their top three choices.
Average starting salary, family medicine: $143,000 plus; cardiology: $268,000 plus; joint replacement surgery: $407,000 plus
Increase in med school grads recommended by Association of American Medical Colleges: 15% by 2015
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