Hospital medicine: A mile wide and an inch deep?

My last post on the hospitalist as a Swiss Army knife drew this comment:

I agree that being a hospitalist is being a Swiss Army knife, but I happen to think these knives are great. I think what you are confusing is being a hospitalist versus being an internist. If we are to argue that hospitalists are a new specialty, which I think they are, then we have to differentiate ourselves from being a hospital-based internist. An internist sees internal medicine problems. A hospitalist manages hospitalized patients, and is a specialist in providing the highest quality care regardless of the diagnosis. An ER doctor specializes in taking care of patients in an emergency setting regardless of
whether it is medical (MI) or surgical (trauma). Likewise, a hospitalist specializes in caring for hospitalized patients. We should not confuse the concept of the hospitalist, which involves improving the care of all hospitalized patients, from the present reality, which is that we are not adequately staffed to do this. These are 2 separate issues.

This comment gets to the heart of some important questions about the hospitalist movement but it makes assumptions about issues that are far from settled. Is hospital medicine a subspecialty of a parent field (such as internal medicine) or, as the commenter suggests, a new specialty altogether? Other new fields in medicine have resolved this question in different ways. Emergency medicine became its own specialty while critical care medicine became a subspecialty of internal medicine. So far the hospitalist work force has been populated mainly by internists, whose training has traditionally focused on hospital medicine. It’s a good fit for them because it provides the best opportunity to practice in the original concept of internal medicine. Internal medicine’s emphasis on in depth care of severely ill patients with complex medical problems also serves hospitals well.

Hospitalists who care for patients outside the domain of internal medicine are aligning themselves with other appropriate specialties. Pediatric hospitalists, for example, according to the American Academy of Pediatrics are simply hospital based pediatricians. For surgical patients there are surgical hospitalists.

The complexity of the hospital today demands a focused and nuanced approach. I hope hospital medicine doesn’t morph into a single specialty to provide care for all inpatients. If it does it will be a mile wide and only an inch deep. That’s not very promising for career satisfaction and, in my opinion, may not be best for patients.