MOUNT SINAI JOURNAL OF MEDICINE 75:415–417, 2008 415

THEME INTRODUCTION

Hospital Medicine in High-Def:Importance of Defining Mission of

Hospitalist GroupsAndrew Dunn, MD, FACP

Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY

Leaders in the specialty of hospital medicine haveworked to define the key roles that hospitalists canplay in improving the care of hospitalized patients.1,2

This issue of the Mount Sinai Journal of Medicine isdedicated to the variety of services that have cometo be provided by hospitalists, including clinical careof medical patients, medical consultation and coman-agement, perioperative assessment and management,education, expertise in navigating and improving hos-pital systems, and contributions to the bottom line(the business of medicine).3–6 However, having eachindividual hospitalist group define its core missionwithin its hospital is equally as essential as nationalleaders defining roles for hospitalists across the coun-try. Defining these core goals will be beneficial forall parties: the individual hospitalist group members,the hospitalist service, and the hospital.

The expression ‘‘if you have seen 1 hospi-tal medicine program, you have seen 1 hospitalmedicine program’’ concisely portrays the hetero-geneity of hospitalist services across the country.Hospitalist programs may be part of communityhospitals, university hospitals, or teaching hospitalaffiliates; may be a major source of referrals for pri-vate physicians or care only for ‘‘service’’ populations;

Address Correspondence to:

Andrew Dunn, MD, FACPDivision of General Internal

MedicineMount Sinai School of Medicine

New York, NYEmail: andrew.dunn@

mountsinai.org

may have a major role in education and/or hospi-tal quality initiatives or solely provide clinical care;and may or may not include prominent roles in medi-cal consultation, preoperative clinics, comanagement,geriatrics, palliative care, and other clinical services.Given the vast array of possible expectations, thepotential for confusion and uncertainty will be highunless each program defines its mission within itsinstitution. Defining program goals can help:

• Promote a sense of purpose by team membersin understanding new initiatives in the context ofstriving to meet and achieve goals.

• Identify characteristics sought in future groupmembers during the interview process.

• Determine time, staff, and other resources neededto fulfill the core roles.

SENSE OF TEAM PURPOSE

We are currently living in an era of intense expansionof hospitalist roles and services. The rapid growthoften results in hospitalist groups being asked to takeon sudden or unexpected roles, such as expansionof nonteaching services and comanagement of surgi-cal services. Aggressive expansion, particularly intonew product lines, is often a source of anxiety forgroup members. Members may feel a sense of uncer-tainty about the duties that they will be asked toperform or the caseload that they will be expected tocarry. By conceptualizing growth as aligning with thegroup’s mission, team members can see expansion asa recognition of their expertise and accomplishments,rather than a threat to their current status. Hospital-ist growth dictated by hospital needs that does notalign with the mission of the service also needs to beaddressed. One strategy for avoiding these situationsis to have frequent discussions with hospital and

Published online in Wiley InterScience (www.interscience.wiley.com).DOI:10.1002/msj.20068

2008 Mount Sinai School of Medicine

416 A. DUNN: THEME INTRODUCTION–HOSPITAL MEDICINE IN HIGH-DEF

departmental leaders concerning the focus of the ser-vice and the areas in which the group will be of bestuse to the hospital. If a responsibility that does notalign perfectly with the group’s goals is unavoidable,reconceptualizing and/or reshaping the role to fit theframework that the group has developed may makethe role more acceptable. For example, in-housenight coverage can be considered an important initia-tive in enhancing quality and patient safety or mighthave a teaching component if oversight of housestaff is part of the new role. Lastly, when the grouptakes on a responsibility that clearly does not fit themission of the service, members will need to under-stand that these duties are essential for the hospital,although apart from the core services provided bythe group. If it is necessary, these tasks can be com-partmentalized, so that group members who are notinterested in a career path in hospital medicine (eg,those transitioning to a fellowship) are preferentiallyassigned the noncore roles and the career-orientedhospitalist can focus on the mission of the service.

INTERVIEWING AND HIRING

Hospitalist applicants are as heterogeneous as hos-pitalist programs. Different candidates have differ-ent training, backgrounds, personal characteristics,and, most importantly, professional preferences. Anexplicit and overarching mission statement will helpclarify the desired attributes of potential team mem-bers. For example,

• A service developing its niche as the main educatorfor an internal medicine residency program maytarget applicants who have a desire to teach anddevelop curricula.

• A program whose goal is to be involved in hospitalsystems may want applicants with backgroundsand interests in improving hospital processes.

• A program seeking to expand clinical care through-out the hospital may want to recruit physicians withstrong clinical skills who are interested in medicalconsultation or comanagement.

Recruiting and hiring candidates whose personalgoals align with the goals of the service will maximizethe career satisfaction of team members. This willhelp foster a healthy working environment for theservice as well as productivity and retention.

TIME AND RESOURCES

Clearly defining the group’s roles is essential toensure that the appropriate resources are provided.

Most importantly, adequate time needs to be allottedfor the various responsibilities to be performed. Forexample, if the hospitalists are expected to playimportant roles on hospital committees, such as thoseinvolving patient safety initiatives (eg, reducing theincidence of Clostridium difficile colitis or meetinggoals for core measures), or if there is an expectationthat the hospitalists will be the primary teachers foraspects of the residency program, the hospital willneed to recognize these crucial roles and ensure thatan adequate amount of nonclinical time is allotted.Expecting hospitalists to provide uninterruptedclinical care while contributing to these otheressential hospital functions will lead to dissatisfaction,burnout, turnover, and poor recruitment.

A challenge for each hospitalist program is tocreate a hospital metric or approach that accountsfor the contribution to quality initiatives, the educa-tional mission, or other roles. For certain activities,the expected hours of work can be strictly calculated;major teaching roles at university hospitals or admin-istrative positions requiring substantial amounts oftime are often handled in this manner. For many hos-pitalist tasks, however, recognition of the essentialnature of the role and the fact that there is a substan-tial time commitment required to fulfill the role maysuffice. For example, the hospital may want a hospi-talist to lead an initiative to decrease the risk of centralvenous line infections or meet the requirements forthe Joint Commission’s National Patient Safety Goals.The precise amount of time allotted away from directpatient care will depend on multiple factors, includ-ing the scope of the responsibilities and local factors,such as financial considerations and culture. A pri-ority for the Society of Hospital Medicine and otherleaders in hospital medicine should be to promotea standard approach to this complex issue in orderto minimize local factors, promote greater uniformityacross hospitals, and ensure that the necessary timefor these tasks is provided.

CONCLUSION

The trend for hospitals to rely on hospitalists toaddress many of their essential needs aligns wellwith the interests of hospitalists, many of whom havea passion for improving hospital systems and patientoutcomes. However, it will be important for eachlocal hospitalist group to consider its strengths, goals,and mission, instead of accumulating an increasingnumber of diverse responsibilities without reflectionof how new roles fit into the group’s current respon-sibilities. An expansion of those roles that align with

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MOUNT SINAI JOURNAL OF MEDICINE 417

the group’s strengths can be sought, and responsi-bilities that do not conform to the mission can beavoided or adopted in an explicit manner that min-imizes disruption to the group. Defining the goalswill allow the recruitment of hospitalists who canbest contribute to the team’s success. Clearly defin-ing the key roles played by the hospitalist servicewill also allow for explicit discussion of the need forappropriate time and resources to be allotted to thegroup to meet expectations. Providing adequate sup-port to hospitalists to fulfill these responsibilities willimprove recruitment and retention, allow the serviceto develop stability and continuity, and provide thenecessary environment for the service to meet hospi-tal goals and deliver outstanding clinical outcomes.

DISCLOSURES

Potential conflict of interest: Nothing to report.

REFERENCES

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4. Auerbach AD, Wachter RM, Katz P, et al.Implementation of a voluntary hospitalist service ata community teaching hospital: improved clinicalefficiency and patient outcomes. Ann Intern Med 2002;137: 859–865.

5. Huddleston JM, Long KH, Naessens JM, et al. Medicaland surgical comanagement after elective hip and kneearthroplasty: a randomized controlled trial. Ann InternMed 2004; 141: 28–38.

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