Hospital Medicine: Organization, Quality Improvement, and Clinical Care

The confluence of a number of factors—advancing medical technology, increasingly ill patients, and financial pressures to shorten hospitalizations—generated the development of hospitalists in the 1990s and their remarkable growth across America. General care of the hospitalized patient has evolved such that a physician is needed to provide undivided attention to these patients. The hospitalist's trade, hospital medicine, is the subject of this issue of the Medical Clinics of North America. The issue begins with a description of the hospitalist model in the United States, followed by articles on geriatrics, perioperative medicine, end-of-life care, pain management, and an update of key research, all specifically geared toward the hospitalized patient. The issue goes on to explore systemic issues of vital interest to the hospitalist, including quality improvement, medical error and patient safety, and ethics, all focusing on the hospital setting. It concludes with a discussion on organizing a hospitalist program. The topics fit into three main categories: broadly organizational (the first and last articles), essential knowledge for direct patient care, and knowledge for good citizenship within the hospital. We included the latter because so much of the promise, indeed responsibility, of the hospitalist lies in not only the care of individual patients but also in the care of the modern hospital. Hospitalists are becoming physician leaders at hospitals.

In many ways, the hospitalist model was spawned by the increasing demands of the hospital setting, exceeding the capacity of physicians also challenged with a busy office practice. Like the site-based specialties of emergency medicine and critical care medicine, hospitalists are developing a unique knowledge base specific to their activities of hospital-based health care. While much of what hospitalists need to know is provided by a standard internal medicine residency training program, there are additional requirements for truly effective hospital-based generalists, such as expertise in health economics, organizational leadership, coordination of care between health care settings, quality improvement, and patient safety, to scratch the surface. The authors featured in this issue were invited to explore some of these topics to begin an elucidation of the hospitalist skill set that will be refined in the coming years.