The hospitalist movement mirrors the health care trend toward ever-increasing specialization. However, hospitalists are fundamentally generalist physicians who provide and coordinate inpatient care, often aided by myriad subspecialists. How can a generalist be a specialist? Specialties in medicine are traditionally defined by organ (eg, cardiology), disease (oncology), population (pediatrics), or procedure/technology (surgery or radiology). The hospitalist, on the other hand, is a "site-defined generalist specialist" (similar to emergency medicine physicians or critical care specialists), caring for patients with a wide array of organ derangements, illnesses, and ages within a specific location.45 Accordingly, the hospitalist should not be seen as a retreat from generalism and its emphasis on coordination and integration9,77 but rather as an affirmation of these values and as a surrogate for the primary care physician in the hospital. The competing pressures resulting from the distance between office and hospital as well as the requirement of around-the-clock availability make the hospital-based generalist a logical evolution. Hospital medicine has already satisfied many of the requirements of a specialty. A large and enthusiastic group of practitioners identify themselves not according to their training background but as hospitalists. The NAIP is almost certainly the fastest growing physician society in the United States. The field hosts several successful meetings each year and has its own clinical textbook.78 To establish themselves as members of a recognized medical specialty, hospitalists must identify a core skill set or body of knowledge and obtain the approval of credentialing organizations. Advocates of specialty status for hospitalists should be encouraged by the history of 2 other site-defined inpatient specialties: emergency medicine and critical care medicine. Like these relatively young fields, it seems probable that hospitalists will ultimately define a unique set of skills and competencies that will distinguish their field. The identification of practice-training mismatches (Table 2) represents an important first step. Credentialing organizations deliver the final stamp of approval on new specialties by creating a board certification or added qualification. Most new fields quickly agitate for such status, their motivation both practical and visceral. However, for unique reasons, few hospitalists are pressing this point. Many physicians—hospitalists and nonhospitalists—worry that if a credentialing body (such as the American Boards of Internal Medicine or Pediatrics) created a hospital medicine credential, health maintenance organizations might require that physicians possess this credential to care for inpatients. This would be unacceptable to many primary care physicians, who would be excluded from the hospital despite their desire and competence to continue practicing there. For this reason, we expect neither NAIP nor the relevant boards to promote separate credentials in the near future. Nevertheless, as evolutionary forces lead to specialized training, some formal specialty designation may emerge.79

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine

John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston. “At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”

“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking

Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.

Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?

Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”

Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls

But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.

The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.

Others are implementing bedside ultra-sonography for procedures and diagnosis, pioneering methods of making rounds more patient- and family-centric, implementing unit-based leadership teams, or applying process-improvement ap-proaches such as the Toyota Pro-duction System to inpatient care.

Many are developing early-warning pro-tocols in which electronic health record data are used to identify patients who are at risk for prob-lems such as sepsis or falls.

mentation of quality- and systems-related initiatives. Hospitalists have been slow to pursue sub-stantial inquiry into discovery re-lated to the common inpatient diseases they see or to lead multi-center trials of new diagnostic or therapeutic approaches. This defi-ciency limits hospitalists’ credibil-ity in academia and the advance-ment of the field.

Many hospitalists have added value as local leaders in quality improvement, safety, and innova-tion, but some have functioned more as shift workers. For exam-ple, many community hospital-ists have a 7-days-on, 7-days-off schedule that focuses mainly on high-volume clinical work and sends an unspoken but clear mes-sage that, at the end of an inten-sive clinical “on” stint, one is “off ” and uninvolved. Our impression is that hospitalist programs pro-vide more value when hospital-ists’ inpatient assignments (clini-cal “systole”) are complemented by a systems-oriented “diastole,” dur-ing which clinical activity is limit-ed but they contribute to key in-stitutional programs. Productive diastole is more likely when hos-pitalists have strong leadership, a robust professional-development curriculum, and a mutual hospi-tal–hospitalist commitment to adding value during specified and structured nonclinical time.

The field’s rapid growth has both ref lected and contributed to the evolution of clinical practice over the past two decades.

Conversely, some traditional programs may develophospitalist tracks that emphasize acquisition of theskills most relevant to inpatient practice. If suchtracks are developed, it will be important not to re-duce training in ambulatory care too aggressively,since the competent hospitalist will need a full un-derstanding of what can — and cannot — be donein the outpatient setting

As a result, we anticipate the rapid growth of anew breed of physicians we call “hospitalists” — spe-cialists in inpatient medicine — who will be respon-sible for managing the care of hospitalized patientsin the same way that primary care physicians are re-sponsible for managing the care of outpatients.

Unfortunately, this approach collides with the re-alities of managed care and its emphasis on efficien-cy.

Strict visiting hours and visitor restrictions are a thing of the past in a patient-centered care model. Patients are given the authority to identify who can visit and when. Family members (as defined by the patient and not limited to blood relations) are invited to visit during rounding and shift changes so they can be part of the care team, participating in discussions and care decisions. When not in the room with the patient, they are kept informed of their loved one’s progress through direct and timely updates. A patient-centered care hospital’s infrastructure encourages family collaboration through a home-like environment that not only meets the needs of the patient, but also meets the needs of family members. For example, maternity wards are being redesigned with family-friendly postpartum rooms that can accommodate the mom, new baby, and family members, who are encouraged to spend up to 24 hours a day together in the room to foster family bonding.

Poor health literacy is a silent and ubiquitous health care issue, and the field of neurosurgery is particularly prone to the consequent adverse effects. Failure to address low health literacy has several detrimental health and economic consequences, and numerous policies have been initiated to address these. Better facilitating patient understanding of neurosurgical disease, treatment options, and care surrounding the operative period may have a positive impact on the health care economy and ultimately achieve improved outcomes for patients.

and like most alternative medicines there is zero evidence that it works

Fort Simpson

Fort Simpson was originally established by the Hudson’s Bay Company at a location on the north shore of the Nass River estuary. In the summer of 1834, the Hudson’s Bay Company moved its fort to a site on the Tsimshian peninsula at McLoughlin Bay, which is now called Port Simpson, British Columbia (Patterson 1994). In 1858 and 1894, Roman Catholic missionaries reached Fort Simpson and permanently resided there. The Roman Catholic Mission provided many resources for the community, such as St. Margaret’s Hospital built in 1916 and a school in St. Margaret’s Hall built in 1917. St. Margaret’s Hall was replaced by the Federal Day School in 1974 and was run by the Federal Government. Fort Simpson is still inhabited today and is a quite popular tourist destination. It is the only village in the Northwest Territories with a population of approximately 1,250. Some people of Fort Simpson still identify as Dene. Fort Simpson is accessible via airplane or highway. The Liard Trail Highway leads to Fort Simpson from British Columbia and the Mackenzie Highway reaches Fort Simpson from Alberta. Since both of these highways pass through expanses of nature, it is possible to see black bear, moose, woodland caribou, lynx, wolves, and bison alongside the highways (Fort Simpson Chamber of Commerce n.d.).