It Is Time for Hospitalists to Own Our Expertise

If you had told me when I was a resident that I would one day become not only a hospitalist but in fact, the Chief of Hospital Medicine, I would have laughed. I would have also been insulted. I would have assumed you didn’t think I was smart enough, capable enough, or ambitious enough to do something ‘better.’

Back then, I thought hospitalists were the doctors who couldn’t cut it anywhere else: the ones who took the overflow patients from the ‘real’ medicine service, the teaching service. In the hierarchy of academic medicine, hospitalists seemed like an afterthought: a necessary patch to prevent resident work-hour violations, perhaps even occasionally helpful, but certainly not aspirational as a field. I saw them as physicians who had never quite moved beyond residency: still doing ward medicine, still managing admissions, but without the trajectory toward a clearly defined specialty. In my mind, they occupied a kind of in-between space: more responsibility than trainees, but not clearly different work. No one ever said this outright, but it was implied everywhere, from how residents directly compared their own workload and responsibilities to those of the hospitalists, and how prestige accrued to some roles but not others. In fact, late in residency when I told an admired attending physician I was considering a general internal medicine fellowship — then, the closest thing to a hospital medicine fellowships — he was quick to tell me that I would never be respected as an academic without subspecialty training, preferably in cardiology or critical care.

That reaction says as much about how medicine has historically viewed hospitalists as it does about my own assumptions. At the time, I didn’t question that hierarchy — I accepted it.

When the term ‘hospitalist’ was first introduced three decades ago, it described physicians defined primarily by where they practiced – the hospital – and by their potential to improve efficiency and coordination. What has been less clearly articulated since then is the distinctive clinical expertise that has emerged from that role.

Understanding that expertise – and claiming it – is essential to the future of the field.

In retrospect, perhaps it was not terribly surprising where I ended up. I trained in a residency environment defined by its intensity – high-acuity inpatient rotations, enormous clinical volume, and patients with layers of medical and social complexity. The more complicated the management or discharge plan, the greater the sense of accomplishment. Residents wore these cases like merit badges. We informally collected them: the most abnormal A1c, the lowest hemoglobin, the largest anion gap, the most improbable successful discharge. The program produced a disproportionate number of intensivists, which made sense. You either learned to tolerate that level of acuity, volume, and complexity, or you didn’t survive.

At the time, I didn’t recognize how profoundly that training was attuning me to the kind of clinical reasoning hospital medicine requires: comfort with unstable patients, rapid prioritization across multiple problems, decision-making before certainty. One of the first moments I recognized this explicitly came later, after residency, when I started precepting in primary care. I noticed something surprising: I felt most comfortable managing patients with long lists of conditions – COPD, obstructive sleep apnea, diabetes, pulmonary hypertension, heart failure – all interacting with each other. When someone presented with a single focused problem, like recurrent bacterial vaginosis, I felt adrift – disconnected from the complexity that had always oriented my thinking. It was the first time I understood that complexity itself could be a domain of expertise, and that it might define where I belonged in medicine.

Hospital medicine sits at the intersection of complexity, acuity, uncertainty, and volume. Hospitalists care for patients when illness is most unstable and least understood. Decisions often must be made before diagnoses are clear, before trajectories declare themselves, and before ideal information exists. We do this at high volume, across nearly every domain of adult medicine. While pulmonologists may see more rare lung disease and cardiologists may see more advanced heart failure, hospitalists see more acute pneumonia, more acute CHF exacerbations, more undifferentiated instability than anyone else. Volume builds a library of illness scripts, the cognitive database that allows experienced physicians to recognize danger early and intervene before deterioration becomes obvious.

But volume alone is not the expertise. The expertise lies in integrating acuity, multimorbidity, context, and uncertainty, deciding what matters most right now, what can wait, and what is safe for this particular person in front of you – in other words, applying evidence-based medicine to patients with multiple competing complex conditions and real-world constraints. Clinical guidelines are written for isolated diseases in controlled circumstances. They tell us optimal hemoglobin A1c targets. They do not tell us what to do when a patient has type 1 diabetes but no refrigerator to store insulin, inconsistent access to food, needle aversion, and limited health literacy. They do not resolve the tradeoffs when treating heart failure worsens kidney function or when blood pressure targets conflict with fall risk. Guidelines describe ideal physiology and circumstances. Hospitalists manage humans in the real world.

This work often becomes most visible after specialists have defined the boundaries of their domains. When a cardiologist evaluates chest pain and concludes it is non-cardiac, the problem is not solved. It has simply changed owners. Someone still has to determine what is causing the symptoms, how dangerous it might be, and what to do next. That someone is usually the hospitalist.

Specialists narrow the question within their domain: “Non-cardiac.” “Non-pulmonary.” “Non-neurologic in etiology.” “Correlate clinically.” Hospitalists reassemble the whole – determining what explains the patient in front of them and how best to move forward.

Years ago I encountered a framing that has stayed with me: generalists as comprehensivists and specialists as partialists. The intent was not hierarchy but orientation. Specialists focus deeply on particular physiologic domains. Generalists focus on the whole patient across systems. Modern medicine depends on both forms of expertise. Comprehensiveness, however, is cognitively demanding in ways that are less visible. Integration rarely looks as dramatic as depth. Yet that expertise is often flattened into something else: hospitalists are perceived less as experts and more as work horses – the solid, reliable physicians who keep hospitals running.

I have experienced this perception directly. More than once, I have been approached by leaders recruiting dual-physician couples with the assumption that the partner seeking a hospital medicine position would naturally find a place in my division. After all, don’t hospitalist programs always need more bodies? The question is rarely malicious. But it reveals an underlying assumption: hospital medicine as interchangeable staffing rather than specialized practice. No field matures academically when it is viewed primarily as labor and rather than respected as an area of expertise.

And if we are honest, we have reinforced that perception ourselves. We talk about census, flow, and staffing ratios more readily than we talk about diagnostic reasoning, integration, and judgment. We have defined our value operationally – and then been surprised when others do the same. That framing does not only obscure our actual expertise, it reinforces the perception that hospitalists do not possess a distinct expertise. That perception shows up most clearly in how hospitalists are compared to trainees. From the outside, resident teaching services and hospitalist services can look similar — teams rounding on wards, discussing plans, writing orders. But the difference between training and expertise is the difference between a cadet and a career officer. The environment overlaps. The role does not. Residents are learning foundational skills under supervision. Hospitalists are practicing independently, making decisions with compressed timelines and full accountability

To be clear, the daily reality of hospital medicine is rarely elegant. Census is high. Pages (or secure chats) are constant. Unremitting pressure for high turnover and improving flow is real. The work can feel grinding and relentless. But the cognitive labor does not disappear simply because it is embedded in volume. If anything, making sound decisions under those conditions requires even greater discipline, clarity and skill.

The problem is not the grind. It is that we have allowed the grind to define how we describe – and even understand – our work.

The intellectual foundation of hospital medicine is general medicine — a discipline often mistaken for the absence of specialization. In reality, it is a specialization in integration, prioritization, and uncertainty management. Hospital medicine is the discipline of general medicine practiced in its most acute setting. The expertise is already there. The question is whether we are willing to articulate it clearly.

Hospitalists are experts in comprehensive, multi-system acute care. That is not a consolidation prize. It is a distinct clinical domain.

The invisibility of that expertise is reinforced even with the name of the field, which doesn’t help. Cardiologists treat the heart. Neurologists treat the nervous system. Hospitalists, in contrast, sound like doctors who treat hospitals. The term describes location rather than knowledge. It obscures the reality that hospital medicine is not about buildings or throughput. It is about acute clinical decision-making across multiple organ systems under uncertainty.

But the field will struggle to grow – academically, intellectually, and culturally – until hospitalists themselves fully claim our own expertise. When we describe ourselves — or accept other’s descriptions of us primarily as coordinators, triage doctors or throughput managers, we unintentionally reinforce the idea that expertise lives elsewhere, in the subspecialties we consult, rather than within our own practice.

If my resident self could see my work now, the surprise would not be that I chose hospital medicine. It would be how profoundly I had misunderstood the field, how much expertise I once failed to see. Hospitalists are not the doctors who know less. We are the doctors who see more: more illness, more uncertainty, more complexity, more context – and we assume responsibility for distilling all of that into decisions that are evidence-based, contextually grounded, and right for the patient in front of us.

Doing that well is its own form of mastery. It is time we own it and practice like we believe it.