The expanding or shrinking universe of the hospitalist

A s a hospitalist of about 6 years, I enjoy hospital medicine and hope, over the course of my career, to see it develop into an increasingly respected, diverse, and influential specialty. There is abundant evidence that this is occurring, primarily through the praiseworthy efforts of the leadership and members of the Society of Hospital Medicine (SHM). Efforts to prove our value to inpatient care and align ourselves with quality improvement, as promoted early in the hospitalist movement, are coming to fruition. However, I would like to raise a flag of concern; and this is based on my experience working as a hospitalist in 10 community hospitals in 5 states, including positions as a locum tenens hospitalist, staff hospitalist, medical director of a hospitalist group, and full-time teaching hospitalist for a community hospital residency program. I believe that hospitalists, particularly those working in community hospitals (approximately 80% of all hospitalists), are currently at a critical crossroad, with the option of either actively expanding their clinical, administrative, and quality improvement roles or allowing these roles to stagnate or atrophy. As in any career, we are, like Alice, perched on a mushroom, one side of which will make us grow taller and the other side of which will make us grow shorter. Which side are we choosing in our careers as hospitalists? Hospitalists currently have numerous opportunities to expand their clinical, administrative, and quality improvement roles and responsibilities (Table 1), and these opportunities are in full alignment with the mission statement of SHM: ‘‘to promote the highest quality of care for all hospitalized patients.’’ My concern is that, for one reason or another, hospitalists in some settings are shrinking away from roles that they could or should fill, and this is a trend that I believe could affect our specialty adversely over time and that we, as an organization, should find ways to prevent. Although family medicine and traditional internal medicine physicians who work in the hospital face similar challenges, if we as hospitalists wish to qualify one day as board-certified hospital medicine specialists, we are obligated to develop knowledge and skill sets that are truly unique to our profession. Holding to this goal, we cannot settle into a narrow comfort zone. I believe that the development of the hospital medicine core competencies by SHM was an important step in helping us define our intended reach, but even so, what