What is a Hospitalist?

Not quite a fundamentalist

Photo by Rafael Hoyos Weht on Unsplash

The burrito game in San Francisco is on another level, my friend, Amir, told me via email. I had messaged him, asking for food recs.

Six months after our exchange, my plane landed at SFO and I took the BART train to Embarcadero to attend UCSF’s hospitalist conference. Every October, the brightest minds from the Bay Area gather to educate healthcare providers on updates in hospital medicine. The conference is moderated by the person who coined the term “hospitalist", Robert Wachter, the chair of the internal medicine department at UCSF. The conference ended after three days and I met Amir at La Taqueria.

La Taqueria is an unassuming white building with large cursive red lettering. Located at a corner on Mission Street, it’s one large room with an open kitchen and always packed. It serves Mission-style burritos. Before Chipotle popularized gigantic custom-made burritos wrapped in foil in the 1990’s, San Francisco was doing this decades earlier (Chipotle’s founder modeled the business after eating at taquerias in San Francisco¹). Rather than serving burritos with sides, The Mission packed rice, beans, and gaucamole into big wrapped flavor bombs. I ordered a carne asada burrito, super style, which included sour cream, cheese, and avocado. While I had eaten at Michelin star restaurants in San Francisco during the conference, the $14 soft pillowy burrito with char-grilled steak at La Taqueria was the best food I ate that week.

I hadn’t seen Amir since he had gotten married six years earlier. Amir, half-Minnesotan and half-Arab, was one of my first friends on campus at the University of Minnesota. He towered over me at 6’3”. I had lost touch with him after college but I always knew I wanted to keep in touch with Amir because of this one fact: he always made me laugh. I sent Amir emails every now and then to let him know I was alive and to see how he was doing. Thankfully, it led to the moment of us meeting at La Taqueria.

Amir asked me what kind of work I was doing. I told him my official job title.

“Have you heard of a hospitalist?

“Umm, I know what a…fundamentalist is!” he replied.

“Yeah…not quite that,” I said, laughing.

The word hospitalist is relatively new in medicine. In 1996, Robert Wachter created the term in a New England Journal of Medicine article. In 2024, it is now the most common internal medicine job. Internists in the past treated patients in the clinic and hospital. It was too difficult to cover both settings, as I hear from my older colleagues, so the job was split into two. Now, clinic docs stay in the clinic and hospitalists see patients only in the hospital.

I explained that to Amir. We caught up and he told me how fatherhood was treating him. Amir loved the little moments of joy. He was happy in San Francisco, despite rising costs; childcare was three times as expensive as what I was paying in Madison.

Amir wiped his hands clean and I shrunk the aluminum foil down into the size of a golf ball. My stomach had a burrito baby sitting in it, but I didn’t regret a single bite. I told Amir I’d see him again in San Francisco.

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If Amir had asked me “What’s the best part of your job?” I would have replied “Cracking a case.”

I don’t get to do that often. Because patients in the hospital have already been seen by emergency department doctors or clinic doctors, they’ve started the work up. Usually, when a patient gets to the hospital ward, there’s a leading diagnosis or thought process on what’s going on.

But, the chance to crack a case is one of the ultimate feelings. Tyler, my co-resident at Hennepin County in Minneapolis, became a hospitalist and he once diagnosed a rare syndrome when a patient kept coming in with recurrent episodes of hypothermia. And, by reading about it after hours at home, Tyler suggested a medication that broke the cycle of the patient’s repeat hospitalizations.

The most recent case I cracked was in March, 2024. Dianne had been admitted to the hospital with weakness. I reviewed my partner’s admission note. Dianne was hospitalized with COVID-19 one month prior and she was treated with steroids and oxygen. The oxygen had been stopped one week ago. My partner’s note said that Dianne had fallen twice and because she couldn’t walk, she had come in to the hospital. The plan was to have her work with physical therapy because maybe her COVID-19 infection made her weak. As I read her chart, I thought it would be odd for a viral infection to make someone weak this far after their recovery.

When I walked in to Dianne’s room, I observed a white middle-aged overweight woman. Her eyes were closed. The gasps in her breath didn’t signal any alarms; only that she was very tired.

“How did you do when you went home Dianne from your most recent infection?”

“I did great. I was up and walking around just fine but then after two weeks, bam, I was just very weak,” she said.

Her COVID-19 test remained positive and when she told me she had recovered well, it made me think of some other process.

“What’s your main issue now?” I asked.

“I can’t get up and walk.”

“Do you feel weak in any particular part of your body, like your arms, legs, or face?” I asked.

“My legs.”

“Both of your legs?”

“Both.”

Her eyes remained closed during our interview.

I tested her strength. It was normal in all of her limbs. I had considered doing an MRI of her brain and spinal cord, but since her exam showed good strength, it wasn’t necessary. Something else was affecting her ability to get up and walk.

I shifted my focus to her home medications. She was on meds for high blood pressure, fibromyalgia, and bipolar disorder. Most concerning were the meds she was on for bipolar disorder, especially depakote. I looked up depakote toxicity on the computer in her room while she laid in bed and read that in some cases, high depakote levels leads to ammonia elevation. Ammonia is a waste product that the liver metabolizes and when it accumulates, it leads to confusion, lethargy, and can progress to coma.

Dianne wasn’t confused, but she was drowsy and it’s hard to be strong when you’re sedated. Perhaps her ammonia was elevated.

“When’s the last time you took depakote?”

“I take it in the evening, so last night.”

She confirmed to me that she took it all the other previous evenings, too. Just because a medication is on someone’s list, it doesn’t mean they’re taking it. She was a good patient.

“Tell you what, I’ll check a few labs on you Dianne,” I said. “You’ll get poked again this afternoon and we’ll see what it shows. I’ll have physical therapy come by and we’ll see where this goes.”

She expressed gratitude and I moved on to my other fourteen patients that day.

In the afternoon, I got messaged by nursing that the ammonia level came back. It was three times the level of normal! I stopped the depakote. I scheduled a sweet green liquid medication for Dianne, lactulose, and the nurses gave her several doses. She had two large bowel movements overnight. She pooped out the ammonia and her levels were normal the next day.

The following day, Dianne said “You fixed me.” She hadn’t felt normal in a while. I called the psychiatrist, who advised stopping the depakote until she saw her regular outpatient psychiatrist. Dianne discharged to a rehab center a few days later.

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A hospitalist can be a valuable person to someone’s care. Often times, in the clinic, there’s less time and resources to figure out what’s wrong. In the hospital, we are afforded more time to think about what’s going on and we have better access to resources; it’s simply the nature of the setting. This is not to minimize what clinic doctors do - they are very skilled at what they do (if you ask me to do a pap smear or a vasectomy, or manage diabetes long-term, you will receive subpar care).

If you ask me what makes a good hospitalist, I would say “Taking the time to do what’s best for the patient, and not what’s convenient.” Sometimes, I can fall into the trap of doing what’s convenient because I’m racing against the clock to pick up my kids from childcare. But the best hospitalists are the ones who take time to think about their patients and act on their best interests. In a way, you want a hospitalist who doesn’t have small kids at home. One day, my kids will grow up and I won’t have a clock to race against during the day.

A good hospitalist needs a system to evaluate patients. For each patient, always look at vitals. Then overnight nursing notes. Look at labs closely. Look at every medication. Examine the patient and always take a thorough history. I’m not saying I do anything perfect. I have made a ton of mistakes along the way. I have definitely overlooked meds and labs. Once, I missed a pulmonary embolism on a patient that my partner picked up on. But, by being thorough, taking time, and considering the possibilities, this bodes well for both patient and provider. These, I would say, are the fundamentals of hospital medicine.

1. https://www.eater.com/2019/4/23/18410654/chipotle-burrito-american-pepper