To understand how difficult it will be to find a primary care doctor in two years, look no further than Massachusetts. In 2006 the state passed a health care law mandating that everyone obtain insurance (sound familiar?). For those unable to afford the cost, subsidies were made available.

Within weeks, the "uninsurance" rate in Massachusetts dropped precipitously. Commensurate with that was a rise in both the number of "closed" office practices and the length of time it took to get a new patient appointment. Nearly six years after the law passed, more than half of the family practice and internal medicine offices in the state are closed to new patients. According to the Massachusetts Medical Society, the average wait for a new patient to be seen by an internist is 48 days. Turns out insurance doesn't guarantee access after all.

For young doctors just finishing residency, practicing as a hospitalist has many attractions. The most enticing aspects are financial and lifestyle considerations. A starting hospitalist (depending on what region of the country they practice in) can earn around $200,000 per year (a starting office-based internist will make in the neighborhood of $150,000). Perhaps more importantly, many hospitalist groups operate with "seven-on/seven-off" schedules. This means that a hospitalist earns that salary working seven consecutive days followed by seven days off. This option is extremely popular with doctors that are parents, as well as those that want to earn extra income or volunteer during their off time.

During the three-year internal medicine residency (like the kind I administer), doctors-in-training will spend about two-thirds of their time on hospital-based rotations. If familiarity breeds comfort, then it's not a surprise that recent residency graduates choose to stay in an environment to which they're well-adapted. And since hospital work is shift work, there is no on-call or after-hour responsibilities to handle. When a hospitalist leaves the hospital, they're done -- unlike office-based internists who still carry pagers and get middle of the night phone calls.

Couple the lifestyle and the training experience with the huge debt burden that U.S. medical students accrue, and deciding on a hospitalist career becomes a rational choice. Dr. Wachter of UCSF compares hospital medicine to site-based specialties that came before it: emergency medicine and critical care. All of these specialties represent a convergence of high-complexity and high-cost care in a single location, where it makes sense to have well-trained specialists who handle the specific set of problems encountered there.

Since the severity of illness seen by hospitalists tends to be high, specialization improves safety and quality, which are key metrics for hospitals as insurers now tie payment to such indices. Hospitals have almost all transitioned to hospitalist models to at least some degree. According to SHM data, the larger the hospital, the more likely it is to have hospitalists. Management likes the efficiency and improved patient satisfaction that comes with having doctors on the premises at all times. Earlier discharges and shorter lengths-of-stay for patients keep the hospital beds turning over and consequently the reimbursement dollars flowing in.