The role of medical generalism in the New Zealand health system into the future.

New Zealand hospitals are facing medical workforce shortages and an ageing population with increasing multimorbidity. To be sustainable in the future, the future medical workforce will need expertise in dealing with the complexity of people living with multiple physical and mental health issues. This will require a greater focus on generalism within the speciality colleges, and generalist doctors within the hospital settings, as well as their traditional home of community settings. Doctors' career choices will need to be matched to changing community need. The Transalpine Health Services generalist, specialist and sub-specialist workforce model developed by the West Coast and Canterbury health systems points the way to future sustainable provision of a quality patient hospital experience as close to home as possible, for people who live in provincial New Zealand, through a regional network approach. System-wide changes are suggested to support a more balanced future medical workforce. These include greater valuing of careers in generalism, aligning of incentives to promote medical careers based in generalism, developing regional networks that cross existing District Health Board boundaries to provide patient care, and application of system outcome metrics that measure quality of care and patient outcomes in an integrated health system.

Pediatric hospital medicine: historical perspectives, inspired future.

Pediatric hospital medicine (PHM) is in an accelerated growth phase. Multiple elements have combined to affect the current state of the field. PHM is similar to other geographic specialties such as pediatric emergency medicine and pediatric critical care that deliver general, comprehensive care to patients based on hospital site. Pediatric hospitalists have been molded by changes in medicine, consumer expectations, and training program modifications. The history of PHM dates back for more than 3 decades, when unwitting pediatricians began to focus on delivering care for the hospitalized child. The ensuing years allowed for natural responses to external pressures that resulted in much of the field's initial development. In more recent years, however, pediatric hospitalists have been catalysts for change and driving forces for health care systems' improvements. Simultaneous with this has been the nearly exponential surge of energy focused on targeted initiatives, which have further defined the field and brought attention on a national level. PHM is at a critical but brilliant juncture in development. Further decisions regarding scope and demonstration of competencies are important to make with clarity of purpose. Pediatric hospitalists are advancing child health in the inpatient setting through evidence-based care, research, education, clinical excellence, advocacy, and health care business acumen. With a strong community sense and leadership evident, PHM has a bright future.

Pediatric hospital medicine and children with medical complexity: past, present, and future.

Children with medical complexity, regardless of underlying diagnoses, share similar functional and resource use consequences, including: intensive service needs, reliance on technology, polypharmacy, and/or home care or congregate care to maintain a basic quality of life, high health resource utilization, and, an elevated need for care coordination. The emerging field of complex care is focused on the holistic medical care of these children, which requires both broad general pediatrics skills and specific expertise in care coordination and communication with patients, families, and other medical and non-medical care providers. Many pediatric hospitalists have developed an interest in care coordination for CMC, and pediatric hospitalists are in an ideal location to embrace complex care. As a result of these factors, complex care has emerged as a field with many pediatric hospitalists at the helm, in arenas ranging from clinical care of these patients, research into their care, and education of future providers. The objective of this section of the review article is to outline the past, present, and possible future of children with medical complexity within several arenas in the field of pediatric hospital medicine, including practice management, clinical care, research, education, and quality improvement.

The hospitalist movement--a complex adaptive response to fragmentation of care in hospitals.

The increasing complexity of healthcare is accelerating the rate of specialisation in medicine, which in turn aggravates the fragmentation of care in hospitals. The hospitalist movement advocates for the return of generalist physicians to the hospital to provide general and more holistic medical care to inpatients. This can be seen as an adaptive response to care fragmentation. Starting in the mid-1990s in North America, where the impact of healthcare complexity and fragmentation has been most widely felt, the hospital movement has gained strength and spread across the continent rapidly. This paper examines the phenomenon of the hospitalist movement in the United States, Canada and Singapore. The conclusion is that variants of the hospital movement may emerge in different parts of the world as healthcare systems adapt to common global trends that drive the increasing complexity of healthcare.