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To Niche or Not to Niche-Should You Subspecialize?

Written by: Paula Skarda, MD; Ethan Molitch-Hou, MD, MPH, SFHM; Melissa Plesac, MD; Laura Paletta-Hobbs, MD
Published on: Apr 4, 2024

Choosing a Specialty
Photo Credit: elenabsl/Shutterstock

Hospital medicine has experienced significant growth since its inception as a career within general internal medicine. Over the past 20 years, this expansion has created numerous opportunities for modern-day hospitalists. Historically, the hospitalist’s role was to provide comprehensive care for hospitalized patients by leading daily clinical decision making, incorporating consultant expertise, and ensuring high-quality, low-cost care.

The diversity of jobs within the field has traditionally been driven by location and employer. A career in hospital medicine can be spent at large academic centers coordinating care for clinically complex patients or at small rural sites functioning as a safety-net physician, always learning and seeing something new.

The ongoing evolution of hospital medicine has added diversity to the field and has expanded into other domains of medicine. Subspecialty roles within general internal medicine have emerged as hospitalists have become experts in areas such as palliative care, peri-operative care, telemedicine, hospital at home, and procedural medicine. Specialized training outside of traditional fellowships has created opportunities for hospitalists to focus on specialty services such as neurology, hematology and oncology, and addiction medicine.

Today, there are numerous opportunities when entering the field, leading many to wonder if there is one “correct path” that will lead to a long and prosperous career. Fortunately, there is no incorrect answer to this question. The decision to begin a career as a general hospitalist or pursue a specialized niche within hospital medicine is a personal one. A bit of thoughtful introspection of professional values and personal needs can create an interesting and fulfilling career.

Being a generalist

When people think of a hospitalist, they first picture a generalist: the physician in charge of a patient’s care from admission to discharge. Hospitalists play a critical role for those requiring inpatient care. As the first internist to receive a patient on admission, they are responsible for the initial diagnostic workup and management of a patient’s medical concerns, often seeing new conditions or unique presentations of common complaints.

Because hospitalists are the primary clinicians for patients who are acutely ill in times of crisis and stress, they can develop strong and intentional relationships with patients and their families. The variety of presentations and diagnoses encountered maintains their broad knowledge base acquired during residency and facilitates opportunities to add to their clinical knowledge. Additionally, hospitalists form collegial relationships with medical and surgical subspecialists, sharing knowledge and patient care decisions in a way that promotes lifelong learning and allows hospitalists to provide current evidence-based care when faced with new clinical dilemmas; these relationships can lead to improved job satisfaction.

Staying generalized allows hospitalists many opportunities to advance in their careers. As experts in inpatient medicine, they are likely to gain leadership roles within the hospital, whether in patient care, teaching, or administration. Hospitalists interact with all health care team members and have a nuanced understanding of the flow of inpatient clinical care, making them effective and collaborative unit medical directors. They are highly skilled clinicians and are the perfect candidates to work on inpatient teaching services leading to opportunities to further develop teaching skills and advance in medical education and academics. As frontline clinicians, hospitalists have a particular understanding of the challenges that affect practitioners every day. They can provide unique perspectives to the administration about key components of the health care system, including the electronic health record, compensation plans, and system processes and policies.

Subspecializing in hospital medicine

For some hospitalists, finding a niche in hospital medicine can be an effective strategy to help build a long-term, fulfilling career. While being a hospitalist is a subspecialty in itself with expertise in inpatient medicine and transitions of care, the scope of practice remains quite general, which precludes extensive depth of knowledge in any particular clinical domain.

Hospitalists may elect to defer to subspecialists when elements go beyond their clinical expertise, which can impact their sense of worth and increase anxiety and burnout. The pursuit and development of a niche within hospital medicine further refines a particular skill set. Subspecializing allows hospitalists to become subject leaders, promoting a sense of personal and professional value. Development of specific skills can also positively affect clinical confidence: hospitalists can serve as their own consultants as experts in opioid withdrawal treatments, anticoagulation, or inpatient diabetes management. Hospitalists who specialize in a specific area can become valuable colleagues, leaders, and mentors in their field.

Having a specialty can be a defining feature in a career trajectory. It can lead to academic and clinical promotion and make you a more competitive candidate when changing jobs. Developing expertise in a specific niche can also increase job satisfaction by allowing you to integrate personal interests into your work and improve your work-life balance.

Subspecialty knowledge is particularly useful for academic promotion, as it demonstrates a path toward expertise and can help fulfill specific criteria. Additionally, subspecializing can be advantageous for clinical promotion and competitiveness for leadership positions in quality improvement, information technology, education, or administration.

When determining which niche to pursue, consider your passions and career goals. Falling into a niche due to an opportunity can be helpful, but it’s important to make sure it aligns with your long-term aspirations. Developing a specific niche within hospital medicine can create an array of clinical and non-clinical service options that total a full-time position and increase the variability of the day-to-day. This allows hospitalists to combine different areas of interest into their everyday work, which can bring joy and purpose and mitigate burnout. Having a niche can also allow for roles that improve work-life balance such as an integration of telemedicine to allow working from home, a procedure service that allows for consistent hours, or a discharge clinic that has weekends free. Fortunately, hospital medicine careers are flexible, and subspecialties can change when new opportunities arise or when interests shift. 


The beauty of a career in hospital medicine lies in its dynamic and flexible career path. Whether you choose to specialize or remain general, there are many opportunities for a fulfilling and sustainable career. As the field continues to evolve, there will always be new chances to change course and grow. 

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