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The pediatric hospitalists in South Carolina at all three academic centers have expanded their clinical role by acting as referral physicians during a patient's hospital stay for surgeons, subspecialists, and/or primary care providers. In addition they have taken on the challenge of improving quality of care by offering clinical services, such as palliative care and consults, and are serving as the leaders for hospital system focus on quality improvement including improved patient safety. Specific recognition of pediatric hospitalists and hospitalists in general as a subspecialty is moving forward. Recently, the American Board of Internal Medicine approved the creation of a certificate for hospitalists in internal medicine and there are numerous pediatric hospitalist fellowships. Nationally, multiple societies have formed for this growing group of new physicians including the American Academy of Pediatrics Section on Hospital Medicine, Society of Hospital Medicine Section for Pediatric Hospitalists, and the Ambulatory Pediatric Associations Section on Pediatric Hospitalists. While it may be thought that hospitalists are merely generalists that work in the hospital and therefore should not be considered a separate group, hospitalists have a narrower focus that allows them to achieve better length of stay with lower costs and potentially improve the quality and safety of inpatient care as demonstrated in the studies referenced in this essay. Along with narrower focus the increased experience of treating inpatient illness and increased in-hospital availability contribute to the benefits described for hospitalist programs. Whether hospitalists will succeed as outlined above and how this group will function within our South Carolina healthcare system is up to the local leaders and state policy makers. Dr Carolyn Clancy, the Director of AHRQ pointed out in her Keynote Address to the Society of Hospital Medicine in May 2006 that "we will need you to expand 2 or 3 times to address this issue of quality". We make the following recommendations to incorporate these potentially beneficial systems: 1) Implemented hospital systems should follow the guidelines in the April 2005 Pediatrics policy statement. It is essential that systems be voluntary and private physicians reserve the right to admit to the hospital since many office based pediatricians have the skills and desire to continue inpatient care. 2) Medicaid and private providers should recognize the safety net function of hospitalist programs and the increasing complexity and acuity of pediatric inpatients and should reimburse pediatric inpatient care at or above Medicare rates to insure that hospitalist programs are financially sustainable. 3) Hospitalists should act as leaders in safety and quality initiatives including the use of evidence-based practice. 4) Implementation of hospitalist programs should be done in collaboration with local physicians to insure success and acceptance. In summary, hospitalists programs are growing and defining new paradigms in the national healthcare system. The programs can offer numerous benefits to patients, hospitals, and payers.