Where Will We Find 50,000 Hospitalists?

Larry Wellikson, MD

There are more than 20,000 practicing hospitalists in the United States, and yet from every corner of hospital medicine it seems everyone is looking for more hospitalists.

While SHM has been touting that there will be 30,000 hospitalists in the next five years, others are now calling for 40,000 and more. At the SHM Annual Meeting in Dallas in May, Bob Wachter, MD, predicted a specialty with as many as 50,000 hospitalists. What is driving this logarithmic growth in hospital medicine?

Initial studies by Jon Lurie, MD, of Dartmouth Medical School, Hanover, N.H., and others dating back to the late 1990s cited the need for “only” 20,000 hospitalists. Ten years later, those studies seem almost primitive.

Originally, hospitalists were perceived necessary to replace the inpatient work for a small percentage of family practitioners and general internists—mainly at larger hospitals. While there was initial resistance from primary care physicians (PCP) in the early years of hospital medicine, the rapid adoption of hospital medicine by most PCPs has driven our rapid growth. Now, hospital administrators are frequently besieged by their PCP base to “get us some hospitalists” rather than to block hospitalists from the medical staff. And this occurs at not only 500-bed hospitals but at many hospitals with fewer than 100 beds.

More recently hospitalists have been active in co-managing surgical patients, handling glycemic control, preventing DVT, and writing scrips for the antibiotics. This frees the surgeon to concentrate on operative and post-operative surgical aspects of the case. This division of labor allows specialists to use their unique talents, which can lead to better patient outcomes. Hospitalists frequently also staff a pre-admission clinic to evaluate elective surgical patients prior to admission to the hospital. Surgical co-management also is happening with orthopedics and neurosurgery at community hospitals and major academic medical centers.

The increasing role of hospitalists in what was traditionally subspecialty cases is further fueling the growth of hospital medicine. Hospitalists now admit more heart failure patients than cardiologists, manage more inpatient diabetic cases than endocrinologists, and have virtually replaced neurologists to manage inpatient stroke patients. Once again this allows specialists to focus their expertise as best they can, while hospitalists manage the aspects of these complex cases that fall under their purview.

SHM will hold the National Summit on Hospital Medicine Workforce Issues later this year. The goal is to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine.

Hospitalists also find themselves with an expanded role in the critical care arena, working with an inadequate supply of intensivists to help manage patients in extremis. And hospitalists are being called into the emergency department (ED), where they serve as in-house consultant, improve the movement of patients out of the ED, and take over some or all the responsibilities of managing the observation units.

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