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Happy Birthday, HM

From: The Hospitalist, August 2011

Hospitalists’ meteoric rise to relevancy is buoyed by a to-be-determined legacy

by Jeff Glasheen, MD, SFHM

Jeff Glasheen, MD, SFHM

Ah, 15 years. My, how time flies. August 1996 seems like yesterday. I had just moved to Denver. It was a hot summer. I still had hair, a normal BMI, and a social life. The world was gearing up for the Olympics in Atlanta; my adrenal glands were gearing up for the hypertrophying journey called internship. The films of ’96 seemed to portend ominously about my year ahead: Twister (a whirlwind ride?), Jerry Maguire (you complete me, internship?), Independence Day (apocalypse?), The Nutty Professor (research attendings on the wards?), Mission: Impossible (hmmm).

The Spice Girls were spreading girl power, this thing called the Internet was sort of catching on with 10 million (yes, that’s an “m,” not a “b”) users worldwide, and the dotcom era introduced us to eBay, which offered to sell your junk “online.”

In Scotland, Dolly the sheep was cloned and the world grappled with the ethical implications. In England, Diana and Charles divorced and cows became mad (coincidence?). Back home, Seinfeld, ER, and Friends teamed for “must-see” Thursday nights, the average car cost $16,000, and Federal Reserve Chairman Alan Greenspan wondered if the Dow Jones was overvalued at 6,400.

Oh, and on Aug. 15, the term “hospitalist” appeared in print for the first time, helping launch the fastest-growing medical specialty of all time.1

Labor & Delivery

I remember as an intern seeing the article by Drs. Wachter and Goldman. I guess I didn’t get it, really. Was it that easy to create a new specialty? Just take something and add “ist” to the end? As interns, we excitedly begin to create new fields to describe our work: “dump-ologists,” “failure-to-thrive-ists,” “rectalists.” Much like Jamiroquai, however, our specialties never really caught on.

But HM did, and this month we celebrate 15 years. Now, I’ll recognize that its impossible to pin an exact date on the creation of a specialty, and in fact, hospitalists clearly existed prior to the term. But in terms of identifying a start date, Aug. 15, 1996, is as good as any.

The Early Days: Doing It

I don’t remember the day I became a hospitalist. It all sort of just flowed together. I finished residency, did a chief year where I taught, attended on the wards, and didn’t do any clinic, and then I took a job at the Denver VA, where I taught, attended on the wards, and didn’t do any clinic. It felt kind of all the same.

But from the outside, this was a significant transition point. Until this time, subspecialists or general internists, family medicine doctors, and pediatricians provided nearly all inpatient ward attending (and indeed, community inpatient care). I recall vividly the reaction of others; it was a mixture of amazement (you do what all year?), concern (you’ll burn out), apprehension (I won’t be able to care for my patients in the hospital), and enmity (you’ll destroy the fabric of internal medicine!).

And this was the point of the first few years: survival. These were the formative years. It was all about showing HM was a sustainable model that could enhance, not detract, from the system of care. And it had its very vocal critics, who saw it as a flash in the pan. They assumed it would go the way of the Tickle Me Elmo doll (a fad, for the record, that needed to die).

And this was the importance of the creation of the National Association of Inpatient Physicians (now SHM), HM textbooks, the development of hospitalist researchers, a national meeting, the creation of sustainable community hospitalist jobs, the growth of academic HM groups, and studies showing the model could indeed be implemented and wouldn’t negatively impact patient outcomes or outpatient provider satisfaction. These things legitimized the field, gave it legs, propelled it to the next phase.

The Next Phase: Doing it Cheaper

To be fair, HM is not all about the money. Even in the early days, it was recognized that at its pinnacle HM was about improving the patient experience—higher quality, safety, and satisfaction. That said, it was Medicare’s diagnosis-related group (DRG) that drove the model forward. To be clear, there were other factors that helped propel the HM movement: staffing issues, the rise in complexity of care, many PCPs and specialists willingly leaving the hospital. But in the end, the bottom line drove many hospital administrations to adopt the HM model.

Most hospital care is reimbursed via prospective payment, which means hospital reimbursement is, in a sense, determined upon admission. Every dollar of that DRG payment that isn’t spent is pocketed by the hospital as profit. As expected, specialists in hospital care were able to significantly reduce the length of hospital stay, costs of care, and, ultimately, save hospitals many dollars for each dollar of investment.

And to be clear, there was nothing unsavory about this. It wasn’t done through rationing care or reducing access, but rather through systematically reducing some of the estimated 30% waste in healthcare. This was shown in numerous studies, with a 2002 report estimating average savings at about 13% per patient cared for in the HM model.2

I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes..

The Current Phase: Doing it Better

Pretty impressive, but mostly unsatisfying. Yes, as a group director that has negotiated for nearly a decade with hospital administrators, I’m well aware of the power of cost savings. Yet, I didn’t go into medicine to save money. I did so to help patients, enhance their experience, and improve outcomes. And indeed, there are data that hospitalists do this. Two 2002 papers showed that hospitalist groups could reduce readmission rates as well as inpatient and 30-day mortality.3,4 A paper in 2004 showed that pairing hospitalists with orthopedic surgeons could reduce perioperative complications.5

Couple these studies with anecdotal experience and perusal of any issue of the Journal of Hospital Medicine, and its clear that hospitalists are fulfilling their promise of doing it better. But we have a long way to go. We must continue to innovative and create better, safer systems of care until we can be confident that not a single one of our patients is avoidably harmed by healthcare. That is the kind of care you’d want for your family member, for yourself.

Our Legacy, TBD

And here we are now, looking forward to the next 15 years. For many hospitalists, this will represent the twilight years of their careers. For others, it’ll be the formative years. What mark will we leave?

Clearly, the premium on patient safety and quality is increasing, morphing from word to deed as we speak. And hospitalists will find themselves in the middle of the fray. The healthcare reform alphabet soup calls for equal parts VBP and ACO, with a pinch of EHR, and a dash of PFP—boiled in a cost reduction. But more than ingredients, it requires a chef—someone to orchestrate the great change that is necessary in American healthcare.

Whether it’s leading inpatient safety, improving the quality of hospital care, bridging post-discharge transitions, or reducing readmissions, someone is required to tend these fires.

And I believe HM’s legacy will be forged in these flames of change. There is no single group as well positioned to impact the outcomes that matter most to healthcare reform now than hospitalists. In most hospitals, we will touch the majority of patients, control the spending of the majority of dollars, and be directly responsible for the majority of outcomes. This is an unfathomable position to be in for a specialty that is yet old enough to drive. Yet this is where we find ourselves.

Our legacy is being written. You are its author.

Dr. Glasheen is The Hospitalist’s physician editor.

References

  1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.
  2. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
  3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
  4. Meltzer D, Manning WG, Morrison J, Shah MN, Jin L, Guth T, Levinson W. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
  5. Huddleston JM, Long KH, Naessens JM, et. al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38.

This copy is for your personal, noncommercial use only. No part of this article can be reproduced without the written permission of the publisher. Order presentation-ready copies for distribution to your colleagues, clients, or customers by contacting our reprints department at reprints@wiley.com. Copyright © 2009 Society of Hospital Medicine, administered by John Wiley & Sons Inc.

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