The biggest challenge hospitalists face is fulfillment of our promise.
by Larry Wellikson, MD, SFHM
Hospital medicine is 15 years old now and, as the fastest-growing medical specialty, has created innovation and excitement in healthcare. With more than 34,000 hospitalists at more than 4,000 hospitals, hospitalists are now an accepted part of the medical community. But clearly HM is still a work in progress, with our best days still ahead of us.
So what’s in store for us as we look to the next five to 10 years?
First, it is important to note that the very institution of the hospital is evolving. Hospitals no longer are defined by the walls of their buildings; hospitals view themselves as significant community resources along a continuum of care that includes care when the patient is horizontally confined during an acute illness. Just as hospitals need to be involved in the care of the community (e.g. to reduce preventable readmissions or ED visits), so too hospitalists’ scope of practice is expanding.
At one time, long, long ago, the scope of hospitalists’ work could be narrowly defined as the care of the acutely ill patient with such a medical illness as heart failure or pneumonia. Today, hospitalists routinely comanage surgical problems and serve as the prime admitter for medical cases (acute chest pain, sepsis, and the like) previously sent directly to specialists.
As surgeons and specialists have narrowed their practices, hospitalists have been called on to be proceduralists, inserting central lines and even doing bedside ultrasound. With a decreasing workforce of critical-care-trained physicians, hospitalists are being challenged to provide an ever-increasing amount of critical care, a phenomenon that will increase in the future and further stretch the competencies and training of most hospitalists.
At the edges of acute care, hospitalists are being called upon to augment the “neighborhood” around the patient-centered medical home. In some settings, hospitalists now provide the initial post-discharge, follow-up outpatient visits to “complete” the hospitalization, stabilize the patient, and transition them back to their community provider. CareMore Health Plan in California is setting the standard for this transitionalist role, also known as an “extensivist.” As the demand from hospitals and payors to reduce post-discharge bounce-back to the ED or to be readmitted increases, hospitalists and the medical home will need to carefully coordinate their roles if HM is to provide our patients (and their families) with what they need and expect—a smooth, coordinated transition from the hospital to home with clear communication and accountability
To do this, and do this well, hospitalists will need to fulfill our promise. We have spent the last decade positioning hospitalists as having two patients: the clinical care of the patient in front of us and the improvement of the system we work in. We have acknowledged that most hospitalists don’t come out of residency, or even years in practice, with all the skills needed for this unique and important role.
In many ways, SHM has become the society of “everything you didn’t learn in training that you found out you need to know in practice.” SHM has trained more than 2,000 hospitalists in our Leadership Academies. We have expanded our annual-meeting course offerings to include perioperative care, neurology, critical care, and procedures.
Through the Center for Hospital Improvement and Innovation, SHM has developed courses in quality-improvement (QI) skills and processes, as well as support and tactics for helping hospitalists make real change at their institutions through SHM’s mentored implementation in transitions of care (Project BOOST), preventing DVT, and improving glycemic control.
But even with SHM and many other organizations touching thousands of hospitalists, the HM landscape is varied. Some hospitalist groups are well-formed, well-staffed and supported, and they are delivering on the full promise of HM today. Yet many HM groups are very much a work in progress.
This is not surprising when you realize that the role of hospitalists has been evolving in real time while the hospitals we all work in are changing as well. Throw into the mix the addition of more than 30,000 hospitalists over the last decade with various training, skills, and experience, and it is not unexpected that the results have been a mixed bag.
In the next decade, however, HM groups will need to step up their game to fulfill the promise of HM more broadly in our nation’s hospitals. SHM hopes to provide a guidepost in this process and is considering developing standards for HM groups (HMGs) and possibly creating an aspirational award along the lines of the Baldrige Award. At the beginning, maybe only a few hundred HMGs will qualify for such an award, but the hope is that other HMGs will use this opportunity to obtain the resources and make the improvements to also achieve the highest standard for hospitalists.
At the same time, it is clear that both the government and private insurers are heading toward a new way to pay for healthcare, moving away from the current transactional manner in which the procedure and the visit is the currency, to something where value and performance become crucial.
This is a system in which preventing the DVT is more valued than waiting for the complication and treating it, where doing the first hospitalization right and working with the family and the patient to make the best transition out of the hospital is rewarded more than billing the insurer for the readmission.
The efficient and competent HM group is an ideal partner for the hospital in this future world.
In addition, the hospital community is being reshaped. More and more physicians are gravitating to the hospital as an employee or essential partner. More than 70% of cardiologists are now hospital-employed. Specialty hospitalists, most notably in the fields of OBGYN, neurology, orthopedics, surgery, and psychiatry, are growing.
Accountable-care organizations (ACOs) are being supported by Medicare and should continue to grow as another hospital-physician risk-sharing entity. In many places, hospitalists have been in place for more than 10 years as the original physician partners with their hospitals. It is very likely that hospitalists will be right in the middle of the new medical staff and in driving the expected efficiencies and improvements as the hospital of the future and payment system changes continue to evolve.
In all of this, it is important for HM to continue to be creative and innovative, and not hamstrung by the conventional and the status quo. This calls for more than just fresh ideas and the courage to be bold. It requires new skills and competencies. We must continue to knock down the barriers of autonomy and exchange that for active participation in, and leadership of, the team. We must continue to move away from the mystique of the physician and embrace the need to set a course for change, be willing to be measured and be less than perfect, and seize the opportunity to improve and innovate.
Although the last decade of HM has been no piece of cake, the next 10 years will be even more challenging. The good news is that our skills and competencies can make us a central player, a key partner. But we will need to rise to meet this challenge.
Dr. Wellikson is CEO of SHM.
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.