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Where Will We Find 50,000 Hospitalists?

From: The Hospitalist, August 2007

SHM poised to shape strategies to avoid a workforce crisis

by Larry Wellikson, MD, FHM

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.

Add to this clinical work the time hospitalists must spend on quality improvement, team building, systems changing, and education. The workload is expanding all the time as the hospitalist job description grows and grows.

With the prospect that almost every hospital is starting and growing its hospital medicine group (HMG)—therefore expanding the scope of hospital medicine—it is no wonder predictions of the need for 50,000 hospitalists are becoming credible.

And almost every hospital medicine company is growing. At this year’s SHM Annual Meeting in Dallas I talked to leaders from Emcare (Dallas), Cogent Healthcare (Irvine, Calif.), TeamHealth (Knoxville, Tenn.), Sound Inpatient Physicians (Tacoma, Wash.), Eagle Hospital Physicians (Atlanta), PrimeDoc (Asheville, N.C.), IPC–The Hospitalist Company (North Hollywood, Calif.), and other large employers of hospitalists. Every one of them saw their organizations adding HMGs, needing more hospitalists, and wondering where they will find them.

SHM has benefited by this recruitment feeding frenzy. Just look at the ads in this issue of The Hospitalist, surf SHM’s Online Career Center, or visit our meeting’s Exhibit Hall to see the tangible expression of the need to find more hospitalists. This cannot be solved by hospitalists jumping from one place to another. We need to find a way to attract a new wave of qualified hospitalists into our specialty.

Where will these new hospitalists come from?

Right now about 8% of internal medicine residency graduates enter hospital medicine. While this is a steady stream of new hospitalists, the flow is but a trickle and we need a rapid current. Is it time for hospital medicine to develop a more aggressive recruitment strategy geared to third-year medical students to pull them into hospital medicine with offers of a job or loan repayment?

In addition, some general internists move into hospital medicine each year, but this is a shrinking pool of potential new hospitalists. While 3% of hospitalists have been trained as family practitioners, there are no good statistics on how many family practitioner residents select hospital medicine as a career or how many family practitioners in practice come to hospital medicine. While the guess is that the pool of family practitioners presents an opportunity for future hospitalists, there are some concerns about how well today’s family practitioner residency training prepares young physicians to step right into the role of a hospitalist.

There are other sources for hospitalist physicians from overseas. Currently 25% of the U.S. physician workforce is made up of international medical graduates (IMGs).1 Further, 35% of internal medicine residents and fellows are graduates of medical schools outside the United States.2 SHM’s surveys indicate that approximately 26% of hospitalists are IMGs. That said, hiring physicians from outside the U.S. can present residency and visa issues that complicate employment. Will hospital medicine employers need to look abroad in the same way the U.S. has become a major importer of RNs and other health professionals?

Speaking of nonphysician providers, 5% of hospitalists are PAs and NPs, and this segment appears to be growing. Are there strategies that allow for increased use of nonphysicians in the hospital medicine workforce that can allow a group of hospitalists to be more productive and meet all their stretch goals?

While the question is clear—where will the next 20,000 to 30,000 hospitalists come from?—the answer is somewhat muddled. With this in mind, SHM will hold the National Summit on Hospital Medicine Workforce Issues in late 2007. This will be a practical work group made up of the key national leaders of hospital medicine employers along with key decision makers from medical schools, family practice, pediatrics, internal medicine residency programs, the nonphysician provider community, and others who can help set a direction to solve what is rapidly becoming a crisis in manpower. From this summit SHM hopes to have clear, actionable strategies to create an environment for continued growth and maturation of hospital medicine and deliver on the promise of better healthcare for the patients and the communities we serve. TH

Dr. Wellikson is the CEO of SHM.

References

  1. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct 27;353(17):1810-1818.
  2. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2004-2005: Trends in primary care specialties. JAMA. 2005 Sep 7;294(9):1075-1082.

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