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An Environmental Assessment for Hospital Medicine
Results of recent SHM surveys
by Larry Wellikson, MD, FHM
In preparation for the SHM Board Strategic Planning Retreat in November 2006, SHM performed a series of surveys to get a handle on the current and future world of hospital medicine. During this investigational process, SHM contacted leaders in hospital medicine and throughout healthcare to get their input and perspectives. In the final phases of understanding the hospital medicine landscape, SHM launched a focused survey of SHM members in fall 2006 to validate what we were hearing from our healthcare experts. Here are some of our findings.
While the list of expectations can seem without end, our survey of hospitalists indicated more than 10 key expectations.
Expectations of Hospital Medicine
While the list of these expectations can seem without end, our survey of hospitalists indicated the following expectations in order of most importance as rated by the survey respondents.
- Provide high quality patient care: At the end of the day even though hospitalists have many roles, the hallmark is to be the best at the bedside that we can be;
- Effectively communicate with other health professionals as well as patients and their families: Hospitalists have crucial information and insights. We have the responsibility to be experts in translating this knowledge so that our patients and their families have an expert partner in their healthcare. This translates into efforts in health literacy and palliative care and end-of-life care;
- Provide leadership in transitions and coordination of care: More and more often there are opportunities for fragmentation and voltage drops as patients move into and out of the hospital. But even within the hospital, the frequent handoffs by staff with shift changes or from ICU or ED to the rest of the hospital create opportunities for errors and quality drop offs. Hospitalists are expected to play a key role in minimizing these valleys in patient care and to set the standard for the institution. You will be hearing more about this in future columns as SHM takes a leadership role on a national level;
- Deliver efficient patient care with appropriate use of resources: This is the most studied aspect of hospital medicine and one trait that is accepted now without much question. Hospitalists are the first physician specialty expected to reduce resource consumption and improve the patient flow at their hospital (i.e., throughput) while improving measurable quality;
- Help hospitals meet regulatory, quality, and safety requirements: It seems that every day brings a new mandate or measurement to our nation’s hospitals. Increasingly it falls to the hospitalist to work with the hospitals and their staffs to meet these requirements. Hospitalists are becoming the de facto chief quality officers (CQOs) in many hospitals;
- Collaborate with other health professionals to form and lead multidisciplinary teams: Hospitalists know that we can’t meet this expectation alone. The day of the individual as the all-knowing solo provider of healthcare is going the way of the dinosaur. There is enough work to go around, and the enlightened hospital is figuring out how to use all the available man (and woman) power at its disposal. If we are to create the quality and efficiency we are expected to produce we will need everyone pulling in the same direction;
- Broaden the scope of hospitalist practice through co-management of patients with surgeons and other specialists: The fastest growing aspect of hospital medicine is the role of hospitalists in co-management with other physicians. The hospitalist has a role as an in-house advisor to the emergency physicians, as an “extender” of the overextended intensivists, as the perioperative manager of the medical problems of the surgical patients, and as the general physician for the acutely ill specialty patient. But this attempt to have hospitalists help everyone with everything creates opportunities for “scope creep.” Hospitalists must be helpful to the rest of the medical staff, but everyone needs to be careful to draw the lines of practice based on competence and expertise and not simply availability and convenience; and
- Be a geriatric expert for the acutely ill senior: Hospitalists are not geriatricians for the most part, but the vast majority of the patients managed by hospitalists who do care for adults are over 65. This vulnerable population has unique needs and the penalties for miscommunication or mismanagement are severe and potentially lethal. Hospitalists will need to work with geriatricians, social workers, patients’ families, and other resources to bring value to this key population of patients.
Education Niche Work
Hospitalists also are expected to play unique roles in healthcare education and the development of new knowledge. While this burden may seem to fall disproportionately on academic hospitalists, many community hospitalists also play a role here.
- Serve as a role model for residents and medical students: Much of medical education in medical school and residencies still occurs in the hospital. Hospitalists can bring the enthusiasm of being on the cutting edge of the future of healthcare to the next generation of physicians.
- Update medical education to address the training of young hospitalists and other health professionals: No one knows how large the gap between what they were taught in med school and what they are expected to perform in real time in real life is as well as hospitalists do. If hospitalists and the rest of the healthcare team are expected to improve quality performance (and measure it), mange patients efficiently, make the patient flow through the hospital go smoothly, and communicate to all stakeholders through the transitions and coordination of care, then we had better change what is taught in our professional schools; and
- Increase medical knowledge in hospital medicine through original research: Hospital medicine is a unique discipline that hopes to rely on evidence-based information. The Journal of Hospital Medicine provides a venue for displaying new information that the cadre of young hospitalist researchers will provide in health systems and quality improvement and patient safety studies.
By no means is this meant to be an exhaustive list, but rather a “Top 10” (or 11) gleaned from our survey of hospitalists. This study also examined the hospitalists’ view of the difficult issues facing hospitalists and the major barriers that hospitalists face in meeting these extensive and lofty expectations. In future columns we will examine these issues and barriers. In the meantime everyone should get back to work. We still have much left to do. TH
Dr. Wellikson has been CEO of SHM since 2000.