Robert M. Wachter, MD, professor and chief of the medical service at the University of California, San Francisco (UCSF) Medical Center and director of its hospital medicine group, addressed the audience at the 8th Annual Meeting of the Society of Hospital Medicine (SHM), along with several other noted leaders. Shortly before the meeting, Wachter shared his insight on the initial years of hospital medicine as well as the complexities, challenges, and opportunities the future holds for hospital medicine groups with The Hospitalist.
Well known for having coined the term “hospitalist” in a 1996 New England Journal of Medicine article, Wachter provided a brief outline of the birth of the hospital medicine discipline. He recalled that the initial growth of the field was slow, but it gained momentum as healthcare facilities began to perceive this specialty as an effective way to fulfill a need. During the last 10 years, hospitalists have made clear their value as agents of throughput, systems management, resource utilization, physician practice improvement, round the clock availability, and medical student education, always placing patient safety, satisfaction, and quality at the forefront of the practice. During the next 10 years―and beyond―Wachter envisions an evolution in the critical role hospitalists will play in the continued delivery of quality health care, although he does admit there are some obstacles in the path.
Having established their core role as managers of medical inpatients, hospitalists are setting their sights on other goals. “It’s logical and inevitable that hospitalists will take on roles in surgical co-management,” Wachter says. “Patients who are sick enough to be inpatients for surgery often have multiple medical illnesses. And surgeons are in the OR for much of the day, in some ways like primary care doctors’ being in the office.” Although the data to support this model are limited presently, he believes that good co-management programs will likely lead to an increase in the quality of care, efficiency and patient satisfaction as well as surgeon satisfaction. “This makes … intuitive sense, just as the whole hospitalist idea made sense 10 years ago,” he says.
Wachter admits that the transition will probably be gradual, because of the many clinical, economic, and political complexities. In many cases, surgeons receive a global fee , linked to the expectation that they will administer preoperative and postoperative care. “It will be tricky to try to figure out how to compensate the hospitalist for surgical co-management,” Wachter says. However, he expects the financial aspect of surgical co-management to eventually work itself out. “If there is a more efficient way to manage patients and a way to free up beds, hospitals will be interested in supporting it,” he says. Wachter anticipates a 5- to 10-year evolution before this model becomes widely embraced.
Patient Safety and Quality Improvement
Timing is everything, and for hospitalists the timing could not have been better. “The hospital medicine movement evolved precisely when American medicine began to care about safety and quality,” says Wachter. ”When I first read the Institute of Medicine report on patient safety, ‘To Err is Human,’ in 1999, I knew that we had a tremendous opportunity to make a difference.” Wachter notes that in the past, incentives for high quality performance were lacking. “That is changing rapidly,” he says. With the profusion of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates, Centers for Medicare and Medicaid Services (CMS) metrics, Leapfrog initiatives, and other quality measures, patient safety and quality have become top priorities. Since hospital medicine encompasses all the vital aspects of quality improvement and patient safety―from understanding transitions and working collaboratively with other medical specialists to improving systems and more effective oversight―hospitalists are becoming the “goto people,” according to Wachter. This is incredibly healthy for our field, he notes, “but more importantly, it will help save.”
As one measure of how the world has changed in just a few years, Wachter reflects on the experience of editing his textbook, Hospital Medicine, in 2000, and again in 2005 for the second edition. He was particularly struck by the chapter he wrote (in the 2005 edition, with his UCSF colleague Niraj Sehgal) on quality measurement and improvement. “It was staggering how much the area had changed,” he says. In the 2000 edition, there were 2 inpatient quality measures: aspirin and beta blockers for patients with myocardial infarction. In the 2005 edition, “we needed a 2-page table to catalogue all of the hospital quality measures produced by an alphabet soup of agencies and organizations.” In fact, he notes, of the 122 chapters in the book, the chapter that had changed the most in 5 years was the one on quality measurement. “This is a complex science that is still evolving,” Wachter says. “I fully expect that the chapter in the 3rd edition will change even more.”
Wachter has spearheaded several other initiatives designed to improve hospital conditions and care of patients. He leads a team of editors for the website, AHRQ Web M&M: Morbidity and Mortality Rounds on the Web (www.webmm.ahrq.gov), which provides expert analyses on medical errors, as well as a forum and online discussions on patient safety issues. He and his colleagues recently launched a second federally sponsored portal for patient safety, “AHRQ Patient Safety Network” (www.psnet.ahrq.gov), which offers regularly updated tools, new literature, surveys, videos, and links to other useful resources and experts and is customizable according to users’ interests.
With all the responsibilities assigned to hospitalists, the issue of burnout might become a concern. Defined as mental and/or physical exhaustion caused by excessive and prolonged stress, burnout can afflict medical professionals who spend long hours caring for complicated patients. Wachter worries about burnout, but not unduly so. “There is nothing fundamental about our field that will cause burnout,” he says. He cites 4 factors that contribute to burnout: doing uninteresting, unimportant work; receiving little or no respect from peers; having little or no time to “catch your breath”; and earning an inadequate and unreasonable income. With the diverse responsibilities and personally and professionally satisfying work in which a hospitalist engages, these risks can be mitigated. “I’ve certainly visited hospital medicine groups that were rife with burned out providers,” he says. “But more often, I’ve seen terrific doctors doing work they love, making a difference in the lives of their patients and their institutions. When that’s the case, you don’t see much burnout.” Wachter believes that the way in which hospital medicine groups are designed influences the potential burnout factor. Considerable thought and planning should precede the creation of a hospital medicine group, he asserts. “Some groups are well constructed,” he says. “They’ve created jobs with reasonable amounts of downtime, an opportunity to earn a good income, and the chance to spend time improving the system and deliver high quality patient care.” On the other hand, groups that care for an unsustainable number of patients with lower recompense might well have burnout; some have even collapsed after the physicians led. “You can be sure,” he notes, “that the second iteration of the hospital medicine programs at these institutions will be structured much more carefully so as not to repeat the same mistakes.”
Using his own UCSF Medical Center as an example, Wachter notes virtually no burnout or attrition among his faculty, even though salaries are on an academic scale, below the prevailing community rate. “We feel supported and have time to catch our breath,” he says. “We are respected by our colleagues and the institution, we have a chance to teach, and we genuinely enjoy each other’s company. And we have a chance to work on other things, not just patient care.” And that makes all the difference.
The Future of Hospital Medicine
Wachter was recently elected to the American Board of Internal Medicine, the only new member and the sole hospitalist to earn this honor. In this role, he will have the opportunity to provide input that will influence the development and expansion of the hospital medicine movement. “The Board is interested in the growth of the hospitalist field and what it means for the future,” he says. “They would like to know how to support the field and how best to attract students to it.” Many members of the Board who were skeptical at first about the hospitalist field have now recognized that “hospitalists have brought back the excitement of being an internist.” Wachter believes that students exposed to hospitalists soon realize that these doctors have fulfilling, diverse careers. “Hospitalists interact with patients, act as leaders to make patient care better, increase quality, and write guidelines,” he says. “This is a rich job description.” At the UCSF Medical Center, students involved in various clerkships have the opportunity to work under the tutelage of hospitalists. These collaborative relationships bring greater understanding of the work a hospitalist does and promotes the future of the field, according to Wachter.
As each new specialty evolves, different requirements for certification arise. Since hospital medicine is still a fairly young field, educational and training qualifications have yet to be determined. In his role on the American Board of Internal Medicine, Wachter will probably contribute to the discussion on what certification can and should look like. “This is an area of active investigation,” he says. “Will there be a separate certification for hospitalists? Should it be given at initial certification or when a physician recertifies after having been a practicing hospitalist with demonstrated competency? Right now there is no widespread model for hospitalist training at the residency level,” says Wachter. “I would not be surprised if in 10 or 15 years specialized training evolves for hospitalists. If so, then it would be logical that there be some type of separate certification. It’ll be fascinating working with the Board and SHM to determine the best course in the meantime.”