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Hospitalist: the iPod of Medicine


Have you ever looked out your window and wondered, “When did that tree get planted?” Or wonder when you pass a new building that wasn’t there last week, “When did they build that?” Or remember a time when everyone didn’t have an iPod or a Treo Smartphone or Blackberry?

Well, hospital medicine and SHM are rapidly becoming the iPods of healthcare. We are still catching some by surprise. Others think we are everywhere, touching everything, and sometimes leaving them asking the universal question from Butch Cassidy and the Sundance Kids, “Who are those guys?”

Most of you know that while the adoption of hospital medicine and its meteoric rise seems at times a force of nature on a random and indeterminate course, the all too true reality is that many of the “sudden” advances by SHM have been many years in the planning. More than that, they have required key partnerships and significant behind the scenes activity.

It is very much akin to the sudden stardom of veteran performers who have been honing their craft under a smaller spotlight waiting for their time to come. The time for hospital medicine is now.

This is all the more important because hospital medicine has been getting by as a growth story for a while now and it is time to add the substance that will propel our specialty forward as a permanent part of the medical landscape and a key partner in improvement strategies for hospitals and our patients’ care.

Hospital medicine has its own repository now for our contributions to science and the formulation of the hospital of the future in the Journal of Hospital Medicine. The inaugural issue has met with accolades and acceptance. The second issue is on the way and soon it will seem like there has always been a JHM.

The first issue of JHM was all the more important and noteworthy because it was accompanied by a supplement: The Core Competencies in Hospital Medicine. Years in the making, this thoughtful document put SHM’s nickel down and said “Here is what makes hospital medicine unique: an evolving specialty, emanating from our roots in internal medicine, family practice, and pediatrics, but with a relevance to the practice of medicine in our nation’s hospitals in the 21st century.”

Fully accepting the hospitalists’ role in building teams, improving quality, driving hospital efficiencies, and promoting effective care, we hope the Competencies will be part of our road map as we participate in such important but disparate efforts as redesigning internal medicine training, developing a unique credential for hospitalists, and planning the hospital of the future.

These efforts, like JHM or The Core Competencies just a few years ago, are concepts today that will form the reality in the near term. As they develop I will use this space to bring you new developments and prepare all of us for our active roles in defining, participating in, and implementing the new future.

At its best SHM is not much more than an aggregator of good ideas and the developer of strategies. We can design the Ferrari and provide a parts list and an instruction manual. But you have to assemble the car and take it out on the road.

Recognition of Hospitalists

For several years SHM has been talking with the thought leaders in internal medicine including American Board of Internal Medicine (ABIM), American College of Physicians (ACP), Alliance for Academic Internal Medicine (AAIM), and others about not only the growth in size of hospital medicine, but the unique practice of hospitalists that defines us as related and as distinct from the rest of internal medicine as cardiology or critical care.

We started with internal medicine because more than 85% of hospitalists are trained as internists. But our strategy is to soon follow on with discussions with the American Board of Family Practice (ABFP), the American Board of Pediatrics (ABP), osteopathic certification organizations, and others who oversee any part of credentialing hospitalists.

The ABIM with the support of the ACP, the AAIM, SHM, and others has embarked on a process to use the Maintenance of Certification (MOC) to create a unique recognition for hospital medicine without requiring additional formal training beyond current residencies. The plan for now is that all graduates of an internal medicine residency would take the same initial certification, but that after entering practice and sometime within the first 10 years of practice, hospitalists could use the elements of the MOC process (e.g., self assessment, a quality improvement process, and a secure test—all specific to hospital medicine practice) to create a recognition of them as hospitalists. Presently, the ABIM has formed a Hospital Medicine Task Force to develop the details that will make this rigorous and meaningful to the key stakeholders (e.g., hospitals, patients, hospitalist employers, referring physicians, and hospitalists).

Getting this far was not in any way a slam dunk or a rubber stamp. SHM didn’t just send in a postcard asking for a credential for hospitalists and ABIM said, “Fine.” This has taken several years of reasoned conversations, meetings to clarify our position, and opportunities to understand the broader aspects of the emergence of hospital medicine’s effect on the rest of medicine. More recently it has taken the courageous leadership and vision of the ABIM, the ACP, the AAIM, and others to meet their missions of promoting quality of care for our patients.

Work still needs to be done and the devil is always in the details. But the current direction is forward, and that is surely welcome.

Working to Improve Quality

There has been much heat and fury around quality—defining it, measuring it, even possibly paying for it, instead of just paying for units of work whether they are any good or not. For many years the role of the professional medical society in the quality arena was to pull together the smartest people in their specialty, latch on to the diseases they knew the most about, define quality, write guidelines, issue a white paper, and declare victory.

From its beginning SHM has taken a different tactic. We believe many smart people have already defined the best quality for DVT or diabetes or CHF, but the remaining gaps have been in implementation strategies to export all these great ideas to 5,000 hospitals and the millions of patients who occupy them.

With this in mind SHM has sought funding in the diseases defined in our Core Competencies such as DVT, diabetes, CHF, and others, and we have looked for ways to provide hospitalists with key tools as well as looking for implementation strategies (e.g., mentorship, training courses in leadership and the quality improvement process, demonstration projects) to make a measurable difference. And as hospitalists begin to become change agents at their hospitals, we hope to use our meetings and our publications to report your successes and the barriers to success.

Once again SHM will not be able to do much on our own. Therefore, our strategy has been to involve very early on the leaders in nursing, pharmacy, case management, and relevant specialties of medicine. In fashioning a strategy for glycemic control in the hospital, for example, SHM works with the American Association of Clinical Endocrinologists, the American Diabetic Association, and others. Once again as early vague ideas take shape and become real programs, it seems as if they have appeared fully formed in short order. But SHM has been working on many of these for years, and we expect that we will be in the quality improvement implementation realm for many years to come. We are just getting started.

But here is where you are so important. At its best SHM is not much more than an aggregator of good ideas and the developer of strategies. You make it happen. We can design the Ferrari and maybe even provide a shopping list for parts and an instruction manual for assembling and operating. But you have to assemble the car and take it out on the road. It is our nation’s hospitalists, along with key partners and team members at their local institutions, who will provide the coefficients for change and the impetus for improvement.

Once you do this, SHM will have a role to praise, reward, and even prod you and to shine a bright light on all your work so others will be encouraged to take their shot and make great things happen.

SHM, like the hospitalists who form us, is a paradox. On first glance, we are patient and thoughtful with a longer look at the future and all the changes that will be required. At the same time we want to take our innovations and put them in place this week. We think the fearlessness of youth and open-box thinking is just what we need in healthcare today. We rely on our partners to temper our rush to action with their experience and wisdom and additional perspectives. The times require change. Together we can make sure it is a change for the better. TH

Dr. Wellikson has been CEO of SHM since 2000.

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