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The View from 2017


 

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

Dr. Robert Wachter donned appropriate retirement garb to address SHM Annual Meeting attendees from the "future."

Dr. Robert Wachter donned appropriate retirement garb to address SHM Annual Meeting attendees from the “future.”

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

These past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries.

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

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