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In The Driver’s Seat


It’s a refrain I have heard too many times in too many places: “Don’t do it.”

You have probably heard it, too—that plaintive cry from some practicing physicians trying to discourage young people from entering a career in medicine. I understand why so many doctors seem so pessimistic about medicine’s future. They’re grappling with a healthcare industry that struggles with overwhelming complexity. They face unrelenting cost pressures, misaligned incentives and policies, massive shortfalls in quality and service, fragmented systems, and disunity among peers.

I understand the pessimism, but I cannot agree with it. At the midpoint of my term as SHM president, I reflect upon the strengths that distinguish our specialty and our society from the general malaise of the broader healthcare industry. These strengths compel me to redouble my resolve to deliver on the promise of hospital medicine.

What is that promise? Hospitalists are poised to lead the way toward a better healthcare system in two critical ways. They are situated to help advance quality control and they are uniquely situated to promote medicine as a team effort, a shared vision with the hospital.

Now, quality control and teamwork are not in the standard curriculum. Medical school training focuses on disease. But in the real world of the hospital, quality control and the teamwork it takes to ensure it are vital issues. This is where hospitalists must prove themselves. This is where our special skills align with the priorities of hospital CEOs nationwide. We must advance the quality agenda and engage other physicians in a shared vision with the hospital.

These factors set us apart from other specialties and allow us to lead from the core of our strength. We lead:

  • Through quality rather than narrow professional self-interests;
  • While valuing the team over the individual; and
  • With openness and inclusiveness to all medical personnel involved patient care, from pharmacists to nurses, to nonphysician providers, to management.

This is our great promise—but only if we exercise it. As the brilliant author and scientist Johann Wolfgang von Goethe cautioned 200 years ago: “Knowing is not enough. We must apply.”

Honesty requires physicians to admit there is sometimes a gap between what we know and what we apply. Many quality metrics measure our performance. For example, we know we must get aspirin to a heart attack victim quickly. But the clinical strides that dictate the care patients ought to get must be moved into the operational area, where optimal care is sometimes lacking.

We next need to work out the systems to ensure that care, turning best practices into routine practice. Hospitalists are in the vanguard on that front, just as other specialties have been on the cutting edge of academic medicine. Our specialty will always need to weigh in on the development and vetting of quality and safety metrics related to hospital care.

We are also poised to advance the implementation and application of systems that drive improvement in those metrics.

Ours is a young specialty—the average hospitalist is 37, the leadership 41. While we have accomplished much in our 10 years of existence, there is much more to do. Hospitalists must meet the extraordinarily high expectations of hospitals and the other physicians who work in them. We must help manage emergency patients, surgical patients, and the in-hospital patient census of primary care physicians.

But there is a shortage of physicians in our specialty because demand is so great. It’s hard to sustain our growth as a specialty and work on quality control at the same time.

We are in the financial crosshairs, as well. Administrators want to see value—that is, money saved. But the fact that we see and manage patients does not generate savings per se because insurance companies do not allow reimbursement as such for our services. “Prove your value,” they say. “Show us the money.” That translates into driving down length of stay, cutting nursing expenses, and reducing pharmacy costs though better quality control and more coordinated care.

But administrators also know that to accomplish these goals and bring other physicians on board, their best ally is the hospitalist.

Our patients demand more of us, too. In “Zen and the Art of Physician Autonomy Maintenance” in Annals of Internal Medicine in 2003, author Jim Reinertsen clearly stated the public’s perspective. “You claim that your profession is based on science … now show us that you can use all the science you know, for our benefit,” he writes. He asks us to “join together—as a profession—with our colleagues, in venues large and small to decide on and apply the best science.”

It is the least we can do as physicians. But in practice, working together to apply the best science is difficult.

All of which brings me to my final point: SHM’s commitment to our members. In October, SHM sponsored two summits, the first on healthcare quality, the second on leadership development. Two themes emerged. First, it takes an unwavering commitment to teamwork to accomplish anything of substance. Second, the educational needs of our workforce are tremendous. SHM’s focus on acquiring skills and applying knowledge are the society’s greatest accomplishment and greatest ongoing opportunity. To that end, we are working on four fronts.

First, we are developing alliances with other like-minded organizations such as the Case Management Association of America, the American Nursing Association, the American Hospital Association, and the Institute for Healthcare Improvement. Through these alliances we hope to foster the teams that will improve the monitoring of parameters of hospital care, and the care itself.

Second, we are committed to creating the tools to equip hospitalists to make the changes that will lead to improvements in the front lines of hospital medicine. We have taken several such steps. SHM has developed a discharge checklist for physicians to use before sending patients home or to other facilities. The checklist, somewhat like those used by pilots, ensures nothing is forgotten or overlooked upon discharge. We believe it will become an invaluable tool.

SHM has also added Resource Rooms to our Web site ( Here, our members can look up and download information on disease states like heart failure or venous thromboembolism.

Third, SHM is funding a group of quality-control mentors available to visit hospitals. These mentors will evaluate and advise on quality-control programs at SHM’s expense.

Finally, SHM wants to train its next generation of leaders. Quality control is a never-ending quest; it can always be better. That is what we at SHM strive for. That is what we owe our patients.

All these tools have one goal: Make quality easy. With so many other pressures of physicians and hospital staff, making it easy is also the key to making it work.

“Knowing is not enough,” Goethe said. “We must apply.” I say: “Willing is not enough. We must do.” TH

Dr. Holman is president of SHM.

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