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The rate of change within hospital medicine has been astounding over the past 11 years, and we have always tried to position SHM to remain nimble to respond to those changes. Racing legend Mario Andretti once said that if everything seems under control, you aren’t going fast enough.

Rapid responsiveness has become deeply ingrained within the culture of SHM. Every member should be proud because this is the result of the hard work and dedication of the many members who simply refuse to accept the status quo.

A few months ago, I met with a group of young hospitalists. We were discussing a variety of topics when one of the hospitalists asked in a frustrated tone, “When is the change going to stop?” Her program was experiencing rapid growth while still trying to recruit sufficient hospitalists. Yet at the same time, she was enjoying involvement in several quality improvement projects at her hospital.

I began to talk with her about schedules, smart growth, time management—all the management techniques I have picked up over time. But she pushed back: “No, when is it going to stop? I love my job, but all this change and push to see more patients and comply with increasing safety/quality mandates is really stressing me. I simply see no end in sight. Our program is going to end up admitting or consulting on almost every patient in this hospital. We can’t find enough hospitalists! When is it going to stop?”

Many of you are still skeptical. Some of you struggle just getting approval for a part-time administrative person. You can’t ever imagine the hospital providing additional resources. Trust me when I tell you times are changing.

Before answering her, I thought about all the accomplishments of hospital medicine, particularly those fostered by SHM. The list is numerous. I wondered whether, despite our nimbleness, we were still helping this frustrated hospitalist and her patients. She was asking what it’s going to take to move beyond the frustration despite 11 years of hospital medicine milestones.

My answer: It is not going to stop until we look beyond our current view. We have laid a great foundation at SHM and in hospital medicine, but we must embrace a different method of delivering care to our patients. Our long-term professional satisfaction demands it. Moreover, if we really want to deliver high-quality care to the many patients we are being asked to see, this change is an absolute necessity. It won’t come easily, but hospitalists are not alone in this; many other specialties must face it, as well.

During my 13 years as a hospitalist—half of which were spent in hospital medicine private practice—I have seen patients in 10 hospitals. These hospitals ranged from a 100-bed community hospital to a 600-bed academic medical center. Some have been for profit, some not for profit, and some government sponsored. What is interesting is that in each of these facilities, my ability to see patients was vastly different. In one hospital, I could comfortably see 25 to 30 patients a day. In another, I could barely see eight to 10. In some, the admission process took me 30 minutes, in another 90 minutes.

What is the difference in these hospitals? It usually isn’t much. Maybe it’s the fact the charts are always in one place. Maybe the electronic medical record is simply better, or the ward secretaries more helpful. Or maybe it’s several of these factors, and others. But the point is that it is possible to vastly improve things with some minor tweaks in the system. It usually happens when the hospital and physicians have communicated with each other to make these changes.

But what if the hospital and the hospital medicine group engage in a true partnership—a proactive joint venture in which each fully appreciates the other’s value proposition? What if each seeks to deliver something greater than the mere sum of hospital resources and hospitalist resources? Suppose the hospital embraces the idea of helping build structure and processes to maximize the number of patients seen by a hospitalist. Suppose the hospital medicine program embraces this but also embraces the goal of high-quality care in all its dimensions. What results is true synergy, where both parties benefit tremendously and the real winner is the patient. This won’t happen just by tweaking to make improvements at the edges; only wholesale change will take patient care delivery to a new level.

This will require hospitalists to embrace new methods of patient care. When I speak of this concept to hospitalists, I ask them to imagine doubling the amount of patients they currently see. If your census is 15 patients a day, imagine seeing 30. Most hospitalists immediately push back and say it isn’t possible because they can’t envision a new way of patient care. But what if by engaging in this partnership, the hospital brought to bear all its potential resources to help you—maybe a scribe, or several midlevel providers? What if there were zero barriers to finding data? What if the pharmacist took such a reliable medication history that you could fully depend on it? How about before you see a patient, a history and physical was already done so all you had to do was review the findings?

Many of you are still skeptical. Some of you struggle just getting approval for a part-time administrative person. You can’t ever imagine the hospital providing additional resources. Trust me when I tell you times are changing. One of the chief concerns all hospital executives have is the imperative to change the hospital-physician relationship. Much has been written on this topic, and the prevailing wisdom among hospital leaders is that the old medical staff leadership concept is dead. New types of leadership are necessary if hospitals and physicians are to survive.1

Because I am a hospitalist and a hospital executive, I feel the hospital part is the easy one. As chief medical officer, my main goal is to improve the quality of care delivered. The chief constraint I encounter is the number of engaged physicians. Much of my day is spent working with physicians to engage them in a hospital-physician partnership. The No. 1 thing preventing engagement is clinical workload. From the hospital perspective, I know I need to mobilize hospital resources to help physicians and remove time as the constraint. But for me to take them away from seeing patients may also hurt the hospital.

Now don’t misunderstand me. I am not advocating an improvement in efficiency just for the sake of it or just to improve our recruiting problems. The vision must be the delivery of higher quality care.

Change is not over. SHM’s responsiveness to change will greatly enhance your ability to promote change from within your hospital. Physician leadership is essential.2 We have much more to accomplish, but SHM is well positioned to continue to help you and your patients. We will continue to be nimble. We will continue to respond to the many changes on the road ahead. Even the road we can’t quite see yet. TH

Dr. Cawley is president of SHM.


  1. Petasnick WD. Hospital-physician relationships: imperative for clinical enterprise collaboration. Front Health Serv Manage. 2007;24(1):1:3-10.
  2. Porter M, Teisberg EO. How physicians can change the future of healthcare. JAMA. 2007;297(10):1103-1111.

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