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Life under the Big Tent


SHM prides itself on being a “big tent” organization—inclusive of care providers with different training backgrounds, from varied clinical settings, and representing a multitude of hospital roles. SHM’s diversity expands beyond care providers to include other key stakeholders, such as administrators of hospitalist programs or departments. The diversity was highlighted in the society’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” which shows that 40% of our members are hospital-employed, 20% are from academic settings, about 15% work in large multistate management companies, and the remaining 25% are equally split between multispecialty practices and local hospitalist groups. The diversity extends to internists, pediatricians, family practitioners, nurse practitioners, physician assistants, specialists—the list goes on.

All of us at SHM appreciate that diversity and routinely try to nurture it. Our board of directors includes physicians from all the aforementioned practice settings and includes dedicated seats for such key constituencies as pediatrics. We have more than 25 committees and task-force groups representing all the key factions of our membership. These groups address issues of relevance to every type of hospitalist and hospitalist group. Our annual meeting has evolved to meet the needs of this diverse membership by addressing an enormous volume of topics and incorporating a variety of tracks that cater to general hospitalists, quality experts, academics, and pediatricians.

One notable area in which we lack diversity: age. We are a young specialty; the average hospitalist is 40 years old.

SHM’s organizational diversity creates challenges; new issues surface every year. One key issue is the balance between academic hospitalists and community hospitalists. Academic hospitalists have wanted SHM to more aggressively support their interests. Community hospitalists want SHM to advocate for their interests, as well as develop programs and projects to meet their needs.

With my election as president and the recent election of another academic hospitalist to serve as SHM president in 2010-2011, there might be some concern that community hospitalists could get lost in an academic agenda. Interestingly, academic hospitalists might have raised similar concerns several years ago following the election of a second consecutive community hospitalist as society president. We have been fortunate to have leaders who can see the whole HM picture, regardless of their professional backgrounds.

We have been fortunate to have leaders who can see the whole HM picture, regardless of their professional backgrounds.

One Tent, Many Spikes in the Ground

The issues are more complex than simply the differences between academic and community hospitalists. Appropriately, each of our members wants their groups’ issues discussed and addressed. Although workforce might be an issue for private-practice hospitalists, academic hospitalists share these same issues—just in a different environment. Pediatricians see SHM develop core competencies for adult medicine, then want their own pediatric core competencies; SHM needs to look for a way to make this happen. Nurse practitioners (NPs), physician assistants (PAs), and administrators have looked to SHM to represent not just physicians in HM, but also their interests.

As a result, SHM has developed committees and approaches to engage the professional societies representing PAs and NPs, along with the Medical Group Management Association, to design specific projects and programs. At any point in time, there might be a group of members who see a need for SHM to pay attention to “their” issue or perceive that a current approach, while relevant to one group, falls short of the needs of another. As our diversity grows, the frequency of these situations will increase.

So, is this worrisome? Quite the contrary. I believe it is healthy.

Having an established organization with members of differing opinions and backgrounds helps challenge our assumptions. It refines our approach to complex problems, highlights issues or concerns we did not anticipate, and, most importantly, guards against “groupthink”—the tendency to agree with one another all the time. SHM’s board of directors is committed to this type of inclusive leadership.

We do need to be cautious and think quite a bit about this issue in the coming years. The big tent is filling up quickly. It’s becoming more diverse by the week. The concern is that in trying to work at a level that keeps all our constituents happy, we might please no one. If all our activities have to be justified as being relevant to every distinct group that makes up SHM, then we might dilute our effectiveness.

Alternatively, we do not currently have the bandwidth as an organization to initiate in-depth projects in areas relevant to all our members. So far, our approach has been to focus on areas core to every hospitalist: quality and safety, process improvement, leadership, practice management, care transitions, networking, and education.

As unique problems or issues arise that are relevant to only a subset of members, we will weigh the importance. In many cases, we have created task-force groups to clarify and tackle the problem. We provide the support, but the members of the group create the solution. It has worked well so far.

One Voice, One Goal

But can we stick to this strategy as the diversity of membership expands and the number of relevant issues grows? I don’t know. What I do know is that there is strength in numbers, and even though we all have different issues we deem more important, there are times when it helps to come together and speak as one very big, very loud voice.

Older specialties like endocrinology, allergy, and others have split into a variety of organizations and potentially diluted their message. SHM needs to look for creative ways to be relevant to many constituencies within the specialty. In the meantime, we must pay close attention to the big-tent issues. An academic hospitalist in leadership needs to listen to the voices of hospitalists in the community, work to understand them, and support efforts to address problems relevant to them.

In the past, SHM leadership from the community hospitalist setting has worked to help address and solve issues relevant to academic hospitalists. We need to understand and respect the diversity within SHM’s tent, and we need to work to keep us all together. I firmly believe that is the way forward, and I assure you that is the goal of SHM’s leadership.

As President Kennedy said, “If we cannot end now our differences, at least we can help make the world safe for diversity.” I pledge to keep SHM your organization, regardless of how you were trained or where you practice HM. I can’t hope to know all of your important issues, but I can commit to stand ready to hear your concerns and do what SHM has always done—give your request a thoughtful response and all of our energy.

SHM is your organization. Let me know the direction you think SHM should go. Send me an e-mail at TH

Dr. Flanders is president of SHM.

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