Let me start my first column as SHM president by introducing myself. I am an associate professor of medicine and the director of the hospital medicine program at the University of Michigan in Ann Arbor. I live in Ann Arbor with my family, which includes my wife, Juliet, and three young children. I also have a “professional family” at U of M, which includes 40 hospitalists and all the staff who facilitate the great work they do every day.
SHM, of course, is another big part of my extended family. I have been involved with SHM since 1997—when it was formed as the National Association of Inpatient Physi-cians (NAIP)—and have watched in awe its meteoric rise. What started as an organization with a handful of members and one staffer fully supported by the American College of Physicians (ACP) has grown into a fully independent society with more than 9,400 members and 50 employees. The growth in scope of SHM’s activities is no less impressive. In the mid-1990s, the society was focused on justifying the existence of a new breed of doctors called hospitalists.
Today, SHM is involved in multiple projects and programs designed to cement HM as the center of a healthcare system being redesigned to deliver high-quality, safe, efficient, and patient-centered healthcare.
As exciting and ambitious as SHM’s goals are, there are innumerable challenges facing the field of HM that stand in its way. Let me touch on just a few.
The first and most obvious is the economy. This country is experiencing the worst recession it has seen in decades, and it is certainly affecting our hospitals. Here in Michigan, the plight of the auto industry graces the front pages of our newspapers daily (at least the papers that still exist). Hospitals that used to gloat about their high percentage of privately insured patients as a result of lucrative auto union contracts now see marked increases in public insurance—or no insurance at all.
Unfortunately, this is not just Michigan’s problem. Recent data suggest that more than 65% of the nation’s hospitals have seen increases in nonpaying patients and, as a result, marked declines in elective procedures and a bleak financial outlook. Many hospitalist programs are tied to the financial viability of their hospitals.
The decline in hospital resources also comes at a time when hospitals are being asked to invest more to promote safety and quality concurrent with growth in pay-for-performance programs and “no-pay” events, which make it clear that the financial picture could get even worse if these investments are not made.
The challenge in positioning hospitalists and HM at quality improvement (QI) ground zero—as we are doing—is that many of the systems and processes that require change extend beyond our usual range of control. The attention that has been given to reducing hospital readmissions by improving care transitions is a good example. It is not news that many bad things can—and often do—happen to patients after discharge. And many of the patients who suffer a post-discharge adverse event get readmitted.
It seems logical to have hospitalists fix the problem. But hospital readmissions are complex. As has been recently argued, some readmissions may even be a reflection of good quality—for example, if we capture a post-discharge problem and “save the patient” by readmitting them before they died at home.1 And to address preventable readmissions, systems must be developed to manage patients after they leave our hospitals, primary-care physicians need to be engaged to create effective ways to “receive” the post-discharge patient, and, finally, the decision to readmit—which often is made by the ED doctor or the PCP—needs to be addressed. This is not easy work.
Additionally, there are some challenges unique to academic hospitalists, a subset of our membership. Academic HM programs have been forced to grow at a dizzying speed in the past several years to keep up with increases in hospital discharges in an era of increased restrictions on the work hours of medical residents. These programs have grown by hiring many junior faculty with no advanced training in research, teaching, QI, or patient safety, let alone all the skills they need to bill, lead large teams, or manage complex hospital processes.
Of those problems, the most challenging, and arguably the most important to fix, is research training. To make lasting contributions to the practice of HM, rather than just implementing the practices, new treatments, and new care processes developed by other fields, HM needs to generate the new knowledge we use. That takes growing research, researchers, and sustainable academic programs. That, too, is not easy work.
HM Can Meet the Challenges
I am optimistic we can meet these myriad challenges, and I believe SHM is positioned to lead the charge. There is nothing we can do about the recession; hospitalists will have to weather the storm. Fortunately, HM has spent the last decade advocating not only its effectiveness, but also its cost-effectiveness. As a key hospital ally in the quality and safety wars, we are entrenched, and most hospital CEOs looking at ways to control costs should look beyond the core aspects of the local HM program. (They can take back my water cooler.)
It has not been lost on many at SHM that improving quality and safety at the hospital level requires engaging those outside our field. SHM is indeed tackling the daunting task of improving care transitions with its Project BOOST (Better Outcomes for Older Adults through Safe Transitions) program, but this comes after years of working with national quality organizations, policymakers, and other professional societies—including those that represent ED physicians and PCPs—in recognizing that fixing poor care transitions cannot be done by hospitalists alone.
Academic HM also is on SHM’s radar. The society, along with the Society of General Internal Medicine and the Association of Chiefs of General Internal Medicine, organized a summit to delineate and address the problems faced by academic HM. That meeting led to increased attention on the problems the field faces, enhanced advocacy at the federal level for research support, a “boot camp” designed for academic hospitalists to develop the skills they need to excel in an academic environment, and the beginnings of an SHM-funded faculty development research award.
All told, while there may be dark clouds on the horizon and rain in the forecast, SHM has spent years building a watertight organization and has foreseen many of the problems we now face. If we keep up the hard work, I am confident we, our patients, and the next generation of hospitalists will have brighter days ahead.
I look forward to the next year at the helm of SHM and am honored to represent SHM and its members, whose hard work and accomplishments never cease to amaze me.
Dr. Flanders is president of SHM.
- Epstein AM. Revisiting readmissions—changing the incentives for shared accountability. N Engl J Med. 2009;360(14):1457-1459.