HM Growth: Phase 2


Scott Flanders, MD, FHM

The growth of our medical specialty is old news. Yes, we now number about 30,000; yes, we now manage the medical care of 50% of hospitalized Medicare patients; yes, hospitalists are in two-thirds of U.S. hospitals. I could go on and on. But recently, I have observed a different type of growth altogether. It is the growth of stability.

In the recent history of HM, the focus was on the increasing number of hospitals that had hospitalists, the growth of SHM’s membership, the growth of our annual meeting, and the ever-increasing number of doctors who, at least when surveyed, called themselves hospitalists. It all looked so impressive.

Many of you know, however, that when you lifted up the hood of our field, it was not always as it seemed. HM actually was a bit unstable. Some doctors who called themselves hospitalists were, in reality, biding time until they moved on to a “real job” or went off to do a fellowship. Multiple groups competed for patients within any given hospital, and also competed for doctors. There were numerous jobs available for any given hospitalist, and, as a result, some groups had substantial turnover despite growth in numbers. In these programs, the group photo from one year to the next had an entirely new set of faces.

In some sense, the perceived slowing in the growth of hospitalists might be concerning. I see it a different way. Slowing growth in overall numbers allows programs and the field to stabilize a bit, and this growth in stability creates enormous opportunity.

Instability did not just affect rank-and-file hospitalists; it also existed within programmatic leadership and entire programs. Annually in many hospitals, the hospitalists had to convince administration that the hospital needed hospitalists and that they were worthy of support. Unfortunately, it was not always successful, so some programs vanished.

Five years ago in Michigan, we were working to create a multihospital safety consortium. We had several participating institutions, all with hospitalist programs. One day, my secretary complained that every time she sent an e-mail to the consortium listserv, a handful would bounce back and indicate a handful of e-mail addresses no longer were in service, or note that an individual had “left the program.” Some of them were HM program directors. Follow-up calls showed that the program had a new director or had folded. In some cases, however, they were just too busy figuring out how to survive instead of focus on safety issues.

Fortunately, that all appears to be changing.

From Unknown to Accepted to Counted On

I have seen the change in my own institution. We, of course, continue to negotiate with hospital administration, but it is no longer about whether we should continue the program or not. Negotiations now center on line items in the budget, how much space we need, where we anticipate future growth, and what quality and safety initiatives we’re working on.

I like to think that the HM program is important infrastructure. Just as you can’t imagine a hospital without an ED or an ICU, the same holds true for the HM program.

Perhaps an even better analogy could be found in technologic innovation. Back when Al Gore invented the Internet, having an Internet connection at home was viewed as a luxury. Now, it nearly is a necessity. Just like HM programs! (OK, maybe that was a stretch.)

There also is stability within the faculty ranks. Many of our faculty have been here for years and plan to stay. Turnover has decreased dramatically. This is not unique to our program, but anecdotally is happening everywhere. In fact, we are in the process of launching additional multihospital HM-based safety projects and collaboratives. And when I reach out to programs to ask them to participate, the directors of these programs are the same ones when I last checked. If they have moved on, it has been to assume a local leadership role. The group photos also show all the same old faces, plus a few new ones. There really has been some stabilization in the field.

New Paradigm Here to Stay

The factors behind this newfound stability are numerous. Among them is the recognized importance of a well-managed HM program. In many institutions, the alternatives to hospitalists (primary-care physicians, surgeons managing all post-operative care, specialists admitting their own patients, etc.) have left the building. There is no going back, and there is no “plan B” if HM programs fold.

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The recognition by prospective hospitalists—residents and students—that HM is a viable career path has increased interest in the field, and, in turn, has given many programs more choices among qualified applicants. Hospitalists currently employed in a reasonably functioning program are less likely to jump ship every year looking for something slightly better. And I expect the current economic climate has been a factor as well. As hospitals see operating margins erode, plans for infrastructure growth are delayed, funding for new programs shrinks, and hospitalist groups are asked to do more with less. In other words, they are not hiring as many new hospitalists.

In some sense, the perceived slowing in the growth of hospitalists might be concerning. I see it a different way. Slowing growth in overall numbers allows programs and the field to stabilize a bit, and this growth in stability creates enormous opportunity. Programs formerly struggling to survive can begin to innovate. We’ve seen that in Michigan, as the interest among hospitalist programs that want to participate in QI collaborations has grown. And when we hear what some programs are working on, it’s an impressive list of high-impact projects.

Hospitalists are taking ownership of care transitions, prevention of hospital-acquired complications, and disease-based QI initiatives centered on patients with heart failure, COPD, and diabetes.

Nationally, we have seen hospitalist programs coming together to successfully compete for federal research grants or foundation support targeting important national healthcare priorities. If the current healthcare reform legislation passes, it will better position HM to lead the transformation of healthcare in U.S. hospitals.

My big hope is that 10 to 20 years from now, HM is better known for its second phase of growth. Right now, we are more famous for our rapid growth and, to some extent, our impact on efficiency of care. Efficiency clearly is important; dollars saved from waste can be better put to use improving quality. But I want the field to be judged by our ability to innovate, improve the quality of hospital-care delivery, and to generate new knowledge that advances the care of all patients. Those accomplishments will have a more lasting impact on healthcare.

The stabilization of HM is making all of this possible. Our population expects and deserves great things from the nation’s fastest-growing “specialty,” and I am optimistic we will not let them down. TH

Dr. Flanders is president of SHM.

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