When Robert Wachter, MD, MHM, delivers his keynote address to unofficially close HM11, he’ll toast the field he helped define. His remarks will coincide with the 15th anniversary of the article he and Lee Goldman, MD, coauthored in The New England Journal of Medicine that coined the term “hospitalist” and fostered an understanding that the HM movement was a true phenomenon.
The milestone presents the perfect opportunity to examine the specialty’s meteoric growth and celebrate the successes of its pioneers, says Dr. Wachter, a professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center. He also considers it an ideal time to examine the unforeseen developments of the past decade and a half, believing a critical analysis of a few key case studies can help lay the groundwork for an even brighter future.
“At 15, you’re in mid- to late adolescence,” Dr. Wachter says. “We can no longer say we’re this new kid on the block and, ‘Gee, whiz, isn’t this neat?’
“This is a good chance to reflect on things that went as we expected,” he adds. “It’s an even better chance to take a second look at things that were surprising but provide valuable lessons as we think about what the next 15 years are going to be like.”
Question: Fifteen years ago, did you envision HM would grow so quickly?
Answer: I had a sense this was a trend that was starting to emerge and could fill an important niche. At the same time, when Sergey (Brin) and Larry (Page) founded Google, I doubt they believed it would become a $200 billion company. In the beginning, I couldn’t have predicted what this would become.
Q: What surprised you most in the past 15 years?
A: I didn’t fully appreciate how quickly the push toward value would become a dominant theme. Once we discovered quality was important and there was a set of skills we needed to learn to improve it, we tackled it aggressively. It has been harder to tackle the cost part of the equation.
This goes beyond making sure patients don’t stay in the hospital longer than they need to. It means looking hard at the cost of care and the way we spend money, such as our patterns of ordering X-rays, consultants, and lab tests. I’m going to focus a fair amount on that.
Q: Why do you want to emphasize that point?
A: The cost of healthcare is going to bankrupt the country unless we get a handle on it. Our field needs to lead the way to show how a good, ethical physician not only focuses on improving quality of care, but also focuses on ridding the system of waste and of care that adds no real value to our patients. We’ve been a little sluggish in that area.
Q: What other surprises do you intend to discuss?
A: I didn’t anticipate the emergence of two different versions of the hospitalist field. One is the role of comanagement. The other is what I call the hyphenated hospitalist—these OB hospitalists and surgery hospitalists. This concept we came up with for general patients has been embraced by a variety of specialties. How do those people fit into our society and our field? Are they really part of us or are they fundamentally different? I think we need to think carefully about it.
Q: Why are the unexpected developments so important to consider?
A: Leaders in the field need to get really good at reading tea leaves. One of the ways you do that is to figure out, when you didn’t read them correctly the first time, why didn’t you? Could you have read them better if you were more clever or more thoughtful?
Q: What is the biggest challenge facing HM?
A: When we have been given new tasks and new opportunities, our members have stepped up to the plate and done what they’ve been asked to do as well, if not better, than expected. I’m a little fearful of the flip side. How we will meet the demand for our services? How do we ensure the job stays attractive and we don’t burn out? We have to demonstrate our value, but we have to make sure the jobs are truly sustainable and that we don’t shoot ourselves in the foot.
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Q:What do you see as the solution?
A: I don’t think we’ll be able to meet all of the demand. There will be hospitals that can only partly staff the needs they have with hospitalists. I don’t want them to go too far down the quality curve. We need to be sure people entering the field are good and have the skills they need.
I think we’ll begin to ask important questions like, “Do I really need a hospitalist for this, or can I leverage fewer hospitalists with other nonphysician providers?” Or, “Can some of the work our hospitalists are doing be done as well and more cheaply by computers?” It opens a pathway to think more creatively about people and tasks and technologies.
Q: Despite the challenges associated with growth pressure, is HM better positioned for the future because of it?
A: Definitely. We will see a further extension of our reach into other areas of the hospital and healthcare system. We will continue to see our people begin as leaders in our world of hospital medicine but rapidly graduate to become hospital CEOs, chairs of departments of medicine, and major leaders in healthcare. There is a recognition that there’s no better training ground to be a leader in healthcare than to be a leader in our field. So I can’t help but be optimistic that our place in the world of healthcare is extraordinarily secure. HM11
Mark Leiser is a freelance writer based in New Jersey.