From the Society

The future of hospital medicine

Assured? Or a definite maybe?


 

When I started at SHM in 2000, there were fewer than 1,000 hospitalists in the US, and now there are more than 60,000. SHM (back then, we were the National Association of Inpatient Physicians) had about 300 members; now, we have more than 20,000.

Dr. Larry Wellikson

Today, hospitalists are part of the medical staff at virtually every hospital in the country, and hospital medicine is recognized as a unique medical specialty with our own knowledge base, textbooks, competencies, meetings, and medical professional society. In a health care environment swirling with change, we are one of the few specialties forged with the ability to adapt and, at times, lead this change. Yet there is so much disruption and instability that there are still many twists and turns in the road that will affect hospitalists’ ability to carve out an even brighter future.

Consolidation has come to health care on a large scale. Hospitals are merging. Health insurers are combining, and even large hospital medicine companies like TeamHealth, Sound, Envision, and others are merging, growing, and acquiring.

At the same time, outside forces from industries not usually associated with health care or inpatient care are swarming into our world: CVS acquires Aetna and aims to reshape primary care; Amazon dominates health care supply chains and moves into pharmacy benefits, and even gets into health care delivery via their partnership with Berkshire Hathaway and JP Morgan; Walmart merges with Humana to create one of the biggest players in Medicare; and Apple expands their inroads into wearables and chronic disease management.

Employment of clinicians has grown logarithmically, especially with inpatient physicians, reshaping the medical staff compensation and accountability. At the same time, payers, both government and private, are evolving into population health with an emphasis not so much on transactions (visits and procedures), but more aligned with outcomes, effectiveness, and efficiency.

All of this leads to a new paradigm of what is important and a new set of values that seems at times more like corporate America where the loyalty of employees can be torn between their employer and the patient. This is especially troublesome in a field traditionally based on the primacy of the doctor-patient relationship. This can put the hospitalist right in the middle at the time when the patient can be most vulnerable.

This has led to new ways to deliver the care that hospitalists provide. First as a pilot and now moving more mainstream, patients with several diagnoses (e.g., heart failure, dehydration, or pneumonia) are now managed not in bricks and mortar hospitals, but in “hospitals at home.” The last few days of a typical hospitalization now take place outside the hospital in a skilled nursing facility (SNF). Fear of uncompensated and unnecessary readmissions leads hospitals to engage hospitalists to handle the first few post-discharge outpatient visits.

This is just a small part of the expanding scope for hospitalists. In addition to managing SNFs and the discharge clinic, hospitalists are now the major providers of perioperative care and play a growing role in palliative care, especially for inpatients. As other specialties that abut hospital medicine have increasing demands and yet fewer new specialists, hospitalists are taking on more critical care and geriatrics, providing procedures, and occupy an evolving role in the emergency room.

There is a lot of work coming towards hospital medicine, and to expand our workforce, hospital medicine groups have incorporated advanced practice providers, including nurse practitioners and physician assistants. But building a true team of health professionals is not seamless or easy with each constituency having a unique scope of practice, limits on their licensure, their own culture, and a distinct training background.

But wait. There will be more new players on the hospital medicine team going forward – some we cannot even anticipate at the present time. In the future, the hospitalist may not even touch the electronic health record (EHR). Clinicians have never excelled at data entry or analysis, and it is time to use a combination of artificial intelligence (AI), voice-activated gathering of history into the record, and staff trained to manage the EHR on both the input and the output sides.

While there may be cheering for this new approach to the EHR – especially because it is a major factor in hospitalist burnout – this will refocus the role and work of the hospitalist to be more of a reviewer and integrator of data, and a strategist and decision-maker overseeing 30 or more patients. As Amazon, CVS, and Walmart move into health care, they will look for the best way to utilize the $300-400/hour hospitalist to the top of our skill level.

In the end, this all comes back to how hospitalists add value, how we can create a career that is rewarding, and how we can help hospitalists be resilient and avoid burnout.

The good news is that hospitalists will not be replaced by AI, nor should we expect to have our incomes cut as less well-trained alternatives replace highly compensated physicians in other specialties. This is a real prospect for many other specialties like dermatology, radiology, pathology, anesthesiology, and even cardiology. But hospitalists will need to adapt to changes in what is valued (i.e., how you can be the most effective and efficient) and to a new job description (i.e., overseeing more patients and managing a team that does more of the H&P, data collecting, and bedside work).

After 20 years of coming out of nowhere to being in the middle of everything in health care, I am confident that hospitalists, with the help of SHM, can continue to forge a path where we can be key difference makers and where we can create a rewarding and sustainable career. It won’t “just happen.” It is not inevitable. But if the past 20 years is any example, we are well-positioned to make the adaptation to succeed in the next 20 years. It is up to all of us to make it happen.

Dr. Wellikson is the CEO of SHM and is retiring from his role in 2020. This article is the second in a series celebrating Dr. Wellikson’s tenure as CEO.

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