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"And this year’s Hospy goes to …"

December 2008

I have read far too little this year. And I’m afraid that my major claim to qualification is the dubious fact that I–along with half the country–have written a blog for just over a year. But I still feel entitled to nominate Dr. David Mitchell’s “The expanding or shrinking universe of the hospitalist” in the July/August issue of the Journal of Hospital Medicine for a Pulitzer in commentary writing.

And if my endorsement of it for a Pulitzer falls short, perhaps SHM can come up with its own annual journalism award. At this point, all our profession lacks is a defining award ceremony like the Emmys. Larry, if you are reading this, how about an award program in which SHM awards a Hospy? (With a bow to Dr.Joseph Li who, I understand, holds a Hospy award ceremony for the hospitalists in his group every year at Beth Israel Deaconess.) I can just imagine Dr. Wachter as the emcee booming, “And in the category of outstanding editorial writing, the Hospy goes to …” But I digress.

Dr. Mitchell writes, “[Hospitalists] are currently at a critical crossroad, with the option of either actively expanding their clinical, administrative, and quality improvement roles or allowing these roles to stagnate or atrophy.” I couldn’t agree more.

To paraphrase what I believe is his major point: As hospitalists are asked to do more, we may paradoxically be doing less. Hospitalists who are told to see more patients for the sake of revenue may end up asking for more consults for medical problems that should otherwise be well within their scope of expertise. The same holds true for our ability to do basic procedures, provide leadership in the quality arena and so on. As we do less in our attempt to do and earn more, we may end up not being able to differentiate our own set of skills from those of a well-trained midlevel provider.

Dr. Mitchell is sounding this alarm at the same time that prevailing economic conditions have sparked a renewed debate on the future financial viability of our profession. The “value added” camp claims that our value is well worth the subsidy paid and that, given the need for increasing hospital efficiency, adding value is the surest way to strengthen our profession.

The “revenue” camp, however, warns of a subprime mortgage-like collapse of our profession if our take continues to be significantly less than what we cost. In my opinion, embracing either of these philosophies to the extreme is a poor strategy. But I believe the latter approach is more likely to lead us down the road to less autonomous and skilled hospitalists, eroding our profession despite the short-term boost to productivity.

No matter how you think the future of our profession should be shaped, Dr. Mitchell’s compelling editorial is a must-read for both newly minted and grizzled hospitalists alike. Now the one question that remains: What should the Hospy look like?

Happy Holidays to all!