Home Cover Story THE PAST: Has the hospitalist specialty lived up to it potential?

THE PAST: Has the hospitalist specialty lived up to it potential?

The hospitalist credited with coining the term talks about how the specialty has lived up to it potential

August 2006

Published in the August 2006 issue of Today’s Hospitalist

Editor’s Note:
In this issue, we commemorate an anniversary of sorts for hospital medicine “the appearance of the term “hospitalist” “with a series of articles that examines hospitalists’ past, present and future.

When the term “hospitalist” entered the medical lexicon about 10 years ago, few could have predicted the fledgling specialty’s meteoric rise to become the country’s fastest growing specialty. But one person who did just that was Robert M. Wachter, MD.

It was 10 years ago this month “Aug. 15, 1996, to be precise “that Dr. Wachter co-authored an article in the New England Journal of Medicine describing a new type of internist. Because of that article, Dr. Wachter is widely credited as coining the term “hospitalist” “and helping put the specialty on the map.

Looking back, Dr. Wachter says he can’t recall where he first heard the term hospitalist, or if he can even take credit for the name. He says he is fairly certain, however, that the New England Journal of Medicine article marked the first time that the word appeared in print.

At that time, probably fewer than 100 physicians were practicing as hospitalists. Dr. Wachter was director of the internal medicine residency program at the University of California, San Francisco (UCSF), when he heard about a few large practices in California who were hiring internists to work in the hospital only. When a colleague at UCSF took a job across town as a “hospital manager,” his interest was piqued.

Dr. Wachter wrote about the trend for a UCSF newsletter, and a colleague suggested that he rework it and submit it to a journal. With the help of Lee Goldman, MD, UCSF’s chair of medicine, he did just that.

At a time when relatively few physicians had taken up the mantle of hospital medicine, Dr. Wachter laid out his vision of hospital medicine and made predictions about where the fledgling specialty would go. Looking back, many of those predictions were on the mark.

Today, Dr. Wachter, who is associate chair of the department of medicine and chief of the medical service at UCSF, is widely viewed as a founding father of hospital medicine. To commemorate the publication of the article that helped jump start the specialty, Today’s Hospitalist talked to him about some of the predictions he made in that article, and about the impact of hospital medicine in the last decade.

You predicted that issues surrounding continuity in the form of handoffs and discharge would be one of the primary challenges for hospitalists. How is the specialty is doing in these areas?

I think good programs do a pretty good job, and bad programs don’t. The fundamental nature of the model is that, in order to do other good things, we create a discontinuity. In the old model, we had one physician following the patient in two different worlds. We’ve now shifted to a world in which we have two separate doctors, so we’ve built in a discontinuity.

The question is whether the benefit of that discontinuity is worth the downside. Moreover, assuming that there is some downside from that discontinuity, how do you mitigate that harm? I think our specialty’s scorecard on attacking this problem is reasonably good.

One of the things that has been nice is that our field recognized from the get-go that this was our main vulnerability. When you look at recent research on the discharge process, people have been thoughtful about it, and they have come up with new strategies and systems to mitigate that harm. I think that’s exciting.

That said, discontinuity remains the biggest problem with the hospitalist model. It remains a work-in-progress that we need to continue to address.

I should add that the discontinuity at the hospital-outpatient interface is only one issue. The old model of the primary care doctor attending in the hospital created a series of other discontinuities within the hospital, so I view hospital medicine as trading off or accepting inpatient-outpatient discontinuity to achieve the benefit of much more continuity within the confines of the hospital. Having someone available all the time to do the things that hospitalists can do is a compensatory advantage.

One of the upsides of hospital medicine that you predicted was the efficiency that hospitalists would bring. Has the specialty met your expectations?

Without any question, the early growth and the early acceptance of the field were largely based on the percep¬tion that hospitalists would shorten length of stay, and that they would do so safely and without harming quality. So the recognition “and ultimately the proof “that a separate group of doctors working as hospitalists would create value and safely shave half a day off hospitalization was critical.

One of the most important things that happened to sustain the field was the emergence of reasonably good evidence saying that when you switch from the old model to the hospitalist model, you do in fact cut costs and length of stay. And very importantly, you do not compromise quality, safety, or in the academic setting, education.

Because of the way that most hospitals are paid in the United States, that cost and length-of-stay reduction creates a savings for the hospital. That has allowed hospitals to conclude that it makes sense to throw some money in the pot to attract good people to work as hospitalists.

To this day, that positive return on investment for hos¬pitals “and their associated willingness to augment the professional fee revenue stream “remains the fundamental economic dynamic of the hospitalist movement.

What will happen to hospitalist programs if they can’t continue to demonstrate that they are producing savings?

Some studies are going to show that when you take mature programs and look at whether they’re continuing to save money or reduce length of stay when compared to other groups of physicians, those savings may diminish considerably. To me that’s not surprising.

Think about it this way: In the first year, a hospitalist group may reduce costs and length of stay compared to the old system. Two or three years later, however, you’ve reached a plateau and you’re not producing significant savings.

I don’t think that this means that the initial premise was wrong. It will, however, create an ongoing political challenge. The hospitalist group’s need for financial support from the hospital doesn’t go away over time, but its efficiency advantage may plateau. What happens when the CEO leaves and the new one doesn’t remember what life was like before hospitalists? This creates an inevitable tension that a lot of programs will experience.

How has the growth of hospitalists in academic centers changed academic internal medicine?

The growth of hospitalists in academia has been far faster than we predicted 10 years ago, in part because we did not anticipate residency duty hours regulations. The meteoric growth of academic hospitalist programs over the past few years has been largely in the creation of non-teaching services that are staffed by hospitalists.

If you walked into an institution like mine 25 years ago, you would have found that many of the attendings hanging out on the wards were basic researcher-rheumatologists or endocrinologists who were doing their one month a year on the wards. That gave the housestaff and students a chance to rub shoulders with people they would have had no other way of meeting, except for an occasional lecture during their pathophysiology courses.

I worry that those faculty-scientists are more marginalized from this central common, that they no longer hang out on the wards. They have returned to their comfort zone, be it their specialty or their research. To the extent that there was value when everybody was mingling, that has been extinguished.

That said, there’s a lot of romantic and revisionist thinking about how wonderful it was to have basic scientists leave the lab and work as ward attendings one month a year. For the most part, it probably wasn’t very good for patients, for supervision and for teaching.

There’s no question in my mind that the quality of education and oversight of housestaff is now many times better than it was in the past. We now have really smart people who like to teach, who keep up with general hospital medicine, and who enjoy working with the housestaff serving as ward attendings. The tradeoff has been very positive.

I think the benefits are even more pronounced in com¬munity teaching hospitals. In the old days, an intern might have eight patients from seven different primary care doctors. He or she would spend half the day on the phone trying to figure out what treatment those physicians wanted for their patients.

Now, most of those primary care physicians don’t come into the hospital. Instead, you have a core cadre of hospitalists who are hired in part because they’re good teach¬ers. That’s a very positive tradeoff for training as well.

Hospitalists are often regarded as effective teachers, but how do you think the specialty has done integrating itself into academia?

Many academic hospitalist groups were formed to supply physicians to take care of patients in place of house-staff because of the work hour rules, and to teach the house-staff. A lot of those academic groups are doing what they were hired to do, but they’re now having a hard time moving to the next level and creating a more academic milieu.

In many academic centers and teaching hospitals, hospitalists are seen as clinician-teachers and maybe system improvers, but not as academicians who can create new knowledge. That makes it very difficult for hospitalists to have the same credibility, legitimacy and visibility nationally as their pulmonary and cardiology colleagues.

In American medicine, success and credibility in academia is important. It helps brand a specialty and gives it legitimacy. Hospital medicine won’t be as strong and won’t recruit as well if, in academic places, the hospitalist group is not as academically respectable as the endocrine division.

How has the growth of hospital medicine affected primary care physicians in the outpatient setting?

There’s certainly a loss of skills, but the impact revolves not so much around the loss of inpatient clinical skills as around the loss of the linkage of the primary care doctor to the whole hospital enterprise. That loss is more important than I would have guessed 10 years ago, in part because the hospital enterprise has become so much more complicated, largely as a result of the quality and safety movements.

Think about what medical staff committees used to do. It was mostly pushing paper, with a bit of credentialing here and some policy work there. A lot of hospitals didn’t really have chief medical officers because there wasn’t much important work to be done in terms of clinical care. Most of the work of a senior physician leader was to discipline problem doctors.

If you look at hospitals now, there’s a night-and-day difference in what they must care about when it comes to improving the quality and the efficiency of care. And quite logically, hospitalists are stepping up to fill those roles. It’s not primary care doctors any more because they’re not in the building. Because of this, the severing of the psychological and physical connection between primary care doctors and the hospital enterprise has been a very big deal.

What do you think the big growth areas for hospitalists will be in the next 10 years?

Looking back, the initial idea was to get hospitalists to do what traditional internal medicine doctors did in hospitals. If you look around the country, in some markets that’s a done deal. In other markets, only half of the hospitals have hospitalists, or individual hospitals have hired hospitalists, but they’re taking care of only half of the patients. So there are opportunities for continued growth.

There are two additional things that will turbocharge the hospitalist movement that we didn’t anticipate 10 years ago. One is the huge need for non-teaching services created by the duty hour rules.

In teaching hospitals, the sky will be the limit as people recognize the consequences of those rules. They are beginning to realize that there are limits on how many residents you can replace with PAs and NPs. They are realizing that some of these tasks and roles really do need to be filled by doctors. So there will be tremendous growth in teaching hospitals. I won’t be surprised if some large academic medical centers have 50 to 100 hospitalists.

The other growth area is the management of surgical patients with medical co-morbidities. In a hospital like mine, there are a couple of hundred patients on various surgical services whose fundamental clinical issues are medical, not surgical. The hospital will be scrutinized on the quality of care of these patients in terms of their heart failure, their diabetes, their pain, etc.

Any way you cut it, I believe that hospitalists are the best group to care for these patients. In the old days, teaching hospitals would try to solve this problem with housestaff, but now they don’t have enough housestaff. When you look at the dynamics of surgical care in the hospital, all the arrows point in one direction, and that’s to a huge role for hospitalists.

What impact will these trends have on the numbers of hospitalists?

In our early predictions, we said that there would ultimately be 10,000 to 30,000 hospitalists, with a mean estimate of about 20,000. We now know that was an underestimate because we didn’t anticipate the growth in surgical co-management or the ACGME duty hours reductions for residents.

And there’s more. Our estimates were based on a premise that hospitals with fewer than 100 beds wouldn’t have hospitalists, and that was wrong. And we didn’t anticipate the pediatric hospitalist movement.

So the bottom line is that our early prediction will fall short. I wouldn’t be surprised if there are 30,000 to 50,000 U.S. hospitalists 10 years from now.

Edward Doyle is Editor of Today’s Hospitalist.