Published in the April 2004 issue of Today’s Hospitalist
Ask Adam Singer, MD, about the threats and opportunities facing hospitalists, and he needs only a few moments to identify his chief concern: defining the identity of the fast-growing specialty.
As CEO and chairman of IPC-The Hospitalist Company, which employs 300-plus hospitalists in more than 70 locations, Dr. Singer has a bird’s eye view of hospital medicine. While he worries about issues like the hospitalist workforce and burnout, he is even more concerned about how the specialty is going to define itself.
For example, how closely will hospital medicine stick to its internal medicine roots as it grows and matures? Will it branch off into an entirely new specialty with a new skill set along the lines of emergency medicine, or will it remain closer to internal medicine along the lines of critical care?
In wondering about the specialty’s identity, Dr. Singer is not alone. When asked to identify the threats and opportunities facing hospital medicine in the next five years, many of the physicians interviewed for this story said that the specialty needs to create a unique identity to cement its place in the U.S. health care system, and it needs to act soon.
As Dr. Singer sees it, the specialty’s entire future hinges on its definition. Get it wrong now, he says, and hospitalists could find themselves working in a model that stymies their role in health care and limits their growth for years to come.
Beyond internal medicine
Hospitalists often find themselves described as “internists without offices,” a label that helps the public “and some in health care “grasp the new specialty. Dr. Singer, however, says that description is not only specious, but threatens the specialty’s growth.
He says that far from simply bringing outpatient skills into the inpatient setting, hospitalists function as drivers of the delivery system. And while internal medicine gives hospitalists an excellent background in clinical medicine, he explains, hospital medicine calls for another set of skills.
“Not all internists are trained to drive the delivery system to ensure utilization and ensure antibiotic choice based on a formulary, or in essence function as the CEO of each individual case,” Dr. Singer says.
By staying too close to its internal medicine roots, he worries that hospital medicine will too narrowly define its core competencies and reduce its potential patient base. “In order to be a new specialty,” Dr Singer explains, “you need a core competency that’s unique and different.”
As an example of how the lack of an agreed-upon definition is hurting the specialty, he points to physicians who view hospital medicine as shift work and don’t work in blocks. “Patients are sick for four or five continuous days,” he says. “It’s very difficult to drive the delivery system working on a shift.”
Dr. Singer says that hospitalists instead need to work a schedule like other specialists. IPC physicians, for example, work Monday through Friday (or some other block of five days), take call at night and make weekend rounds. They receive some help from moonlighters but provide most patient care themselves.
He worries that the specialty’s lack of a definition is leading to hospitalist models that aren’t effective “and could drag down the reputation of the entire specialty. “Some people are approaching it differently,” Dr. Singer explains. “It’s more like episodic care to them, more like ER medicine.”
He points to another way that the lack of a definition is already affecting the specialty. While just about every hospital seems to want a hospitalist program, there is confusion about exactly what that means. “Those hospitals don’t really know what a hospitalist is, so they build crazy systems that eventually don’t work,” says Dr. Singer.
“Until we as an industry can get ourselves together and agree on our core competencies and what is unique and different about us, we’re never going to be able to define ourselves as a specialty,” he says. “We’re going to be limiting our market size, limiting our reimbursement, and it will threaten the very fabric of this specialty.”
A core curriculum
Larry Wellikson, MD, executive director of the Society of Hospital Medicine (SHM), agrees that the specialty needs to define itself. He points out that he increasingly hears from his group’s members that hospitalists want to differentiate themselves from other physicians like general internists.
To do just that, SHM is creating a core curriculum for hospital medicine. The curriculum will focus on a wide range of areas that are critical for hospitalists, from caring for pneumonia, DVT and stroke to administering quality improvement programs and looking at patient care with an eye toward epidemiology. (For more information on SHM’s curriculum, see “The struggle to build a better hospitalist“.)
“While internists tend to think about how to treat one pneumonia,” Dr. Wellikson says, “hospitalists need to think about how to treat 300 pneumonias.” He adds that while hospitalists can trace their roots to internal medicine, they are practicing in a very different discipline.
While developments like SHM’s core curriculum will give go a long way in helping to define hospital medicine, Dr. Wellikson says that the efforts of individual physicians will also help that effort. Most hospitalists currently have their noses to the grindstone and are busy caring for patients, but he says they will need to expand their professional horizons.
“You need established areas of expertise in which you can train the rest of the medical staff,” he explains. “You need to take the time to be the person who gives the lecture on DVT or end-of-life care or palliative care, or you need to be the one who is seen as the systems expert when the hospital wants to put in a computerized order-entry system.”
Dr. Wellikson says a similar shift occurred in emergency medicine. While emergency physicians were originally viewed largely as service providers, they eventually positioned themselves as experts in emergency care. That transition, he explains, gave the entire specialty a boost.
As hospitalists develop their own identity, some wonder whether hospitalists will slowly drift away from their internist colleagues.
Fitzhugh Mullan, MD, former director of the Bureau of Health Professions and National Health Service Corps, says that from a primary care perspective, the question is simple: Are hospitalists one of us or one of them?
Dr. Mullan, who is clinical professor of pediatrics and public health at George Washington University and a contributing editor of Health Affairs, says he would be concerned about a permanent “bifurcation” between inpatient and outpatient care. “I’m not sure it’s good to create a permanent division between physicians who function in the hospital and people who don’t,” he explains.
He is most concerned about continuity of care, particularly when patients are handed off between physicians. When you have a community of physicians who move back and forth between the hospital and the outpatient setting, Dr. Mullan says, a “common culture” develops that helps ensure continuity of care. Inpatient physicians understand what their outpatient colleagues face, and vice versa.
Create two completely different cadres of physicians who are trained differently and function independently, however, and Dr. Mullan says there is likely to be less continuity when patients move back and forth between these two groups. “That creates a situation that could be disruptive and has the least likelihood of ensuring continuity,” he explains.
Drs. Wellikson and Singer both say they would like internal medicine to remain an important part of hospitalists’ identity. Dr. Wellikson, for example, compares hospital medicine to specialties like critical care or infectious disease, both of which have retained strong ties to internal medicine.
And while Dr. Singer points to significant differences between hospitalists and internists, he likes the idea of giving hospitalists a one-year fellowship after an internal medicine residency. It’s important, he says, that hospitalists keep their roots in internal medicine “but get extra training in their new specialty.
“In order to be a driver of the delivery system,” he explains, “you need the stripe on your shoulder that comes from being an internist first.”
Hospitalists like Stacy Goldsholl, MD, however, say they feel like they increasingly have less in common with outpatient internists.
“I think we’re moving farther apart than together,” says Dr. Goldsholl, who is medical director of Covenant Health Care’s hospital medicine program in Saginaw, Mich. Because the acuity of the inpatient setting resembles critical care or emergency medicine more than outpatient medicine, she says a split is natural.
“Hospitalists will experience a divergence from outpatient internists as we specialize more and more in inpatient care,” explains Dr. Goldsholl, who is also founder of Catalyst Inpatient Solutions LLC, a consulting firm based in Wilmington, N.C. “And by that I mean total inpatient care, which encompasses not only clinical excellence, but includes quality and patient safety initiatives, utilization and availability.”
By availability, she means the growing trend in which hospitalist programs have a physician on-site 24 hours a day. Dr. Goldsholl, who has long been an advocate of around-the-clock coverage, says the model will be a critical part of hospitalists’ ability to address concerns about patient safety and quality improvement.
“Some hospitals are saying that the inpatient of today is just too acute to have physicians managing them on-call from home over the phone, as opposed to having a real presence at the bedside,” Dr. Goldsholl explains. “There’s a new pressure for hospitals to provide that level of service, and I believe that physician presence will translate into quality.”
While only two major studies to date have shown that hospitalists can reduce mortality, Dr. Goldsholl says, she is confident that future studies will continue to demonstrate the quality advantage that hospitalists can bring, particularly models that provide 24-hour coverage.
She also predicts that around-the-clock coverage will be good for hospitalists because it improves their lifestyle and helps eliminate burnout. “Physicians know they’re going to work intensely when they’re at work,” she explains, “but they also know that they’re going to have blocks of time off they can spend with their families.”
Dr. Goldsholl acknowledges that the move away from the system of call coverage used by most other specialties could lead to even more of a separation between hospitalists and outpatient internists. As hospitalist programs develop tight teams to ensure continuity of care, outpatient internists may have fewer chances to work on these teams as moonlighters.
While the trend may put some distance between hospitalists and their outpatient colleagues, Dr. Goldsholl thinks it will also help cement the reputation of hospital medicine as a specialty.
“We’re entering a pay-for-quality era of medicine,” she explains, “and the third generation of hospitalist programs will be built on quality. Consumerism and patient safety will be the forces driving the future of hospital medicine.”
Edward Doyle is editor of Today’s Hospitalist.