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Hospitalist leader looks at the new field's evolution

From the October ACP Observer, copyright © 2004 by the American College of Physicians.

By Phyllis Maguire

Few physicians get the chance to take a career innovation and help grow it into a national movement.

Robert M. Wachter, FACP, chief of medical service at the Moffitt-Long Hospital, University of California, San Francisco (UCSF), has done just that. Eight years after he and Lee Goldman, FACP, coined the term "hospitalist" in an article published in the Aug. 15, 1996, New England Journal of Medicine, Dr. Wachter has seen the hospitalist movement grow to include 8,000 physicians. Those physicians are now working in close to 2,000 hospitals nationwide.

A growing body of evidence indicates that hospitalists deliver efficient, cost-effective care—and that the unease many office-based physicians felt when the field first emerged has largely dissipated. Although an ACP member census shows that more than 60% of College members engaged in clinical practice continue to follow their hospitalized patients (see "A snapshot of ACP member practices"), many community-based physicians who use hospitalists now wholeheartedly support turning over inpatient care.

Dr. Wachter co-authored this year's "Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes" and is co-recipient of a 2004 John M. Eisenberg Award in Patient Safety and Quality from the Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum. He recently spoke to ACP Observer about trends in the hospitalist field.

Q: Hospitalists are positioning themselves as leaders of patient safety efforts. What are some areas of inpatient care that hospitalists are focusing on to improve safety?

A: Many are chairing patient safety committees (as I do at UCSF) and scores are leading new teamwork-training programs, creating new models for morbidity and mortality conferences, helping to successfully implement new hospital information technologies and leading root cause analysis groups. It all comes from a happy coincidence: The hospitalist movement's evolution took place just as the patient safety movement was heating up, and the merging of the two fields is completely natural.

One key safety area relates to the process of hospital discharge. Research shows that a patient's transition from the hospital back to office care is fraught with potential hazards, and hospitalist programs are developing innovative solutions to fill that black hole. We're seeing everything from PDA-based solutions to greater use of hospital information systems. And not all solutions are based on technology. In many programs, hospitalists—or the pharmacists or nurse practitioners they work with—are making phone calls to patients and primary physicians to bridge that gap.

Q: Do most hospitalists still receive subsidies from hospitals or medical groups, or is the field moving to be more self-sustaining?

A: I hate the word "subsidy" because it implies that you're being given charity. Most hospitalist programs receive support for all the services they perform—creating bed capacity, coordinating complex discharge plans, leading quality improvement efforts—that are not adequately compensated under the fee-for-service system.

Unfortunately, when you need outside support to pay the bills, you're going to have a somewhat fragile enterprise subject to the vagaries of the marketplace. I've seen hospitals whittle away at program support to the point that hospitalists, instead of seeing 15 or 16 patients a day, are now forced to manage 25 to 30. The hospitalists end up burning out, and the hospitals lose the efficiency and safety advantages of having a program in the first place.

I tell every new hospitalist leader to expect his or her program to have a near-death experience at some point, when a hospital administrator will say, "I want to give you less money." In many cases, the hospitalists will have to go to the mat, knowing that they may win or lose. If, in the end, the hospital is unwilling to fund the program adequately, there have to be consequences. I've seen a handful of programs around the country implode around these issues.

Q: How do you see the hospitalist movement playing into efforts to revitalize internal medicine?

A: My personal view is that the growth of the hospitalist field is one of the most important innovations in revitalizing internal medicine that we've seen in the last 20 years. For people drawn to generalism, who really like medicine's breadth and the ability to work across different specialties, the hospitalist field has breathed new life into medicine and given these physicians a career choice they didn't have before.

Some people bemoan the field as yet another nail in the coffin of internal medicine, but I see it as just the opposite. I think many physicians miss the collegiality of spending three hours every morning at the hospital, rubbing shoulders with each other and specialists—but that type of practice was disappearing anyway because of shifts in both inpatient and outpatient care. For office-based physicians, inpatient medicine—even in the absence of hospitalists—is now a very small part of what they do for a living.

As far as where we fit into revitalization efforts, the hospitalists I see are energized by their work and the contribution they can make. They're also playing a larger and larger role in teaching and training.

Q: Part of the efficiency hospitalists achieve is due to their heading up hospital-based teams. Medicare is now starting demonstration projects to look at how office-based physicians can lead teams to manage chronic illnesses. What lessons can chronic care teams learn from hospitalists?

A: Starting out, hospitalists understood that if we were going to be successful, we would have to attend to two "patients." One was the individual patient in front of us; the other was the hospital system in which we work—and both were equally sick.

One thing our field did well was realize that we needed data to demonstrate the quality and efficiency improvements we create. We recognized from the outset that unless a business case was generated to support this type of generalist, largely coordinative, practice, our field would never survive. Under the modern payment system, this is going to be true for any nonprocedural field that is about coordination and integration of care. So the notion of collecting data to prove the business case might well apply to the chronic care model.

Ten years ago, we hoped data would push hospitals, medical groups, patients and payers to help support the model. And by and large, that's the way it's worked out.

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