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Hospital medicine: New factors drive dramatic growth

Managing greater numbers of surgical and post-op patients are just two of the many forces expanding the field

From the June ACP Observer, copyright 2005 by the American College of Physicians.

By Deborah Gesensway

SAN FRANCISCO—One of hospital medicine's leading proponents made this prediction at an Annual Session presentation: Over the next 10 years, hospital medicine will see more dramatic growth than it did in the past decade, with the ranks of hospitalists—now estimated at 12,000 strong—possibly swelling to 25,000 nationwide.

Robert M. Wachter, FACP, associate chair of the department of medicine and director of the 20-physician hospitalist group at the University of California, San Francisco, said he also wouldn't be surprised to eventually see more hospitalists than cardiologists working in the nation's health care system. And while he said the field is "not pushing for it," he can envision hospital medicine eventually getting its own certification or recertification track.

In the meantime, however, the rapidly growing movement must learn how to avoid common pitfalls—and harness those emerging forces that are driving its fast-paced growth.

New challenges

Dr. Wachter also pointed out some major caveats. First, hospitalist groups need to determine how to make the job sustainable, not just a career path that physicians follow for a while in their 30s and then burn out.

"I don't think burnout is inherent to the job," said Dr. Wachter, who coined the term "hospitalist" in an Aug. 15, 1996, New England Journal of Medicine article, "but it's a challenge."

Another big challenge: how hospitalists will work with surgeons. In some hospitals, assuming responsibility for complex surgical patients is becoming a key component of a hospitalist's job.

But assuming more care for surgical patients comes with some pitfalls. How do hospitalists avoid becoming a "dumping ground" for surgeons who don't want to care for complex or poorly insured patients? How should hospitalists be paid for that work—and how do they make sure caring for these patients is within the scope of their practice skills and knowledge?

Solving 'the full house' problem

Other forces continue to drive the movement's rapid growth, he said.

Many of today's drivers are different than they were eight years ago when hospitalists first began flocking to new positions. Then, he said, hospital administrators were looking for ways to reduce length of stay and bring down hospital costs—problems that hospitalists helped solve.

Now, Dr. Wachter said, length of stay has probably come down as far as it can in most places, while excess capacity has been trimmed away. Today, hospital administrators are looking to hospitalists to solve their problem with "the full house" and to find beds for high-paying procedural patients. The more hospitalists argue that they help improve "throughput," he said, the more they will secure their position in the nation's hospitals.

The resident duty-hour limits that took effect two years ago are also now driving teaching hospitals to create more hospitalist teams.

And when hospital medicine first emerged, the mandate for improving safety and quality wasn't even on the radar screen. But since the Institute of Medicine issued its landmark 1999 "To Err is Human" report, many hospitalists have put themselves front and center in hospitals' quality improvement and patient safety efforts. Pressure to improve inpatient quality and safety will only grow with more public reporting and pay-for-performance programs, said Dr. Wachter, who co-authored "Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes," published in 2004.

The factors that will affect the field over the next five years will continue to boost hospitalists' numbers, and perhaps lead the American Board of Internal Medicine (ABIM) to establish a board exam for hospital medicine.

Certification in hospital medicine may not happen until "there are training programs" in the field, he said—and those currently are few and far between.

"But I think the parallels here are with emergency medicine and critical care medicine," said Dr. Wachter, who was recently elected to ABIM's board of directors. "The knowledge base and core competencies will ultimately differ enough from other fields that hospitalists will want to say, 'we've got whatever the requisite training was, and we passed the test.' "

Deborah Gesensway is a freelance health care writer in Toronto.

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