What's the future of hospitalist care?

Hospital-based care may not be a good fit for population health, researchers say

Hospitalists are an integral part of medicine—but they are also at a crossroads, Elizabeth Whitman reports for Modern Healthcare.

Since the term was "hospitalist" coined 20 years ago in a New England Journal of Medicine (NEJM) article by Robert Wachter, of the University of California, San Francisco, and Lee Goldman, of Columbia University, the field has grown immensely.

The number of hospitalists has grown "from a few hundred" to more than 50,000, according to data from the American Hospital Association. "The field's rapid growth has both reflected and contributed to the evolution of clinical practice over the past two decades," Wachter and Goldman wrote in a follow-up article published this month in NEJM.

Twenty years in, the hospitalist landscape is shifting—and prompting new debates

New challenges

But while research has found that hospitalists deliver effective high-acuity care and improve certain outcomes, such as length of stay, new market pressures suggest their role needs to evolve, Wachter and Goldman wrote in the follow-up piece. "Although we continue to believe that the hospitalist model is the best guarantor of high-quality, efficient inpatient care, it's clear that today's pressures require innovative approaches around this core," Wachter and Goldman said.

For instance, Wachter and Goldman said that the increase in hospitalists has diminished the role of specialists and researchers who instruct trainees.

And in a separate NEJM article published this month, Richard Gunderman of the Indiana University School of Medicine wondered whether hospitalists are well-positioned to thrive amid the increased focus on population health care in a value-driven health system. "The acute care focus of hospital medicine may not match the need of many patients for effective disease prevention and health promotion," he wrote. "I suspect the inherent tensions will remain fundamentally irresolvable."

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He added, "What we don't yet know sufficiently well is the impact of the rise of hospital medicine on overall health status, total costs, and the well-being of patients and physicians." And he argued that the inpatient focus of hospitalists may unintentionally divide hospital-based care from community-based physicians, who he said are increasingly being pushed to focus exclusively on outpatient care.

A growing field

Regardless of new market challenges—and shifts in how care is delivered—Wachter told Modern Healthcare that hospitalists are here to stay. "There are people talking about how we can eventually close down all the hospitals," he said. "That's not going to happen."

Instead, the market is asking hospitalists to do more. Larry Wellikson, CEO of the Society of Hospital Medicine, said, "What we're seeing is an expansion of the scope of hospitalists," adding, "We're being asked to do critical-care medicine. We're being asked to go out and manage nursing home care."

But as hospitalists are asked to do more, Wachter said it is important that they remain self-critical and nimble. "We're now a mature, really important field," he explained. "That's my biggest worry: that we'll become old and staid and rest on our laurels" (Whitman, Modern Healthcare, 8/11; Wachter/Goldman, NEJM perspective, 8/10; Gunderman, NEJM perspective, 8/10).

How to capture the full value of the hospitalist programs

In most hospitals, hospitalists care for over 50% of patients, but few hospitalist programs have been fully leveraged to advance outcomes.

To help hospitalist programs realize their full potential, we break down four imperatives to help physician leaders overcome the major, consistent challenges hospitalist programs face. In addition, our downloadable templates and resources will help you implement these imperatives at your organization.

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