After 20 Years, What's Next for Hospitalists?

August 11, 2016 - When the idea of a hospitalist — a doctor, usually an internist, based in the hospital and specializing in caring for patients with complex cases — first emerged 20 years ago, it was considered novel, even fringe. Today, hospitalists in the US rival pediatricians in number and have developed into an essential field in healthcare.

As hospitalists have found their place in the medical world, however, fresh questions and challenges have emerged. Two Perspectives in the New England Journal of Medicine this month, one of them by the two doctors who coined the term hospitalist, Dr. Robert Wachter and Dr. Lee Goldman, examined the specialty's ascendance and its future role in an ever-evolving healthcare landscape.

"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, of the University of California, San Francisco, and Goldman, of Columbia University, wrote.

The other Perspective, by Dr. Richard Gunderman of the Indiana University School of Medicine, questioned the impact of hospital medicine on healthcare overall. "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."

These questions emerge amid a growing emphasis in medicine on coordinated, integrated care. And while in many ways a hospitalist's job is to provide precisely that, some see the growing reliance on them as indicative of healthcare becoming too hospital-centric, in a way that hinders comprehensive care.

"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," Grunderman wrote.

If a 70-year-old patient comes into a hospital with a fractured hip and in need of orthopedic surgery, the hospitalist would manage that patient's treatment by taking into account not just the injured joint but any other comorbidities that an elderly patient might have, such as heart failure that increases their risk of a blood clot. A common metaphor for a hospitalist is an orchestra conductor or a ship's captain, ensuring the harmonious and efficient delivery of medical care.

In 2003, when the American Hospital Association first began tracking the specialty, the US had slightly more than 10,000 hospitalists. In 2016, the country had more than 50,000, an increase driven by both economic necessity and a spate of government changes that emphasized efficiency and quality in healthcare. The field's boom is showing no signs of slowing.

"We're seeing many medical students start medical school saying. 'I want to be a hospitalist,'" Wachter said. Indeed, hospitalists will remain vital to the healthcare system even as the industry tilts toward population health, he added.

"There are people talking about how we can eventually close down all the hospitals," Wachter said. "That's not going to happen."

Today, patients that end up in the hospital tend to be even sicker, presenting with even more complex cases than previously, making doctors who specialize in handling these types of patients ever more necessary.

The challenge now for hospitalists is not so much in staying relevant but in remaining innovative and in continuing to deliver better care, especially as they are tasked with more diverse responsibilities. In recent years, hospitals looking for ways to improve efficiencies and lower costs, have begun outsourcing hospitalists. That's lead some hospitalists to raise concerns about being spread to thin.

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

Hospitalists do not merely aim to provide seamless, high-quality care for patients in hospitals. Their focus on integrated, managed care has also put them at the vanguard of the biggest systemic shifts in healthcare. But after 20 years, hospitalists will have to work to maintain that momentum.

"We're now a mature, really important field," said Wachter. "That's my biggest worry: that we'll become old and staid and rest on our laurels."

By Elizabeth Whitman
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