Section 1: The Value and Values of Hospital Medicine

The Face of Health Care: Emerging Issues for Hospitalists

INTRODUCTION

Hospital medicine is entering its third decade since the term “hospitalist” was first created by Wachter and Goldman. There are now approximately 40,000 hospitalists and the number is likely to reach 50,000 in the next decade. The specialty has emerged from vigorous early debate about whether there was sufficient evidence to justify the role of hospitalists to a point where hospital medicine programs are hard-wired and indispensable in the majority of US hospitals. Early leaders and pioneers in hospital medicine were frequently two to three physician programs with heavy call burdens. Current hospital medicine groups, particularly in larger hospitals, average approximately 15 clinicians and have complicated alternating schedules with clear time off. Early hospitalists often served in hospital leadership roles with no dedicated time. They were often the only source of quality and safety leadership across the hospital. Today, hospitalists frequently have committed time to serve in quality and safety positions as well as other medical leadership roles. Most hospitals now have numerous staff that oversee various quality functions and ably assist these hospitalist leaders. While some aspects have greatly advanced for hospital medicine, two things have not changed:

• Pressure to care for sick patients requiring hospitalization—In many hospitals, the severity of illness across the patients cared for by hospitalists continues to rise. The number of patients covered by hospitalists grows in most hospitals and it is not unheard of for all medical inpatients to be cared for by hospitalists.

• Juggling time between clinical care and hospital leadership— While there are greater numbers of hospitalists and more hospital staff focused on quality and safety, the need for clinician leadership has never been more necessary. The vacuum caused by physicians no longer seeking hospital staff privileges as well as the overall urgent need for a new paradigm in health care to increase quality and decrease the cost of care has only resulted in greater need for hospitalists and physician leadership. Hospitalists are quickly expected to assume formal leader roles as well as clinical team leaders.

The need for inpatient care will not go away but how we care for the acutely ill may change. The demand for physician leadership does not diminish, but our focus on certain issues will vary. So what are the issues facing hospitalists in the next decade? Based on careful study of patients, families, hospitalists, hospitals, and health systems, we can predict the likely emerging issues.

“VALUE”

Similar to history, certain issues in health care predominate during a particular era because of timing related to unique discovery, emerging evidence, or simply greater knowledge by the masses of a problem. In the late 1990s, quality began its emergence as the principal concern in health care. This started in the 1980s with early studies examining inconsistency and errors as well as problems associated ...