I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.
Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.
Dr. Robert Wachter donned appropriate retirement garb to address SHM Annual Meeting attendees from the “future.”
But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.
In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.
Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.
Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)
Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.