As one measure of how the world has changed in just a few years, Wachter reflects on the experience of editing his textbook, Hospital Medicine, in 2000, and again in 2005 for the second edition. He was particularly struck by the chapter he wrote (in the 2005 edition, with his UCSF colleague Niraj Sehgal) on quality measurement and improvement. “It was staggering how much the area had changed,” he says. In the 2000 edition, there were 2 inpatient quality measures: aspirin and beta blockers for patients with myocardial infarction. In the 2005 edition, “we needed a 2-page table to catalogue all of the hospital quality measures produced by an alphabet soup of agencies and organizations.” In fact, he notes, of the 122 chapters in the book, the chapter that had changed the most in 5 years was the one on quality measurement. “This is a complex science that is still evolving,” Wachter says. “I fully expect that the chapter in the 3rd edition will change even more.”
Wachter has spearheaded several other initiatives designed to improve hospital conditions and care of patients. He leads a team of editors for the website, AHRQ Web M&M: Morbidity and Mortality Rounds on the Web (www.webmm.ahrq.gov), which provides expert analyses on medical errors, as well as a forum and online discussions on patient safety issues. He and his colleagues recently launched a second federally sponsored portal for patient safety, “AHRQ Patient Safety Network” (www.psnet.ahrq.gov), which offers regularly updated tools, new literature, surveys, videos, and links to other useful resources and experts and is customizable according to users’ interests.
Burnout
With all the responsibilities assigned to hospitalists, the issue of burnout might become a concern. Defined as mental and/or physical exhaustion caused by excessive and prolonged stress, burnout can afflict medical professionals who spend long hours caring for complicated patients. Wachter worries about burnout, but not unduly so. “There is nothing fundamental about our field that will cause burnout,” he says. He cites 4 factors that contribute to burnout: doing uninteresting, unimportant work; receiving little or no respect from peers; having little or no time to “catch your breath”; and earning an inadequate and unreasonable income. With the diverse responsibilities and personally and professionally satisfying work in which a hospitalist engages, these risks can be mitigated. “I’ve certainly visited hospital medicine groups that were rife with burned out providers,” he says. “But more often, I’ve seen terrific doctors doing work they love, making a difference in the lives of their patients and their institutions. When that’s the case, you don’t see much burnout.” Wachter believes that the way in which hospital medicine groups are designed influences the potential burnout factor. Considerable thought and planning should precede the creation of a hospital medicine group, he asserts. “Some groups are well constructed,” he says. “They’ve created jobs with reasonable amounts of downtime, an opportunity to earn a good income, and the chance to spend time improving the system and deliver high quality patient care.” On the other hand, groups that care for an unsustainable number of patients with lower recompense might well have burnout; some have even collapsed after the physicians led. “You can be sure,” he notes, “that the second iteration of the hospital medicine programs at these institutions will be structured much more carefully so as not to repeat the same mistakes.”
Using his own UCSF Medical Center as an example, Wachter notes virtually no burnout or attrition among his faculty, even though salaries are on an academic scale, below the prevailing community rate. “We feel supported and have time to catch our breath,” he says. “We are respected by our colleagues and the institution, we have a chance to teach, and we genuinely enjoy each other’s company. And we have a chance to work on other things, not just patient care.” And that makes all the difference.