Under Pressure

The threats are real, of course, but HM advocates and practitioners say that, for now, they remain just that. HM groups continue to grow, and HM job postings are plenty. To date, hospital administrators have been mostly loathe to lay off the staffers they count on to lower costs through patient safety initiatives, reduced length of stay, and faster throughput. The most optimistic of hospitalists view the threats as opportunities to further establish themselves as thought leaders who can prove their worth through quantifiable metrics. Still, hospitals are increasingly in dire straits, and that means hospitalists could be in the same situation.

“The dilemma is that hospitalists are tied to the hospital as an institution,” says Larry Wellikson, MD, CEO of SHM. “It doesn’t really matter what causes the hospital to have less discretionary capital. … These things play against the hospitalist.”

Beyond Staff Cuts

Dr. Jackson’s case is typical. Her institution—a two-hospital center with 510 combined beds—recently eliminated 70 positions. None were physicians, but several care-management jobs were lost. Add in a local unemployment rate of almost 12%, and it’s no surprise the hospital is buckling under the weight of uncompensated charity care. And even though Sacred Heart lists patient safety initiatives as a top priority, “it always comes up that it can be cut,” Dr. Jackson says.

The bar-coding initiative was put on hold until the end of 2010, despite the hospital’s purchase of a packager that separates medications into individual packets. Dr. Jackson thinks the new technology could cut medication errors by at least 25%. Updates in information technology have been put on hold. And even if President Obama’s stimulus plan supplies money for electronic medical records (EMR), much of that money might not make it to the hospital-floor level for another 12 to 18 months.

Budget cuts aren’t relegated to large-scale initiatives, either. “Positions have been frozen, perks disappearing,” Dr. Jackson says. “At medical staff meetings, food is getting sparse. Educational opportunities that would have been there before, they’re not going to pay for that. My money to go to [HM09] is frozen right now.”

Stay the Course

Greg Maynard, MD, MS, clinical professor of medicine and chief of the division of hospital medicine at the University of California at San Diego Medical Center, also identifies the threats to HM in personal terms. Cutbacks on spending are hard to avoid in tough economic times, he reasons, but the key for hospitalists is to not allow those discussions to affect the interpersonal relationships between HM groups and hospital executives. He also echoes the sentiments of burnout fears and morale issues. In the past year, his 24-member HM group has added primary coverage of the adult oncology unit and adult cystic fibrosis patients, among other responsibilities. It also started night coverage shifts. All the while, Dr. Maynard and his staff have heard UC San Diego is having financial issues, including troubles with its pension investments. Budget discussions are more strained because of the overall economic crisis, which makes professional relationships even more important to maintain, he says.

“You have to empathize with the medical center administrators as they struggle,” he adds. “I think there’s a threat of a dialogue. When pressure comes on, debates can become contentious. It’s important to avoid that.”