What have been some of the most significant changes in hospital medicine since the specialty was established? What recent highs and lows have occurred in hospital medicine or healthcare as a whole? The Hospitalist spoke with several experienced hospital medicine physicians to gather their perspectives. They were also asked to share their predictions for changes they expect to see in the next decade. Here are excerpts from their insights.
Weijen W. Chang, MD, FAAP, SFHM
Chief of pediatric hospital medicine and vice-chair for clinical affairs at Baystate Children’s Hospital, associate professor of pediatrics at the University of Massachusetts Medical School Baystate, both in Springfield, Mass., and physician editor for The Hospitalist
Dr. Chang trained in a combined internal medicine-pediatric residency program and began his career in primary care, after which he worked in both adult and children’s medicine at UC San Diego as well as at locations in New England. He currently spends more than 90% of his time in pediatrics and occasionally covers shifts in adult hospital medicine.
It’s becoming a lot harder for us to do our job. And as hospitalists, we’re being asked to extend our scope more and all sorts of things that we probably didn’t cover very much of when we first started off. —Weijen W. Chang, MD, FAAP, SFHM
The biggest change he has seen in hospital medicine has been the conversion to electronic health records (EHRs), not just for its technological changes, but also in how it has changed a personal feel within medicine.
Before, “you would hang out in the doctor’s lounge and drink coffee and talk about family. It was a much more personal type of profession. Now it seems very impersonal, where your meetings are electronic. You don’t run into people as much, and most of your rounding feels somewhat isolated these days,” Dr. Chang said.
Although the pandemic accelerated this change, it was already heading in that direction, he adds.
At the same time, Dr. Chang sees some pluses to that change (such as not burning fossil fuels to get to meetings) and in the fact that health systems made it through the COVID-19 pandemic. “I don’t think that’s any small feat,” he said.
Yet as federal subsidies and support have run out, many hospital systems are now struggling, he adds.
The biggest challenge over the next decade for both adult and pediatric hospital medicine will be workforce shortages within other specialties—and how that will have an impact on the broader responsibilities of hospitalists.
“It’s becoming a lot harder for us to do our job,” Dr. Chang said. “And as hospitalists, we’re being asked to extend our scope more and all sorts of things that we probably didn’t cover very much of when we first started off.”
The trend of hospitalist care at home also will affect the specialty, as will the continued expansion of telemedicine, Dr. Chang adds.
Gregory B. Seymann, MD
Vice chief of hospital medicine at the University of California San Diego School of Medicine
Dr. Seymann has been a hospitalist with UC San Diego for his entire career. He was one of two physicians who founded a part-time hospital medicine program that has grown to 60+ hospitalists.
Done well, it [AI] could make a huge improvement in the ability of the hospitalist to maximize ‘top of license’ work, spend more time at the bedside, reduce burnout rates, and create more time for systems-improvement work. —Gregory B. Seymann, MD
He sees the biggest change in hospital medicine as a shift from measuring the impact of hospitalists by looking only at productivity and efficiency metrics to a broader concept of hospitalists as partners in the evolution of care models to those that advance systems toward safe, patient-centered care.
Dr. Seymann also perceives some recent high points for healthcare that came out of the COVID-19 pandemic, such as the use of telehealth and remote visits. Another recent positive trend has been a focus on incorporating social determinants of health and addressing disparities within systems-improvement initiatives.
Going forward, leveraging artificial intelligence (AI) efficiently will affect hospital medicine and healthcare in a major way, Dr. Seymann says. “Done well, it could make a huge improvement in the ability of the hospitalist to maximize ‘top of license’ work, spend more time at the bedside, reduce burnout rates, and create more time for systems-improvement work,” he said. “Done poorly, it could affect safety, erode trust, affect jobs and salaries, reduce face time with patients, and dehumanize the field.”
He makes the comparison to the initial use of EHRs, which promised—and often delivered—leveraging access to data to improve care. “We saw lots of that, but also many areas where technology implementation was clunky … Learning from those implementation mistakes for the next phase is critical,” Dr. Seymann said.
Danielle Bowen Scheurer MD, MSCR, MHM
Hospitalist, professor, and chief quality officer at the Medical University of South Carolina Health System in Charleston
Dr. Scheurer has been a hospitalist since 2002 and believes that the biggest change to hospital medicine has been the expansion of hospital medicine programs. “We started as rare gems in hospitals, but now, hospital medicine programs are present in almost every single hospital in the U.S.,” she said.
It needs to be abundantly clear that we provide higher-quality and lower-cost care than what would be provided without us. In short, what is our return on investment? —Danielle Bowen Scheurer MD,MSCR, MHM
The expanded presence of hospital medicine programs has enabled the specialty to positively impact quality, efficiency, and cost of care.
Conversely, however, this has led to more burnout. “While not unique to hospital medicine, as the complexity and volume of patients go up, many of our teams are struggling with burnout, to the same degree as other specialties,” she said.
Over the next decade, hospital medicine will need to continue to demonstrate its value to hospitals and the healthcare industry. “It needs to be abundantly clear that we provide higher-quality and lower-cost care than what would be provided without us. In short, what is our return on investment?” she said. “We have to be able to have a positive impact on the field and ensure we are publishing our successes.”
Heather E. Nye, MD, PhD
Professor of medicine at the University of California, San Francisco, associate chief of medicine at San Francisco VA Health Care System (SFVAHCS), and director of its consult/co-management service and veterans integrated perioperative clinic
Dr. Nye has been a hospitalist since finishing her meds-peds residency in 2003 and has spent all of those years with UCSF.
She sees the evolution of the hospitalist role as the biggest change within hospital medicine. “Hospital beds may be on the decline nationally, but hospitalists have differentiated into several niche areas, including post-acute care settings, perioperative medicine, palliative care, quality and patient safety, and many others,” Dr. Nye said. “This shift has been exciting and has provided us with an endless stream of possibilities in the field as hospitalists serve to bridge gaps and create solutions to complex problems in evolving healthcare systems. A hospitalist isn’t just a hospitalist anymore.”
This shift has been exciting and has provided us with an endless stream of possibilities in the field as hospitalists serve to bridge gaps and create solutions to complex problems in evolving healthcare systems. A hospitalist isn’t just a hospitalist anymore. —Heather E. Nye, MD, PhD
The rapid differentiation has served as a high point for hospital medicine, which has “grown into its britches in admirable ways,” Dr. Nye said. “Hospitalists are still front-line care providers, but also service chiefs, C-suite members, and distinguished federal officers who garner respect as systems experts and innovators … Now, our challenge is to stay relevant and remain a worthy investment for hospitals.”
Yet she advises proceeding with caution.
“While efficiency and low-cost care are grounded in sound principles, they can burden providers in unintended ways that jeopardize the ability to do what’s right for patients versus follow algorithms,” she said. “We risk being number-centered, not patient-centered, and it’s causing burnout, goal misalignment, and feelings of depersonalization.” If taken too far, it could lead ‘thinking’ (non-procedural) specialties and those that provide the ‘glue’ (such as primary care practitioners) to become overburdened and leave medicine altogether.
It’s possible that AI may help reduce the administrative burden for all physicians and increase the amount of time spent with patients in the future. “It’s hard to know all the ways it might impact our day-to-day work, but I’m hopeful that, counterintuitively, AI will return us to some of the humanistic reasons for which we entered medicine,” she said.
Daniel Rauch, MD, FAAP, SFHM
Professor of pediatrics at Hackensack Meridian School of Medicine, and director, divisions of pediatric hospital medicine and general academic pediatrics at Hackensack Meridian Children’s Health in Hackensack, N.J.
Dr. Rauch has been a hospitalist for nearly 30 years. With his background in pediatrics, he believes that one of the biggest changes has been recognizing pediatric hospital medicine as a subspecialty within pediatrics. This was formally recognized in 2016, with the first certifying exam given in 2019. It was a process that he was able to help steer.
We’re not people plugging a hole, but we are actually specialists with a skill set and a knowledge base that’s different than our peers. We have a value to add to pediatric medicine that’s important. —Daniel Rauch, MD, FAAP, SFHM
“We’re not people plugging a hole, but we are actually specialists with a skill set and a knowledge base that’s different than our peers. We have a value to add to pediatric medicine that’s important,” Dr. Rauch said. “It put us at an equal footing at the academic table with our peers and really helped us standardize training in PHM.”
Dr. Rauch points to improved treatments for children as a positive for pediatric hospital medicine in recent years, including shorter lengths of stay and treating children with certain health conditions on an outpatient basis. Work in this area continues in a variety of areas, such as for sickle cell disease, for which Hackensack has helped steer some trial work.
“The downside is the logistic challenges, so payment is a huge issue, and making sure that inpatient pediatric services are viable. We, unfortunately, as a society don’t value care for our children. We pay pediatric care differently than we do adult care and it’s put at risk care of our children in places that are closer to families’ homes and that aren’t necessarily the highest level of specialty care, but that’s not what most hospitalized children need,” Dr. Rauch said.
Over the next decade, Dr. Rauch sees a lack of understanding of the outpatient generalist’s role as a hindrance for hospitalists and other physicians. “When you don’t understand where your referrals are coming from and how patients can be managed once they leave your service, that’s a risk to care,” he said. He wants to ensure that children in all settings—be it at the hospital or as outpatients—get appropriate care.
Margaret Fang, MD, MPH, MHM
Chief of the division of hospital medicine at UCSF Health and director of research and UCSF Academic Hospital Medicine Fellowship, both in San Francisco
Dr. Fang joined UCSF as a hospitalist in 2003. Like her colleagues interviewed for this story, she marvels at the diverse roles now filled by hospitalists, from triage and admitting to overnight care, to neuro-hospitalists and OB-hospitalists.
While at the beginning of the hospitalist movement, we could clearly point to comparative advantages in quality, safety, and efficiency compared to the prior system, now that the hospitalist model has been widely adopted, we are facing new questions about our value. —Margaret Fang, MD, MPH, MHM
Welcoming more internal medicine graduates to the field is a definite high point within the specialty, she says, although she also worries about the high rate of burnout. “Although some of this might have been due to the pandemic, I think it’s also a result of how much harder it feels to practice medicine these days,” she said.
In the coming decade, a major challenge will be to showcase the value of hospitalists to hospitals and healthcare systems, she explains. With financial pressures and consolidation of health systems, there will be ongoing incentives to increase hospital throughput and reduce costs. “While at the beginning of the hospitalist movement, we could clearly point to comparative advantages in quality, safety, and efficiency compared to the prior system, now that the hospitalist model has been widely adopted, we are facing new questions about our value,” Dr. Fang said. “This has led to the growth of clinical models that incorporate advanced practice professionals, the expansion of large physician staffing groups, and unionization.”
Alpesh N. Amin, MD, MBA, MACP, MHM
Associate dean for clinical transformation at the University of California Irvine Health, and professor and chief, division of hospital medicine and palliative medicine, department of medicine, at the University of California in Irvine, Calif.
Dr. Amin founded the hospital medicine program at UC Irvine in 1997. In addition to being chief of hospital medicine and palliative medicine, he is associate dean for clinical transformation and served as chair of medicine at UC Irvine for the past 16 years.
he way we’ve managed certain disease states has evolved and changed. We’re getting patients out faster than we were before. We’re getting them set up with proper therapies that they can take at home. I think there will be more and more of that kind of care delivery that will help either get patients discharged a little bit sooner or [help in] preventing readmission. —Alpesh N. Amin, MD, MBA, MACP, MHM
Dr. Amin believes the evolution of hospitalists working in other roles, including chairs of medicine, associate or vice deans, and quality officers, points out their valuable leadership role.
Hospitalists also have been able to help identify research opportunities in the hospital from a systems approach, he adds. This comes from rich experience treating patients with different conditions and attempting to streamline care and improve it throughout the hospital.
Since the specialty began, hospitalists also have taken on a broad teaching role with residents, pharmacy students, advanced practice practitioners, nurse practitioners, and others. “The whole teaching opportunity is value-added but has challenges in terms of reimbursement,” he said. “A lot of these things are a huge value added when you look at it from an all-encompassing role that hospitalists play.”
Over the next decade, Dr. Amin believes a major issue will be treating sicker patients that hospitalists will have to care for. That will be combined with how care delivery is accomplished using AI and other tools. Care at home also will be part of the delivery-of-care model.
“The way we’ve managed certain disease states has evolved and changed. We’re getting patients out faster than we were before. We’re getting them set up with proper therapies that they can take at home. I think there will be more and more of that kind of care delivery that will help either get patients discharged a little bit sooner or [help in] preventing readmission,” he said.
He also believes that hospitalists will continue to get engaged with certain high-volume services, such as heart failure or orthopedic service.
Vanessa Caceres is a medical writer in Bradenton, Fla.