Thursday, December 28, 2006

Top 10 issues in hospital medicine for 2006---issue 10: state of the hospitalist movement

As 2006 draws to a close it’s time again to reflect on important issues in the field of hospital medicine for the past year. As was the case last year the selections are confined to adult hospital medicine and reflect the opinions of a biased committee of one: me.

I ranked the state of the hospitalist movement first last year. I’m ranking it number 10 this time because 2006 saw no movement-defining developments.

Economic pressures a decade ago created a niche for the movement in areas of heavy managed care penetration. The pressures of managed care relented, but a new niche was created as more and more primary care physicians chose to increase their efficiency by dropping hospital practice. These physicians can more easily stay on schedule in their offices, a patient satisfaction advantage counterbalanced by some patients’ frustration with receiving in patient care from strangers.

Some feel that hospitalist medicine is opposed to the agenda of primary care. Robert Wachter, M.D., a leader in hospital medicine, disagreed in a recent interview in Internal Medicine World Report: “Rather than feeling that hospitalists are another nail in the coffin of primary care, I hear from many primary care doctors that hospitalists have helped them tremendously. They realized long ago that they simply could not take care of sick hospitalized patients and manage their office practice simultaneously, and hospitalists have helped them make their jobs more survivable.”

Professional satisfaction seems to be shifting in favor of hospital medicine. It’s at an all time low in traditional primary care practice leading more and more internal medicine trainees to choose hospital medicine. According to Wachter, Society of Hospital Medicine surveys show a high rate of professional satisfaction among hospitalists. Wachter also predicted that the number of hospitalists needed may reach 50,000, a higher estimate than those made previously.

A few decades ago the hospital was a jungle, a combat zone inhabited by people with competing agendas and a culture of blame. Booby traps posed dangers to patients at every turn requiring the vigilance of the “superdoc” to head them off. The dream for the hospital of tomorrow is that of a safe place where a nurturing spirit of teamwork pervades the facility and computer enhanced system improvements all but eliminate errors. Movement along this path may gradually shift the role of the hospitalist from superdoc to systems management team member. But we’re not there yet. It’s a slow journey and in 2006 we’re somewhere between The House of God and the safe place. Systems improvement is too early in its development to solve the problem of patient safety. There will be a role for vigilance on the part of the individual hospital physician for years to come.

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