What’s hospital medicine’s raison d’etre?

One of Kevin’s commenters, writing in response to my post from yesterday, said:

I have long been a sole dissenting voice in the hospitalist debate; I do not think the model will last. Most hospitalist programs are subsidized under the argument that they save money. However, this has not been proven in a significant way. Eventually, they will have outlasted their usefulness and be replaced either by cheaper hospitalist midlevel providers or by the primary care doctors returning to hospital care (not subsidized).

So we need a reason for our existence---a raison d’etre as Donald Berwick put it in his address at SHM 2008. It was the topic of mental masturbation in San Diego last April and centered around the concept of value. As I posted yesterday, the opening panel talked around what seemed an elusive definition. A disturbing consensus emerged that hospitalists may have to reinvent themselves to take over the inpatient environment and function as “house doctors”, going beyond their comfort zone and training, admitting all patients, doing virtually everything. I noted serious professional satisfaction and burn out issues for hospitalists if that scenario plays out. I’m not the only one concerned. Today another one of Kevin’s commenters said this:

I was a hospitalist for 5 years at a major New York hospital. Their solution for getting the most for their money was by having us do a lot of non-hopsitalist work.. i.e. teach physical diagnosis to med students, farm us out to a nursing home, cover a dedicated service for a certain insurance company. It sucked, which is why I left. They say the average life span of a hospitalist is 5 years. There's a reason.

That should sound a note of caution regarding what we ask and expect hospitalists to do.

IHI CEO Donald Berwick, in the talk that followed, presented an even more grandiose vision that takes hospitalists outside the walls of the facility to become “integrators” in the grand scheme of public health and advocates for a universal system. But then we wouldn’t be hospitalists any more, would we? How many of us entered the field to be public health experts and policy wonks? Not many, I’d say.

Judging from today’s blog reactions I think I may have been misunderstood to say the movement is in jeopardy. I don’t believe that at all. Retired Doc said this:

Even as the future for hospitalist might appear less rosy, we should not forget that the safety and quality movement leader guru, Dr. Donald Berwick still has much for them to do as they become the change agents and integrators of a new medical system that will provide quality care, reduce costs and improve public health. I guess it is better that I did not become a hospitalist as all I could do on a good day was to take as good of care of my patients as I could leaving the problems of maximizing public health and obtaining universal medical coverage to someone else.

As a hospitalist I can take the same view. If I succeed in stabilizing a few patients and making my hospital a better place I’ve had a good day.

I’ve been an observer and a participant in the movement since the early years. For me the reason to be a hospitalist has always been simple. There’s a niche to fill. That niche was created by professional and economic factors in our health care system. And it’s not going away.