By Bob Wachter

A paper in today’s New England Journal
proves what we all know – the hospitalist field is the only thing 
growing faster than the national debt. Even though that’s not news,
this elegant biopsy of the Medicare database offers some new insights
about our field, the fastest growing specialty in medical history.

Briefly, the study used a methodology developed
by Sanjay Saint a decade ago: by examining evaluation and management
(E&M) codes submitted by general internists to Medicare, one can
determine which physicians do virtually all their E&M work in the
hospital, which have traditional general internist practices
(part-inpatient, part-outpatient), and which do virtually no inpatient
work (“ambulists” or “officists” – somebody will ultimately need to
settle on a term).

The NEJM authors defined a
hospitalist as a general internist who cares for over 100 Medicare
patients per year and whose E&M codes are at least 90%
hospital-based. This is a reasonable methodology for highlighting
trends, but it misses vast numbers of hospitalists. Surely, every
internist with more than 90% inpatient codes is a hospitalist, but
someone with 75% inpatient codes is probably one as well. In some
academic centers, for example, hospitalists do 2 half-days a week of
pre-op clinic, post-discharge follow-ups, or even traditional
outpatient practice, and thus fall below the 90% threshold. For this
and other reasons (the study excludes pediatricians, family physicians,
subspecialty hospitalists, and those who work in organizations like
Kaiser Permanente or the VA, who submit very few Medicare bills), the
paper’s estimate of about 14,000 hospitalists is probably low by a
factor of two. The actual number of U.S. hospitalists is closer to the
American Hospital Association’s estimate of 28,000, making the field larger than cardiology.

But
the news is in the growth curve. From 1997 to 2006, the hospitalist
workforce increased by 29% a year! In keeping with this growth, the
percentage of Medicare patients cared for by hospitalists increased
from 9% to 37%, and now exceeds 80% in some high penetration markets
such as Austin, Texas and Mesa, Arizona. Paralleling these trends is
substantial growth in ambulatory internists (<10% hospital codes),
now up to 35% of all internists and rising fast.

As you know, the American Board of Internal Medicine has been developing
a certification program to recognize the “focused practice” of
hospitalists. Some have fretted about a slippery slope – if we’re going
to recognize hospitalists, they say, why not recognize those internists
who have taken a particular interest in diabetes, heart failure, or
thyroid disease? The Board (which I’m on, BTW) has taken the stance
that it will consider for “Recognition of Focused Practice” areas in
which large numbers of general internists only do the thing, and large numbers never
do it. Hospital Medicine clearly vaults way over that bar. Conversely,
clinical areas of focus like diabetes wouldn’t qualify, since virtually
every general internist still sees diabetics, even though some have
taken a special interest in such patients. (HIV is the only clinical
domain I can think of that might pass this test.)

Another
interesting trend raised by the paper: In 1995, 46% of all Medicare
admissions were associated with a general internist E&M claim.
Assuming somebody was taking care of the patient, this means that most
hospitalized patients were being managed by subspecialists
(cardiologists, gastroenterologists, etc.) or specialists (surgeons,
gynecologists). This percentage rose to 61% in 2006, all on the
strength of the growth of hospitalists. In other words, hospitalists
have not only taken over for PCPs in overseeing and coordinating
hospital care, they have taken over for specialists and subspecialists.
A 2002 paper
demonstrated that specialists caring for patients whose main problem
fell purely within their specialty sweet spot achieved good quality and
reasonable efficiency… but when specialists cared for patients with other
problems (the gastroenterologist caring for the hospitalized asthmatic,
for example), they had poor quality and miserable efficiency. So this
replacement of specialists and subspecialists with hospitalists as
primary managers of inpatient care is an important, and to me a
positive, development – particularly since so few of today’s inpatients
are cooperative enough to limit their problems to a single organ system.

In
a related note, the skyrocketing penetration of hospitalists in the
care of patients with “medical DRGs” was matched by that seen in
patients with “surgical” and “neurologic” DRGs. This is quite
remarkable; it means the chances that a patient admitted to a U.S.
hospital with an orthopedic DRG (i.e., hip fracture) or a neurologic
DRG (i.e., stroke) will be taken care of by a hospitalist is the same
(40%) as one admitted with a pulmonary or GI DRG (pneumonia, GI bleed).

These data portend a future in which hospitalists (if enough can be found) will be involved in the care of virtually every sick patient – medical and
surgical – in the building, something I’ve predicted for years. This
has major implications for training. Future hospitalists need to be as
comfortable helping to manage hip fracture or subarachnoid bleed
patients as they are COPD patients. The old residency model of doing a
couple of weeks on “med consult” (we come when you call us, we make a
few recommendations, you may or may not listen, and we slink away) is
increasingly out of sync with modern practice. Accordingly, at UCSF we
are blowing up our med consult model – our “consult” residents next
year will probably spend more time working with hospitalists
co-managing complex patients on our neurosurgery and orthopedics
service than they do in more traditional “come when called” consult
arrangements.

And since most hospitalists have been
undertrained in these areas of surgery and neurology, CME needs to
refocus as well. My Management of the Hospitalized Patient CME conference (Sept 24-26 this year) has more neurology than pulmonary content, and attendees of our Hospitalist Mini-College
(Sept 21-23) will spend three half-days gaining hands-on experience
with neurology, periop, and ICU patients. [More info on these courses
coming soon, once the agendas are finalized.]

The final bit of
news concerns the career longevity of hospitalists. In the early days,
lots of folks worried about the sustainability of a hospitalist career.
(I’ll never forget our first hospitalist meeting in 1997. I asked an
audience of about 150, “Everybody’s worried about you burning out –
that this is a young person’s job. What do you think?” One guy stood
up, chuckled, and said, “I was in office practice for 15 years. You
want to see me burn out, just make me go back there.”) I’ve
always felt that hospitalist jobs that were structured correctly,
compensated fairly, and embedded in a strong culture carried no undue
risk for burnout. A 2001 study
confirmed this impression, and a 2005 Press Ganey survey of physician
career satisfaction placed hospitalists second from the top, behind
only radiation oncologists. (Fun facts: most medical subspecialists
clustered near the mean, CT surgeons were in last place [the
consequence of training for 12 years and then having your
bread-and-butter procedure replaced by stents], dermatologists were
near the top (duh), and radiologists were slightly below the mean –
which I interpreted to indicate that they didn’t understand the
question).

Anyhooo… today’s NEJM study confirms my
impression. In the early years, lots of folks were dipping their toes
in the hospitalist pool but weren’t fully committed: of internists
identified as hospitalists in 1995, only one-third met the definition
two years later. Some tire kicking is natural, of course, since there
isn’t a special training requirement and it doesn’t take much effort to
leave a hospitalist practice. But the paper found that, of those who
met the hospitalist definition in 2004, two-thirds still were
hospitalists two years later, a doubling in this surrogate measure of
career stability.

The accompanying editorial, written by Mary Beth Hamel, a general internist-researcher at Beth Israel Deaconess, NEJM
editor Jeff Drazen, and Harvard health policy guru Arnie Epstein,
struck me as another in a long line of articles from those who
appreciate that the world has changed but are still not quite willing
to trade their Walkman for an iPod. After a thoughtful review of the
forces promoting the hospitalist model and a discussion of the benefits
and the liabilities of the model (the latter focused on the usual
culprits: discontinuity and potential primary physician skill loss,
dissatisfaction, or attenuated links to the hospital), the authors
concede the obvious:

No matter what the balance of
benefits versus adverse effects related to hospitalists, the economic
and practical forces that promoted the growth in the care of patients
by hospitalists are intensifying, not lessening, and hospitalists are
here to stay. It is time to focus on how to enhance the value of
hospitalists and more fully acknowledge and address the compromises the
hospitalist movement has required of patients and primary care
physicians.

I couldn’t agree more, and wish the
authors had ended there. But they couldn’t quite bring themselves to
conclude without resurrecting an alternative model – one I first described
in 1999 – in which primary care doctors rotate into the hospital for
periods of time. Although they quite correctly state that this
rotational model has some advantages over the traditional PCP-based
hospital care system (namely, on-site presence of the rotating
physician), they gloss over its glaring liability: the physician doing
one-week-in-8 in the hospital is spending no more time, in aggregate,
caring for hospitalized patients than the PCP who spends 45 minutes
each morning (each spends 8-12% time in hospital care overall). Without
a focus in hospital medicine, the chances that the PCP-rotator (who is
decidedly NOT a hospitalist, in my view) will achieve
expertise or efficiency in hospital care or will lead hospital quality
improvement efforts are really no greater than they are under the old
system (not to mention that the office practice goes to hell during the
rotator’s week away). I predicted then and continue to believe that
these liabilities will consign this model to a small, perhaps even
trivial, place in the world of modern hospital care.

By
coincidence, I was visiting professor at Dr. Hamel’s superb hospital,
Beth Israel Deaconess, just last week. By all accounts, the hospitalist
group there, led by Joe Li, does a great job in clinical management,
coordination, quality improvement, and education. Most of the primary
care internists hold the hospitalists in high regard, and many – though
not all – have become comfortable handing their patients off to them
for hospital care. Communication and collaboration seem excellent and
there is a palpable amount of mutual respect. In other words, the
system is working well, and virtually everybody (including all the
trainees and most ambulatory internists I met) agrees that it is a vast
improvement over the old model. So it is not entirely clear what
problem the rotating PCP model would be trying to fix; it would, in
many respects, represent a step backwards.

The bottom line is
that the rotating PCP model might work here and there, and it is
probably better than the traditional model of every PCP coming in every
day at daybreak to see 1-2 very sick patients. That said, I believe
that calls for its revival represent wistful longings for a system that
has clearly lost in the marketplace of ideas and data that determines
the organization of hospital care.