Hospitalist Potpourri

I’m just back from the annual meeting of the Society of Hospital Medicine and, as usual, I was blown away. I’ve not seen a medical society meeting that is remotely like it. As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the world, and just plain sizzle,” and I completely agree. I was also amazed by the size: having hosted the first hospitalist meeting in 1997, with about 100 people, seeing an audience of 3,600 fill a Las Vegas mega-ballroom was just plain awesome.

This enthusiasm did not equal smugness. Folks know that change is the order of the day, and with it will come upheaval and some unpleasantness. But the general attitude I sensed at the meeting was that change is likelier to be good for patients – and for the specialty – than bad. Whether this will ultimately be true is up in the air, but the mindset is awfully energizing to be around.

Here, in no particular order, is my take on a few of the issues that generated hallway buzz during the SHM meeting.

The Closing of Hospitals

While much is uncertain in the era of health reform, the number of hospitals is clearly going to shrink, perhaps by a lot. A healthcare system that tolerated the inefficiency of having two mediocre 125-bed hospitals in adjacent towns will no longer do so: one 200-bed hospital will be left standing when the dust settles. If that.

The betting is that 10-20% of hospital bed capacity will be taken out of the system in the next few years. It could be even more, depending on the answers to several questions. Will electronic monitoring and telemedicine allow increasing numbers of sick patients to be cared for at home or in sub-acute settings? Will payments for non-hospital care systems (home care, SNFs) be enough to expand their capacity to care for acutely ill patients? Will ACOs, bundling, and other similar interventions truly flourish? Will a shift to population health and a new focus on wellness make a dent in the prevalence of chronic disease? These are just some of the known unknowns.

What does this mean for hospitalists? Obviously, if you happen to work at a hospital that closes, you may be out of a job. But pick up a copy of the NEJM or the Journal of Hospital Medicine: there are still far more openings for hospitalists than there are people to fill them. Although I’m expecting few if any unemployed hospitalists, there will be change: hospitalists will be working in fewer buildings, they’ll be working a bit harder, and the hospitals that do stay open will be more efficient.

Out of the ferment will come new opportunities for hospitalists. I’m on the board of IPC, the largest hospitalist company in the U.S. Several years ago, the company recognized that many patients who used to be in the hospital were now in sub-acute settings. Today, nearly one-third of IPC’s clinicians work in SNFs and long-term care facilities. I suspect that some of the hospitalists displaced by hospital closures will find work in these kinds of settings – and these will not be your father’s SNFs. The level of patient acuity may be similar to that of hospitals a decade ago.

In addition to closures, we’ll see plenty of mergers and affiliation. I’m also on the board of Salem Hospital in Oregon, a terrific, mid-sized hospital that is – to a large degree – the only game in town for Salem, a mid-sized city with a population of about 160,000. The hospital is well run: we have had computerized order entry for a decade, have been running a robust physician leadership academy since 2009, and adopted Lean well before it became fashionable. The hospital enjoys a healthy bottom line and significant reserves. Yet in the current environment, it was the judgment of the leadership and the board of directors that we could not go it alone. We announced last month that we are in talks with Oregon Health Sciences University (OHSU) to affiliate.

And at home, UCSF just merged our children’s hospital with Oakland’s. For those of us working in or running hospitalist programs, these new relationships are likely to mean significant change. In a three-hospital system with 100 hospitalists, I doubt there will be three different leaders and three independent programs. Sorting out the relationships, the money, the schedules, and the culture will offer a new and complex set of challenges to those of us who have had the luxury of managing a single program in a single building.

Hospitalist Workload and Support

Last month in JAMA Internal Medicine, researchers at Christiana Health in Wilmington, Delaware correlated hospitalist workload with both quality and efficiency outcomes. Their findings were striking: when hospitalists ran censuses of more than 15 patients, for each additional patient costs per case went up by $262. These increases varied a bit depending on how full the hospital was, but no matter how full the building, the relationship held.

As I noted in an accompanying editorial, this study is important for several reasons. First, it illustrates a point that I’ve made since the early days of the field (but without much evidence to support it, until now): there must be a workload above which some of the advantages of the hospitalist model – on-site presence, constant availability – begin to erode. Just think, if you’re managing 20 patients and you spend 15 minutes seeing (and charting on) each patient, you won’t get to your last patient till well after noon. And if a couple of patients get sick… well, the ballgame is over. I’ve frequently counseled hospitals that were considering supporting hospitalist programs that it might be in their financial interest (i.e., there might be an ROI) to do so if their dollars helped the physicians maintain a manageable census – independent of any advantages gained in recruiting, retention, and allowing hospitalists time to work on systems improvement.

The reason this is important is that, as hospital budgets tighten, hospital support payments to hospitalists will come under increased scrutiny. In primary care, the lack of evidence that bad things happen (other than physician burnout and patient unhappiness) when visits shorten to 14 minutes meant that there were no compelling counterarguments to briefer visits. For hospitalists, the Christiana study creates such a counter argument.

Will this mean that hospitalist support payments will go unchallenged? Hell, no. IPC has grown to become the biggest player in the hospitalist staffing business in part because the majority of its programs do not receive significant hospital support (let me remind you again of my conflict here). They do this by running programs efficiently, by billing effectively, and by employing a schedule that has people work more days per year than hospitalists do under the more common and very popular 7-days-on/7-days-off structure. Although IPC hospitalists have had a reputation of carrying large caseloads, I’ve seen the data and I know that their average census is, in fact, about 15. The point here is that, just as hospitalists took over the world of hospital care because they demonstrated that they could provide high-quality care at a lower cost, the increasing financial pressures that hospitals are under will create, in turn, pressures on hospitalist programs to achieve quality, safety, patient satisfaction, and efficiency outcomes at the lowest possible cost to the hospital. In this environment, every program needs to be looking at its caseload and outcomes to defend any support payments it gets. The Christiana study provides a strong argument that those support payments may be cost effective if they allow a hospitalist group to maintain market-appropriate salaries while keeping volumes manageable.

Also, the paper was important in that it is one of the first to look at the relationship between physician volume and outcomes, in any specialty. Such studies are familiar in nursing, and have led to major policy changes. In California, for example, nurse-to-patient ratios are mandated to be no more than 1:5 on med-surg floors, in part based on such studies. But physicians have always had a Super Doc attitude: That they could see any number of patients and nothing bad happens. This defies the laws of both physics and physiology, and I hope the Christiana paper ushers in studies of other fields asking the question: what physician volume maximizes value.

There is another point about hospitalist organization that is worth paying attention to. The latest American Hospital Association data show that there are more than 40,000 hospitalists in the U.S. As the fastest growing specialty in modern medical history, it’s easy to think that the field has “won” and is safe from competitive threats. But with so much change afoot, such thinking is dangerous.

My friend David Meltzer of the University of Chicago is testing a model of comprehensive care – in which a select group of high risk, frequently admitted patients is cared for by a single physician in both the inpatient and outpatient setting. Sound familiar? It should: that’s the old system! Meltzer’s early results, presented at SHM and elsewhere, are promising.

Some people have asked me, given my advocacy for the hospitalist field, whether this bothers me. If it did, I’d be a hypocrite. The reason the hospitalist field thrived was that it demonstrated that it delivered better value than traditional models. But it is a completely plausible hypothesis that – for a subset of patients – the continuity of the old model might win out, particularly if these comprehensive docs are advantaged by the on-site presence of hospitalists (for nighttime coverage or if their patients crump acutely) and by the latter’s work improving the system of care.

So I applaud David and his colleagues for testing this model in the 5-10% of patients who might benefit from it. We must always stay open to the idea that there are better ways of doing things.

Leadership and Burnout

At the meeting, I was also struck by the degree to which hospitalists have emerged as leaders in systems of care, a point made nicely in a recent article in The Hospitalist. During the week, I saw plenty of hospital CMOs, CQOs, and even a few CEOs – such as Brian Harte, my former trainee who now leads one of the Cleveland Clinic’s major sites, and Pat Cawley, the former SHM president who runs the Medical University of South Carolina’s hospital. On the national scene, it is no coincidence that Medicare’s top physician (Pat Conway) and the nominee for Surgeon General (Vivek Murthy) are both hospitalists. The field’s focus on improving value, systems of care, teamwork, and collaboration; its natural integration with hospitals; and its breadth (who else knows how things really work on medicine, in the ED, in the ICU, and on surgical services?) make us a obvious training ground for leaders. At UCSF, the medical center’s lead physicians for quality, patient experience, cost reduction, and IT are all hospitalists.

Interestingly, there is another thing driving the push toward hospitalist leaders, and that is less positive. Burnout from clinical work – which was remarkably low in the old days – is a growing threat. A recent study found rates of burnout rivaling those seen in the angst-ridden field of primary care – not a benchmark we should be aspiring to.

Of course, some of this was inevitable as the early novelty of the field began to fade. The buzz at SHM convinces me that it hasn’t entirely worn off (at least for the segment of the field that attends the meeting), but a 45-year old hospitalist doing 12 hour shifts of 7 days on, 7 days off is going to begin feeling it in his or her bones. While the movement to leadership and administrative roles is fantastic, it should also make us ask whether the jobs we’ve created are truly sustainable.

Although the evidence of burnout is a concern, overall I continue to be wowed by the energy and enthusiasm of the hospitalists I meet. The field has – at least so far – managed to resist the temptation to become overly protective of turf, cynical, soulless, or humorless. Seeing the young people in the field is remarkably energizing.

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An SHM postscript: for the past ten years, I’ve been asked to give the conference’s closing address. This is both a great privilege and a growing challenge – the latter since it’s awfully hard to remain fresh after a decade of talks. From time to time at family events, I rewrite the lyrics to a song and sing and accompanying myself on the piano. I’m a decent piano player and an enthusiastic crooner, and, playing to a home crowd lubricated by bonhomie and prosecco, it usually goes pretty well. A friend heard me do such a song at my own wedding a few years ago and suggested that I consider something similar at SHM. Well, one thing led to another and – the meeting being in Vegas and all – the next thing I knew, I was opening a FedEx box from Candy Apple Costumes (“Deluxe Rocket Man Costume,” $69.99), which consisted of glittering jacket, white pants, blonde wig, and star-shaped glasses. I should have realized that this Elton John outfit was sized for a lanky teenager headed for a costume party, not a 56-year old man with a paunch. But after the costume arrived, it seemed too late to turn back.

Pre-meeting, I planted a few cryptic tweets about an “unforgettable finish” to my talk, but, with the help of the stellar SHM staff, I managed to keep my plan a secret. After my 40-minute closing address, I left the podium and did a frantic backstage makeover. SHM CEO Larry Wellikson introduced a special guest, “Dr. Elton John,” and there I was. The result is here. I’m pretty sure the standing ovation I received was for chutzpah rather than talent, but I’ll take it.