We all know that hospitalists’ scope of clinical practice has been evolving in significant ways for a number of years. At many hospitals virtually all medical subspecialists have backed away from active attending roles and serve only as consultants. Surgeons are demanding greater hospitalist participation in surgical co-management, often as admitting/attending physician. For example, I’m guessing that around 70 or 75% of non-academic hospitalist practices now serve as admitting/attending physician for all hip fracture patients – though my experience is anecdotal and I’m not aware of any hard data about this. In larger hospitalist programs we are seeing some hospitalists dedicate their full professional focus to the general medical care of oncology patients, or stroke patients, or hip fracture patients. Hard-pressed intensivists are asking hospitalists to care for more ICU or step-down patients or to provide nighttime ICU coverage. And hospital administrators increasingly see their hospitalists as the answer to everything from pre-op clinics to chronic care for high-risk patients. An enviable position to be in, right? Yeah.
More recently, the advent of alternative payment programs such as readmission penalties, ACOs, and bundled payments have driven high levels of interest in deploying hospitalists in post-acute settings from transition clinics to skilled nursing facilities and LTACs. I even know of a hospitalist program that is becoming involved in providing Hospital at Home services (talk with Per Danielsson at Swedish in Seattle about this).
Of course there is a lot of variation in how HMG clinical scope is evolving, depending on local market factors like hospital and group size, academic vs. not, the relative availability of physicians in other specialties, and the organization’s level of involvement in alternative payment models. But in my view, the external pressures driving scope expansion aren’t going away anytime soon. Whether we like it or not, the healthcare system will require that the nature of hospitalist work will evolve over time, just as it did with emergency medicine. Not only will most hospitalists eventually be near-universal admitters – essentially the ED doctors of upstairs – but working in a wide variety of roles outside the acute care setting will become commonplace in many hospitalist practices.
I think this need to adapt to a constantly changing definition of what a hospitalist is has real implications for how hospitalists view the sustainability of their role over a career. Many of the services hospitalists are being (or will be) asked to provide are beyond the clinical competencies they gained in internal medicine or family medicine training. Some of the services may be clinically within the hospitalist wheelhouse but may require a different approach or mindset – think palliative care or caring for patient in SNFs. And a lot of it just feels like “dumping,” whether or not the clinician has the needed knowledge and skills.
Hospitalist groups need to be proactive in addressing their providers’ readiness for scope evolution, rather than letting it grow organically. I’m convinced that feeling either resentful or unprepared for the challenges of an expanded clinical scope represents a meaningful risk to hospitalists’ morale and job satisfaction, and ultimately to their longevity in their career. It’s a risk that hospital and hospitalist group leaders can anticipate and often mitigate by providing hospitalists the support they need to grow and evolve their skills and mindsets as their responsibilities change over time. Here are a few suggestions:
- Actively Manage Your Group’s Scope Evolution. Every hospitalist group should sit down once a year and take inventory of the additional services being asked of it as well as the opportunities the group sees that it would like to pursue. Then, taking into consideration the input of key stakeholders, the group should prioritize the change requests, determine what they can take on in the coming year, and identify the resources will be needed to do so. You won’t win by consistently saying no to everyone, but if you say yes to some you gain credibility and support to enable you to say no to others. And the group itself gains some measure of control over how their clinical scope evolves and the timing of that evolution, even if it has no control over whether it evolves.
- Ensure Needed Training and Clinical Competencies. There’s nothing worse than being asked to do something new when you don’t have confidence in your own skills and abilities in this area. And no one should make the mistake of assuming that a hospitalist who is excellent in the acute care setting will also be equally effective at the LTAC or in a post-discharge clinic. Too few hospitalist groups think deliberately about what types of training and mentoring are needed to support their hospitalists in taking on new clinical roles or adjusting to the needs of new settings of care.
There should be a specific line item in every hospitalist group’s budget for training and mentoring related to scope expansion, over and above individual hospitalists’ CME allowances. In some cases training and/or mentoring might be available from internal resources like the very specialists who are asking the hospitalists to take on more responsibility for their patients. External courses and/or online CME may fill the gaps. In some cases simply spending time shadowing and talking with experienced providers in other settings can help.
- Provide Emotional and Moral Support. Change is hard for everyone, and it’s harder when people feel like it is being forced on them by others who look down on them and don’t value their contributions. Engage hospital and medical staff leaders in providing recognition, appreciation, and support to the hospitalists, especially during the initial stages of a painful scope expansion. One important way these leaders can support the hospitalists is by holding other medical staff members accountable for treating the hospitalists with the respect and consideration due from a professional to his or her professional peers. Another is to help hospitalists understand how the services they are being asked to provide are linked to the bigger picture of taking better care of patients and building healthier communities.
I’m convinced that hospitalists will have greater job satisfaction and will be better positioned for a satisfying, sustainable career in hospital medicine if they have the training, clinical competencies, and support to comfortably perform in expanded clinical roles.