Will the last traditionalist leaving the hospital please turn in your parking pass.

By  |  December 11, 2008 | 

John Nelson writes…

I live in the Seattle area and lately have been reminded of an often repeated story that happened here.  In 1971 the local economy, then very dependent on Boeing, fell on hard times and people were leaving the area and housing prices were falling dramatically.  Two realtors put up a billboard saying “Will the Last Person Leaving SEATTLE — Turn Out the Lights.”

It won’t surprise me if a similar sign appears in hospitals around the US.  “Traditionalists,” which I’ll define as doctors with an active outpatient and inpatient practice in the traditional model of the last century, are leaving in droves.

My experience suggests that given the opportunity, a lot (most) doctors in nearly every specialty will choose to leave hospital practice behind.  Of course we hospitalists, and other specialties like ER Medicine, will always be there.  But most specialties that have historically divided their time between the hospital and outpatient practice have found that the center of gravity of their practice has shifted significantly to the outpatient setting and the hospital work can become increasingly burdensome.  While this isn’t really a new trend, it does seem to be accelerating.

Just to make this interesting, let’s assume for a minute that no one believes that a practice focused on a site of care, such as hospitalists, ER doctors, and intensivists, offers no improvement in quality or efficiency.  Would ER doctors and hospitalists have still been “invented?”

I’m confident the answer is yes.

ER doctors appeared in the 60’s and 70’s largely because existing specialties on the medical staff were less willing to treat emergency patients, especially if the patient was “unassigned.”  And hospitalists began appearing in the ‘90s because PCPs were less willing to provide hospital care.  It seems to me that the doctors are becoming less willing to take ER call in nearly every specialty, and in fact the hospitalist model has been adopted in at least a few institutions, by nearly every specialty you can name.  This includes GI, nephrology, general surgery, orthopedics, psychiatry, etc.  (I’ll concede that I haven’t heard of a dermatology hospitalist yet, but I bet there is one somewhere.)

I would have never thought general surgeons would adopt the hospitalist model, but in the last decade or so many have seen the center of gravity of their practice move from the hospital to the ambulatory surgery center, and clinic.  And for many of them hospital practice just seems to offer lots of night and weekend work, difficult emergency cases with lots of social and medical co morbidities, and a poor payer mix.  There are now dozens of surgical hospitalist practices in operation, and I think we will see a lot of ongoing growth.

The challenge for those of us who have chosen to focus our practice on the hospital is to ensure we continue to improve the care provided there while creating sustainable and attractive careers for ourselves.  Where we once had a deep bench of specialists ready to jump in and help with patients, we may find that we now have only a few available to us.  We should work to slow the departure of other doctors by making it attractive for them to stay.  But because I don’t think we can fully reverse the exodus, all the stakeholders in hospital care must work diligently to make the hospital a better place for our patients, and for the caregivers that choose to stay there.  If you want to play a leadership role in your hospital, this would be a good place to focus your energy.


  1. […] Dr. RW provided this link to a John Nelson blog entry.  John is a great guy who help found the organization now known as SHM.  Will the last traditionalist leaving the hospital please turn in your parking pass. […]

  2. Your Reader January 27, 2009 at 6:46 pm - Reply

    Wow! Thank you very much!
    I always wanted to write in my blog something like that. Can I take part of your post to my site?
    Of course, I will add backlink?

    Regards, Timur Alhimenkov

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