I just returned from the Society of Hospital Medicine’s annual meeting in Dallas. Seeing more than 2,000 hospitalists in one place is remarkable, since I remember the days when we all fit into a mid-sized conference room at a Holiday Inn.
I have clearly assumed the mantle of elder statesman at these meetings. I find this odd, since my idea of an elder statesman is UCSF’s former chair of medicine, Lloyd Hollingsworth (“Holly”) Smith, a man of unbelievable accomplishment and grace. Holly is now in his late 80s, and every year we ask him to say a few words at our department’s annual faculty dinner. Holly is the best after-dinner speaker I know – his comments, always insightful and hilarious, are increasingly peppered with “old guy” references (my recent favorite: “I’ve now reached the age of – when I reach down to tie my shoes, I ask myself, ‘Is there anything else I need to do as long as I’m down here?’ before I get up.”)
I’m not complaining: for the past decade, I’ve had the honor of giving a closing keynote address at the annual hospital medicine meeting. In this week’s talk, I reflected on the history of the hospitalist field, in the 15 years since Lee Goldman and I coined the term in the New England Journal of Medicine.
This kind of reflection is useful because, in a world in which we’re all drinking out of a huge information hose, it’s easy to focus on the short term and lose track of the arc of history. Self-help guru Tony Robbins had it right when he said, “Most people overestimate what they can do in a year, and underestimate what they can do in a decade.” Our 15-year history proves that.
I began my talk by asking the audience members to think back to 1996. “Who was already in practice?” I asked. A few hundred people in the audience of about 1,000 raised their hands. “In residency?” A few hundred more. “Med school? College?” Many more. Depressed, I asked, “Were any of you not yet born?” Luckily, no hands went up. The point is that ours is a young field, and 1996 is ancient history for many of today’s hospitalists.
I described the early years of the hospitalist field and some of our initial decisions. We knew that a physician specialty that depended on non-procedural billing, that focused on coordination of care, whose physicians usually covered nights and weekends, and that cared for a random sample of a hospitals’ payer mix (including many uninsured and Medicaid patients), could never develop an adequate funding stream through professional fee billing alone.
This meant that that we were destined to be dependent on winning the support of our hospitals – both psychic and financial – in order to compensate hospitalists adequately. In fact, in the meeting’s opening session, John Nelson described recent SHM/MGMA data that demonstrate that the average hospital support payment per hospitalist FTE is now up to $130,000 (up $30,000 in just a year!). While we didn’t dream of support of this magnitude, we recognized from the start that hospital support payments were crucial, and would hinge on hospitals’ perception of a positive return-on-investment. This, in turn, would depend on hospitalists’ ability to shorten lengths of stay and decrease hospital costs.
This dynamic meant that our early focus was on efficiency. Proving that we could cut costs without harming quality was central to gaining hospitals’ support and creating a viable economic model for hospitalists. The early research unambiguously supported this proposition, as I knew it would.
But even as I championed hospitalist cost reduction to hospitals, I saw this very dynamic as the greatest long-term threat to the field. By 2000, when I assumed SHM’s presidency, I worried terribly about our field being branded as being all about saving money for hospitals – not a particularly satisfying self-identify for a professional, and highly vulnerable to caricature (think “death panels” and you’ll know what I mean).
Luckily, in 2000 the Institute of Medicine published To Err is Human. After that seminal publication, I strongly suspected that the field of patient safety would take off, and it didn’t take a genius to realize that a parallel healthcare quality movement would follow closely behind. We recognized that hospitalists had a once-in-a-lifetime opportunity to brand ourselves as being about quality improvement and patient safety, not just cost-savings. Not only was this completely in sync with our own view of what was important, but we would have a clear playing field, as traditional physician specialties were likely to ignore or disdain the quality and safety movements because they seemed too “soft,” because “systems thinking” sounded like business-speak or might promote “cookbook medicine,” or just because established fields rarely embrace change.
Our decision to embrace the quality and safety movements was the best call we ever made. In my closing talk this week, I reviewed an 11-year timeline (2000-2011), demonstrating the breakneck pace of change in these fields, as the IOM report on safety was followed by another on quality, then by public reporting of quality data, changes in Joint Commission accreditation standards, residency duty-hour restrictions, two IHI campaigns, the emergence of bundles and checklists, large-scale safety collaboratives with measureable outcomes, and billions of dollars to promote healthcare information technology. In this new environment, our field reaped tremendous advantages by being leaders. I went on to illustrate how new value-based purchasing, “no pay for errors,” penalties for readmissions, and other similar initiatives will make it increasingly important for all physicians and hospitals to focus on quality and safety as core competencies. All of them are turning to hospitalists and SHM, with a decade of this work under our collective belts, for leadership and advice.
While the choice to pivot to quality and safety in 2000 was a wise one, I don’t want to give the impressions that I, and we, got every decision and prediction right. Among the ones I blew were:
1) I didn’t anticipate the pushback from critical care physicians in the early years, when some thought we were encroaching on their turf. This remains relevant today since most hospitalists see patients in ICUs, largely because of the national shortage of trained intensivists. It is vital that we are appropriately trained to do so, that we work closely with intensivists when they are available, and that we don’t overreach and claim that we’re as good as fully trained intensivists are in the ICU, since we’re not.
2) Both primary care physicians and patients accepted the hospitalist field more quickly than I would have guessed. While I took a lot of heat from PCPs in the first few years, by 2000 many of them were clamoring for their hospitals to build hospitalist programs. As for patients, I was also surprised by how quickly most came to accept the idea of a separate doctor – a stranger, after all – taking the reins of their hospital care.
3) I thought the pressures on our field to re-focus on cost reduction would be greater, sooner. Just as it was important for us to move away from a narrow focus on cost reduction in the early years, it is also a mistake for us to exclusively focus on quality and safety now. We need a balanced approach, one that focuses on value (quality divided by cost). After all, Medicare announced this week that it will go broke in 2024, 5 years earlier than the projection of just one year earlier.
I recently asked the following question of some 30 faculty in my division: “How many of you are working on quality improvement, patient safety, or patient satisfaction projects?” Nearly everybody raised a hand. Then I asked, “How many of you are working on cost or waste reduction projects?” Three people raised their hands. This isn’t the right balance – the hospitalist field has established its brand in quality and safety; today we need to broaden the brand to be improvers of value.
4) I failed to appreciate the challenges of managing staggering growth. My own UCSF program, like programs everywhere, has grown from about 10 faculty to 50 in five years. There are techniques and best practices to manage that kind of growth, but few of us knew about or took advantage of them. We just winged it.
Part of our difficulty in managing our growth came from an absence of leadership or business training. But it was also due to our failure to anticipate that the hospitalist field would be the fastest growing specialty in medical history. In a 1999 American Journal of Medicine paper, using what seemed like reasonable assumptions, my co-authors and I estimated that the ultimate size of the hospitalist workforce would be 19,000. The field blew past 19,000 five years ago, on our way up to about 33,000 U.S. hospitalists today.
Why did we guess wrong? We didn’t anticipate surgical co-management, hyphenated hospitalists (neuro-hospitalists, ob-gyn hospitalists, surgical hospitalists), pediatric hospitalists, or residency duty-hour reductions, all of which have catalyzed major growth spurts. We thought that a hospital with fewer than 100 beds wouldn’t be able to support hospitalists (false) and that a 500-bed hospital would ultimately have about 20 hospitalists (false again; most have 40 or more).
Despite these miscues, I was surprised by the number of decisions we got right, a track record that hopefully portends well. I left the audience at last week’s meeting with these thoughts and observations about future directions for our field and society:
1) There will be intense pressure on the denominator to improve value. We must embrace the challenge of delivering safe, high-quality, satisfying care at a far lower cost. A hospital operating in an increasingly tight reimbursement environment while writing a multi-million dollar check to its hospitalist group each year will not tolerate a group that fails to be value-enhancing.
2) In part because of this – and the fact that the pressure on quality, safety, and patient satisfaction will also grow (within a few years, up to 10% of Medicare reimbursement will be at risk based on performance) – we can expect that the budget battles between hospitalists and their institutions will become far more hard edged. Just in the past few weeks, several of the top hospitalist leaders in the country have told me that their yearly budget negotiations, which were always challenging but never nasty, culminated in the kind of brinksmanship (with threats of resignations, or of capping volumes or withdrawing from certain services) that would have been inconceivable a few years ago.
3) It will be critical that hospitalist groups produce measurable value. I worry about programs organized around the convenience or the income of the physicians. You know the ones – programs whose patients say, “Oh, the hospitalist just flies in and out of the room,” or “I saw a different hospitalist every day,” or ones in which every patient complaint and lab abnormality reflexively triggers another subspecialty consult or CT scan. Such programs are not likely to achieve the status of being indispensable.
And the opposite of indispensable is, of course, dispensable.
Much of what we have succeeded in is creating a unique brand, and it has served us very well. But brands are extraordinarily fragile, and they can’t be sustained by pronouncements from leaders. Instead, as former Disney CEO Michael Eisner said, “A brand is a living entity – and it is enriched or undermined cumulatively over time, the product of a thousand small gestures.” We must make sure these gestures are creating and solidifying the brand we want to have.
The annual meeting of the Society of Hospital Medicine and my San Francisco meeting every October are the two chances I get each year to see hundreds, even thousands, of hospitalists gather in one place, and to take their collective pulse. I remain struck by the fact that – while there are pockets of burnout, cynicism, and poorly organized practices – the dominant zeitgeist remains one of enthusiasm, optimism, and gratitude for the chance to be driving a bus heading toward the future of healthcare, a future in which we deliver better, more satisfying, safer care at a lower costs. It remains a thrilling experience.