Practice Management

Envisioning the future of hospital medicine


I have written frequently over the last few years on topics related to the sustainability of the hospital medicine practice model. I continue to be concerned by what I see as a confluence of significant trends that are conspiring to challenge hospital medicine’s status quo.

Dr. Leslie Flores

On one hand, the financial pressures on U.S. hospitals are unrelenting, and their willingness or even ability to continue providing significant funding to support their hospital medicine groups is in question. Combine this with hospitalists’ rapidly evolving clinical scope and the ever-increasing demands of physicians in other specialties for hospitalist support, and the result is hospital medicine groups that will continue to grow in size, complexity, and the demand for ever more financial support.

On the other hand, the hospitalists I interact with in my work all over the country seem more stressed out than ever, and many are questioning whether this is a job that can be satisfying and sustainable for a career. Increasing patient complexity, productivity pressures, a lack of resources to address patients’ social issues, a systole-diastole schedule, the frustration of EHRs and other documentation responsibilities, and feeling “dumped on” by physicians in other specialties all contribute to hospitalist job stress.

A quick look at the literature confirms that in 2019 hospitalist burnout is definitely “a thing.” Interestingly, it’s been a thing for a while; the risk of hospitalist burnout was first identified by Hoff, et al., in 2002 (doi: 10.2307/30902462002). My colleague, John Nelson, MD, MHM, has written a number of times about strategies for preventing or mitigating hospitalist burnout.

As these trends converge, the hospital medicine practice model as we know it may be facing an existential crisis. If that sounds overly dramatic, let me say instead that the hospital medicine practice model will need to evolve significantly over the next decade in order to continue to meet patient and institutional needs while remaining both affordable and sustainable for the clinicians who work in it.

In September 2019, SHM’s Multi-Site Leaders Special Interest Group met in Chicago for their second annual Multi-Site Leaders Summit to explore the theme of sustainability in hospital medicine. The participants held robust discussions about coping with our changing practice environment, issues relating to hospitalist burnout and resiliency, innovative staffing models, the role of technology in HM sustainability, and financial sustainability

At the end of the meeting, the group engaged in a visioning exercise designed to move beyond what we are doing today by envisioning what the future of hospital medicine will look like and what interventions will be necessary for us to get from here to there. I’d like to share this visioning exercise with you and encourage you to “play along” by thinking seriously about the questions it poses.

Visioning exercise

Feel free to jot down some thoughts as we go through this exercise. But otherwise, just close your eyes and come along for the ride. Imagine yourself sitting at your desk looking at a desk calendar showing today’s date. Watch the pages flip from today, to tomorrow, to the next day, then to next month, and the next, and then to the next year and so on, until we arrive at December 2029.

Imagine that you look up from your desk, and suddenly realize that you aren’t in your office at all, but instead in a huge auditorium where someone is speaking about an award that is going to be announced. It’s crowded and a little stuffy in the auditorium, but people around you are whispering to each other with an air of eager anticipation, their eyes glued to the stage. You realize that the person being introduced up on the podium is the President of the United States, and the award is the Presidential Medal of Freedom, which is only awarded to people or groups who have made “an especially meritorious contribution to the security or national interests of the United States, world peace, cultural, or other significant public or private endeavors.”

Today, the Medal is being awarded to the Society of Hospital Medicine on behalf of all hospital medicine leaders nationally, for their collective accomplishments in saving the specialty of hospital medicine and, by doing so, ensuring that sick people are able to continue receiving the care they need in our nation’s hospitals – and that the hospitals themselves have become reliably safe, efficient, and effective in achieving high quality outcomes.

The President says, “At no time in the history of this award until now have we given this, the highest civilian award in the land, to a whole group of physician leaders across an entire specialty. But the achievements of this group of people in preserving and even enhancing the presence of highly energized, dedicated, capable clinicians in our nation’s hospitals against the significant odds they have faced over the last 10 years is nothing short of extraordinary.” There is a standing ovation, as people jump up out of their chairs to cheer and applaud. When the applause finally dies down, the President goes on to list all the accomplishments that made this group of leaders deserving. Listen to what she is saying. Fill it in in your own mind. What is it that this group has accomplished?

[Brief silence]

Up on a huge screen beside the stage, a video starts. In it, there are several hospital and physician executives in a focus group, and one exec says, “The thing that is great about what these leaders have accomplished in the field of hospital medicine is…” Fill it in – what did that executive say? Another leader jumps in: “That’s all fine and wonderful, but the thing that really makes hospital medicine stand out today compared to where they were 10 years ago is…” Listen to what these executives are saying. What accomplishments are they praising?

The video then moves on to show a focus group of recent hospital patients. One patient says, “10 years ago when my mom was in the hospital, the poor hospitalists caring for her seemed completely overwhelmed and burnt out, and the whole care system seemed fragmented and inefficient; but my own recent hospital experience was so different because…” Additional patients chime in, talking about how confident they felt about the care they received in the hospital and the reasons for that. What is it these patients are describing?

SHM’s CEO gets up to accept the award and explains that 10 years ago, a group of multi-site hospital medicine leaders from across the country came together to begin addressing the issue of sustainability; this led to a formal process for developing a vision and a plan for the future of hospital medicine, and the execution of that plan eventually resulted in the outcomes recognized by this award. She acknowledges that over the years many people questioned whether the hospital medicine model should even continue to exist or whether some other model for inpatient care should be adopted. She talks about all the compelling reasons that supported the continued existence of the specialty of hospital medicine. What are some of the reasons she listed? The SHM CEO goes on to describe some of the key things that were done to address the issues associated with sustainability of the hospital medicine practice model. Listen to what she says; what was it that SHM and the hospital leaders it represents did?

As you are leaving the auditorium, you overhear a group of mid-career staff hospitalists talking. They are saying that they didn’t originally believe the specialty would actually change, and they weren’t sure if they could do this job for a career – but that it did change. They begin talking about what it feels like to work as a hospitalist now, and how these changes have improved their lives. Listen to what they are saying. How does it feel to work as a hospitalist?

As you leave the auditorium and go back to your desk, you sit down to record some of the things you heard. What was it the President of the US said as she presented the Presidential Medal of Freedom? Why did SHM and the hospital medicine leaders it represents deserve the award? What was it that the SHM CEO said was done to bring about the successful changes? What did the staff hospitalists say about working in the specialty?

Whenever you are ready, take a minute to jot down the specifics that came to mind as you read through this exercise. If you are willing to share your thoughts about sustainability in hospital medicine, I’d love to hear from you. Feel free to email me directly at [email protected].

Let’s build the foundation for a sustainable future for our specialty.

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants, La Quinta, Calif. She serves on SHM’s Practice Analysis Committee, and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey. This article appeared originally in SHM’s official blog The Hospital Leader.

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