The unprecedented rise of hospitalists as a physician specialty is supported by responses from a 2012 American Hospital Association survey, extrapolated with survey data from the Society of Hospital Medicine.
Robert Wachter, MD, director of the UCSF Division of Hospital Medicine, is usually a dignified man. But last April, he donned an Elton John wig, a white and gold lamé tux and tails, and star-framed rhinestone-studded glasses. Then he bounced onto a Las Vegas stage.
Seated at a piano, he played and sang Elton John's classic "Your Song" doctored with his own version of the lyrics as some 3,000 physicians attending the Society of Hospital Medicine's annual conference laughed in their seats.
Wachter's ballad describes how hospitalists, a term he coined in the late 1990s to define a new physician specialty dedicated just to inpatient care—are now taking over the healthcare world, growing "faster than weeds."
I'm not sure about growth "faster than weeds," but a very rapid vertical trajectory of the hospitalist doctor is supported by responses from a 2012 American Hospital Association survey, extrapolated with data from the Society of Hospital Medicine's own survey through 2014.
Joe Miller, SHM's senior vice president, says the hospitalist "is the fastest growing specialty in medicine's history." To wit, Miller says these are the markers:
Growing Numbers
The number of U.S. hospitalists has quadrupled, from 100 in 1996, to 11,000 in 2003, to 44,000 today, changing life as we know it for hospital staff, community physicians, and for acute care patients who previously had to wait for a community doctor to take call, write orders, or even decide to admit or discharge which patients.
The percentage of hospitals using hospitalists has risen from 29% in 2003 to 50% in 2007 to 72% in 2014.
More Services
Hospitalists are providing more services. In 2006, about one in three hospitalized Medicare beneficiaries was discharged by a hospitalist. In 2012, it doubled to two in three. In 2014, 57% of hospitalist groups provided "tuck-in" service, which means they admitted other physicians' patients during the night compared with 44.2% in 2012.
Rising Pay
Hospitalist pay is rising. SMH survey data shows a 12.2% increase in hospitalist pay from hospitals, to $156,000 in 2014. Hospitalists overall earnings are increasing too, from $215,000 in 2010 to $251,996 in 2014, up 17.1%.
Advocates for Quality
Hospitalists have an increasingly important role in pushing quality through readmission prevention, infection control, electronic health records use, patient experience scores, core measures, and appropriate use of order sets. Survey respondents told SHM that their employers are increasingly using these measures to determine hospitalists' compensation.
Presence in Other Venues
Hospitalists are not just working in hospitals anymore. They're in skilled nursing facilities, rehab units, long-term care, and even pre-op and post discharge clinics. And they don't just work for hospitals. About two in five work for medical groups or private clinics.
Other Subspecialties
There are now even "hyphenated hospitalists," another term coined by Wachter. These are hospital-based doctors board-certified in neurology, ob/gyn, orthopedics, otolaryngology, oncology, and psychiatry, who don't keep office based practices.
Reflecting back 15 years to the start of the field, Wachter says even the motivation for becoming a hospitalist has changed. Early on, it was driven by executive leadership who "wanted to keep costs and lengths of stay down. An economic engine was the early driver for this," he says.
At teaching hospitals, limits on residents' duty hours in 2003 meant hospitals could no longer use "unlimited residents' bandwidth." Hospitalists could fill that gap.
Initial Pushback
There was early pushback from community doctors, who saw a theoretical idea and said it was very bad. "They'd say 'my patients need me in the hospital,' and the hospital is core to what I do for a living; giving it up would lose too much income," Wachter recalls.
But as more hospitals hired hospitalists, attitudes changed. "Doctors saw their partners choose to hand off their patients to hospitalists, saw they didn't have to come in at 6 a.m., and these patients seemed to be getting good care; hospitalists seemed to communicate. Now you had a tangible entity with real people, real flesh and blood. Real outcomes."
"When primary doctors looked at this in the cold light of day and did the math, they realized, 'No, financially, I'm better off if I don't go into the hospital.'" and instead see office patients scheduled for visits.
The other thing that changed was the volume of patients in the hospital that they could see in one trip. In the last 10 years, hospitalized patients were fewer because the threshold for admission was higher. By the thousands, doctors started to realize "It doesn't make sense for me to do my own hospital work anymore."
What kind of doctors choose hospitalist medicine has changed too. In the earlier years, some were burned out clinicians wanting a change, or a step back from office practice, Wachter says. Today, the hospitalist is likely to be a new doctor fresh out of residency who is choosing a career.
In an important way, however, hospitalist movement is still in its infancy. And that is the evidence needed to prove it improves quality.
Wachter believes it does. He believes that outcomes, driven by rapid delivery of care must be better in a hospitalist system. "No question I'd rather be in one, with someone there who knows the ecosystem… knows where to find the nurse, knows when something doesn't smell right, when someone needs a CT scan, and knows how to make that happen, who understands all the unspoken rules."
He acknowledges, however, that the evidence to say hospitalist systems are better "is not that persuasive. Studies clearly show that care is significantly more efficient, and that quality, safety and patient experience are at least not harmed. But it would be a stretch to say the literature proves that quality of care is better."
That will come, he says. It has to. "Unless you believe hospitals are really sort of stupid, how else can you explain a field that is the fastest growing in medical history without any changes in payment systems, federal regulation, real marketing or branding or budget to promote it."