Hospitalist Medicine. Mary Nettleman, MD, MS Professor and Chair Department of Medicine Michigan State University
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1 Hospitalist Medicine Mary Nettleman, MD, MS Professor and Chair Department of Medicine Michigan State University
2 Revolutions in the Medical System Advent of Medicare and Medicaid Prospective payment Quality and accountability Hospitalist medicine
3 Why did it start? Natural outgrowth of prospective payment and pay for performance. Hospitals needed more control. Popular demand. Community physicians didn t want to come in at night. Busy office practices not compatible with sick inpatients for small or moderate size groups. Resident-based teams capped.
4 Studies of Hospitalists Often not blinded Often not randomized Really asks the question: Are hospitalists better or worse? Than what? Should there be hospitalists?
5 Membership in the Society for Hospital Medicine
6 Chair Perspective Hospitalist medicine is here to stay Most are internists Issues: Training/teaching Faculty development/retention Economics Research
7
8 Where do Hospitalists fit? Hospitalists are primary care physicians Generalists by training Cover range of specialties Hospitalists are specialists No focus on primary prevention No continuity Proceduralists, inpatient specialists Not all hospitalists are internists
9 Department of Hospitalists Medicine Advantages Coordination of inpatient needs Economics clearly defined Faculty could be exclusively hospitalists Incorporate multiple disciplines Disadvantages Faculty isolated from others in their disciplines Cross-cultural differences among specialties Training programs may be more problematic Probably not enough specialists are hospitalists yet. Those who focus on inpatient consultation are unlikely to leave their current Depts/Divisions
10 Separate Division of Hospitalist Medicine Advantages Inpatient specialists interact closely with each other Economic model not diluted with outpatient medicine or (possibly) teaching Prestige? Research? Easier for hospitals? Disadvantages GIM would likely not give up inpatient medicine leaving 2 Divisions doing essentially the same job. Fails to take advantage of opportunities for cross coverage, joint teaching GIM may be pushed into high-overhead settings. Salaries may fall.
11 Hospitalists in GIM Division Advantages Teaching and economic model intact. Reduces competition Ability to share coverage in teaching and service, reduce burden if one hospitalist leaves Broader research setting Disadvantages Hospitalist identity may blur Easy to drift into status quo, fail to make important changes
12 What is the answer?
13 We are not asking enough questions! Not just: Where can hospitalists fit in our system? But: How should our system change to accommodate hospitalists?
14 Where should hospitalist fit? Division of General Medicine IF the system can adapt to the needs of the hospitalist Higher salary for increased clinical work, longer hours Change promotion guidelines as needed Mentorship from senior hospitalists Changes in existing faculty clinical practice Willingness to admit current model is not the best model Willingness to change resident education model
15 Salary Inpatient setting has little overhead Hospitalists probably devote more total time to the clinical setting, which is where the money is generated Hospitalists make more than generalists (MGMA) Under most models, hospitalists should earn more than traditional generalists in GIM
16 Academic Promotion Usually pays little attention to clinical accomplishments Hospital committee work or quality improvement activities also not sufficient Teaching is difficult to quantify Guidelines need to change. Opportunities for research need to improve
17 Existing faculty Changing Practice May have to cross cover nights and weekends in rotation May have to bring their skill level to that of the hospitalists in some areas May have to spend more time in clinic and less in inpatient settings May have to meet productivity guidelines that are driven by hospitalist-type productivity
18 Opportunities!! Inspire medical students and residents to enter Internal Medicine Added economic opportunity beyond the traditional teaching service Opportunity for hospital leadership Research/Scholarship: How do we make hospitalist medicine a viable career across the physician lifespan? How should we teach hospitalists? How do hospitalist faculty get promoted? Communication between inpatient and outpatient? Tests that come back after discharge?
19 I want to be in the GIM Division because.
20 If we split off, I would have to cover lots more nights and weekends My research program is embedded in GIM I enjoy teaching. I have inspired IM residents. I think we are a leader in hospitalist training. I make just as much money here as I would in a separate Division GIM respects me. I get opportunities for faculty development. They nominate me for awards. They help me get grants/organize conferences. I am on track for promotion. Through my Division, hospitalist medicine has a strong voice in the Dept/College
21 Where will it end up? Subspecialty of Internal Medicine Distinct specialty like ER medicine Will IM residencies no longer train in inpatient settings and instead outsource this to hospitalists?
22
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