Q & A: Holman Anticipates Continued Growth for Hospital Medicine


March / April 2008

Q & A

Holman Anticipates Continued Growth for Hospital Medicine

Patient Safety and Quality HealthcareRussell L. Holman, MD, is a hospitalist, president of the Society of Hospital Medicine and chief operating officer of Cogent Healthcare, an industry-leading organization that manages hospital medicine programs throughout the country. His commitment to hospital medicine has rendered nationally recognized standards in the areas of quality improvement, leadership development, palliative care, medical education, cross-cultural care and service, case management, and solutions to hospital overcrowding. Dr. Holman recently discussed the development of the specialty and looked ahead to future challenges as hospital medicine continues to evolve.

Q: The Society of Hospital Medicine has just celebrated its 10th anniversary. How far has hospital medicine come in 10 years?
A: Hospital medicine is undoubtedly the fastest growing specialty in medicine. As the Society of Hospital Medicine has just celebrated its 10th anniversary, so too has the industry. The term “hospitalist” was coined in a New England Journal of Medicine article in 1996 by Dr. Robert Wachter and Dr. Lee Goldman. At that time there were roughly 300 to 500 physicians practicing hospital medicine.

Today, there are more than 20,000 hospitalists practicing nationwide, which is just shy of the number of cardiologists (22,000) and emergency medicine physicians (26,000). We believe the number of hospitalists could be 30,000 by the end of the decade.

Q: Are there other specialties that have traced a similar growth path?
A: The origins of hospital medicine have many similarities to the development of emergency medicine 40 years ago. At that time, surgeons and primary care physicians cooperatively cared for emergency patients — a process that was inefficient and at times chaotic. Emergency medicine evolved as a specialty based on a specific site of care and encompassed a set of comprehensive clinical skills to address the broad needs of emergency patients.

The same is true for hospital medicine. There are unique skills required to address the complex needs of hospitalized patients and to effectively coordinate care in the complex environment of the hospital. The resulting model can be more efficient for primary care physicians and specialists, as well as make more efficient use of healthcare resources.

One key difference between the two specialties is the rate of growth. Emergency medicine took nearly 40 years to amass 20,000 physicians as a specialty — the same number that hospital medicine has reached in 10.

Q: What do you believe is the catalyst for such explosive growth?
A: There are many reasons, but overall I’d start with the fact that never before have hospitals experienced a more complex operating environment. They face unrelenting cost pressures and ever-changing systems, technology, and regulatory issues. There is a public call, which is only growing louder, for greater transparency and more stringent reporting measures, with a microscope focused on quality and safety outcomes. Meanwhile, patients are sicker, with more concurrent medical conditions, and physicians — both inpatient and outpatient — are stretched thin.

Hospitals turn to hospitalists to improve quality and safety and to meet the demand by primary care physicians, surgeons, and specialists for physician availability and greater coordination of patients during their hospital stay. At the same time, this is a very attractive career option for graduating residents and established physicians alike in internal medicine, family medicine, and pediatrics who prefer to serve a broad range of clinical needs in an acute care setting.

Q: What challenges does the industry face?
A: Today, most hospitals would tell you that they have a dire need for hospitalists and are unable to successfully recruit them. The demand has far outpaced the supply. In fact, for every one hospitalist, there are several opportunities. In a national survey of hospital medicine group leaders conducted by SHM in 2005, the top two concerns cited were recruitment and establishing work/life balance for physicians of the group.

As a result of the workforce shortage, many hospitalists are struggling to keep pace with the patient service demands. At the same time, there are quality, safety, and process improvement imperatives in the hospital that are difficult to fully address given the workforce limitations.

Q: What are the key benefits of hospital medicine?
A:Hospitals nationwide utilize hospitalists in an effort to:

  • Create seamless continuity for patients from inpatient to outpatient settings.
  • Improve efficiency or patient throughput, by reducing hospital wait times and delays that otherwise result in prolonged length of stay.
  • Enhance quality in measurable ways, such as reduction of readmissions and medical errors.
  • Improve referring physician satisfaction by allowing them to focus on outpatient care or other patient populations.
  • Retain & recruit medical staff physicians who prefer working with hospitalists to coordinate care of their patients.
  • Educate clinicians, such as medical students, residents, and RNs.
  • Improve the patient experience by creating coordinated care teams (nurses, pharmacists, physicians, case managers, others all working together on site in the hospital to coordinate care for the benefit of the patient).

There have been a number of studies conducted to assess the impact hospital medicine programs have on hospitals nationwide. A summary article in JAMA in 2002 by Drs. Wachter and Goldman demonstrated approximately 15% improvements in costs and length of stay, while a 2007 retrospective study in NEJM by Dr. Peter Lindenauer showed 12% length of stay decreases but not statistical cost improvements. Put simply, evidence shows that the hospital medicine model reduces cost and waste without any measurable decrement in quality.

But, we are in an early stage of maturation, and I believe the full promise of hospital medicine will be achieved over time. Across the board, we will see measurable, positive impact on quality, satisfaction, and the bottom line — but that promise ultimately depends on how the model is implemented.

Q: So, what is the best way to implement hospital medicine?
A: There is no right answer to this. But, I do see many hospitals make the mistake of hiring a few hospitalists as a solution to unclog the ER or to appease local primary care doctors who are lobbying for an easier way to admit. Their hospital medicine program in turn becomes a band-aid-like staffing solution instead of a well-planned new service line with a foundation for success.

In my experience, the more successful programs approach implementing hospital medicine just as they would any other specialty. For example, our model at Cogent Healthcare is focused on delivering not just a staffing solution, but a system of care that includes structure, a coordinated care team and process, rigorous ongoing training, and experienced leadership for physicians and data-driven processes that produce measurable ROI.

Without this kind of deliberate structure, expectations for the model are difficult to realize.

Q: Where do you see hospital medicine in another 10 years, when SHM celebrates its 20th anniversary?
A: Everyone knows that a perfect storm is fast approaching in our nation’s healthcare system. And though hospitalists are just one part of the healthcare system, we find ourselves right in the eye of the storm.

Today, in the U.S., there is one geriatrician for every 105,000 people, according to the 2006 AMA Masterfile. And with the population at age 65 and older expected to double by 2030, care for this critical mass of patients will fall into the hands of hospitalists. Thus, hospitalists are an important piece of the future of healthcare in this country, and we need to provide commensurate training, support systems, and leadership to meet future challenges.

To meet that need, I believe in 10 years there will be 40,000 or more practicing hospitalists nationwide. Hospital medicine will be a Board-certified specialty, and a majority of hospital care in the U.S. will be provided by hospitalists.

Most importantly, I believe hospital medicine will have fulfilled its promise in a demonstrable way, making care truly patient-centered and led by true teams. There will be extensive evidence that hospital medicine improves quality, increases satisfaction of all stakeholders, improves patient safety, improves efficiency, and strengthens physician leadership in stimulating change in the care of hospitalized patients.