The Evolution of the Hospitalist
By Susan Maas, freelance writer, written for the Association of Staff Physician Recruiters
Twenty years ago, most people had never heard the term “hospitalist.” Today this organized, tech-savvy, skilled communicator and team player is sought after nationwide — and demand continues to build. According to the Society of Hospital Medicine, it’s the fastest growing physician specialty in history, with some 31,000 hospitalists nationwide.
“There’s no question that it’s proven itself as a specialty,” says Joan Wallent, director of specialty physician recruitment at IPC, a Los Angeles-based hospital medicine services provider. According to Wallent, “[the hospitalist] improves patient care dramatically. It’s going to continue to grow.”
That means competition for hospitalists is intense, and recruitment times are long. And the exploding demand is reflected in the hospitalist’s paycheck: Salaries for hospitalists continue to outpace inflation, with the mean earning around $230,000 in 2011, according to an October survey by Today’s Hospitalist. That’s a nearly six percent increase over last year’s mean compensation. Moreover, many analysts believe that hospitalists’ pay hasn’t yet peaked — though rising compensation will likely come with increasingly higher quality and productivity expectations.
Pay is generally commensurate with productivity; the more patients a hospitalist sees, the higher his or her compensation tends to be. A recent survey of ASPR members showed that the largest share of hospitalists in their organizations, 30 percent, see an average of 13 to 15 patients a day. The next largest group, 22 percent, reports a daily patient load of 16 to 18 patients.
That same poll bears out the increasing pervasiveness of hospital medicine. Among the 78 ASPR members responding, all but four percent reported using hospitalists at their organizations — whether employed by the hospital, or employed by a hospitalist staffing company — either exclusively or in combination with community physicians.
Wallent’s employer, IPC, works in 24 states. In her two decades with the company, she says she has watched hospital medicine evolve from a small, little-known interest group to a full-fledged specialty. Like Wallent, Michael Griffin has watched the discipline since its inception. Griffin, ASPR past president and manager of physician/provider recruitment for the HealthEast Care System in St. Paul, has helped set up hospitalist models at institutions around the country, and says the growth of hospital medicine shows no signs of slowing.
Subspecialty hospitalists on the rise
Among the newest developments in this young field is the fledgling sub-specialty hospitalist movement. In recent years, Wallent has seen burgeoning demand for hospitalists from specialties other than internal medicine and family medicine: those with training in neurology, psychology, endocrinology, surgery, geriatrics, obstetrics, hepatology and more. Many have their own professional groups, journals and websites, and their growth is propelled by the same factors that gave rise to what Wallent calls “the original hospitalists.”
“There’s a tremendous need” for specialists in larger hospitals full-time, providing 100 percent inpatient care, Wallent says. In major cities, opportunity — and compensation — for those specialty hospitalists is growing on par with that for hospitalists.
Walid Maalouli, MD, medical director of the Hospitalist Program at Children’s Hospitals and Clinics of Minnesota, sees demand for pediatric hospitalists continuing to swell in the next several years. “You’ll hit the point of saturation eventually, but we’re a long way from that,” he says. Training for pediatricians has begun reflecting the increasing prevalence of hospital medicine, Maalouli adds, with more residencies developing dual-track (inpatient and outpatient) programs and a growing number of pediatric hospitalist fellowships around the country. Would-be pediatricians now weigh whether they’re drawn to “the excitement of critical situations, or prefer the more sedate setting of the clinic,” Maalouli says.
Movement is enhancing quality, patient satisfaction
The advantages of using a hospitalist — versus an internist (or neurologist, or endocrinologist, or geriatrician) who’s also balancing pressing outpatient demands — are many. “The hospitalist movement has driven a lot of quality improvements in terms of focusing on the patient when they’re in the hospital,” says HealthEast’s Griffin. The steady presence of one accountable, engaged physician means that “there’s going to be more consistency for the patient and for the hospital.” It’s also easier on the primary care physician, who can then focus exclusively on outpatient care.
While some patients may initially feel uneasy about the prospect of working with a new doctor when hospitalized, wondering why the primary care physician isn’t on the scene, several strategies have proven effective in educating patients and assuaging their fears. A September 2009 article in Today’s Hospitalist explores ways that hospitals and hospitalists can avoid some of the confusion and put patients at ease — including communicating with the primary physician on admission and discharge and asking for suggestions that might help in that particular patient’s care.
The hospitalist model has been shown to reduce the length of patients’ hospital stays with no adverse impacts: A 2009 Loyola University Health System study showed that patients who were co-managed by a hospitalist had an average length of stay of 3.8 days, while patients who were not seen by hospitalists had an average stay of 5.5 days. And evidence is growing that hospitalists make for happier patients: A 2010 Press Ganey study of 1,777 hospitals and 2.6 million patients found that facilities with hospitalists resulted in significantly higher patient and nurse satisfaction.
That hospitalists apparently help create a better work environment for other health care professionals isn’t surprising. Key to this physician’s effectiveness is the ability to work across disciplines to coordinate care with a range of health care professionals — and to serve as an organized, articulate liaison between the entire team and the patient. Of the ASPR survey respondents, a majority of hospitalists — 52 percent — work collaboratively with advanced practice nurses, physician assistants, or both.
“They have to work well with nurse practitioners, pharmacists, social workers, respiratory therapists,” Griffin says. “They have to be masters of communication.” A generally young group (the average age is 37), they also tend to be fairly tech-savvy, able to comfortably navigate different Electronic Health Record (EHR) systems.
Scheduling models vary widely
Work routines for hospitalists vary. Some — including those Griffin hires — happily work the seven-days-on, seven-days-off schedule familiar to medical residents. That’s attractive and “comfortable” to many young physicians, Griffin says. “You end up working 14 days in one month,” he says. That leaves two full weeks a month for travel, uninterrupted family time or other pursuits. Some “block model” hospitalists opt for half-time positions — meaning they work just seven days a month. Many supplement their income by moonlighting, says Kirk Mathews, senior vice president for Eagle Hospital Physicians (former CEO and founder of Inpatient Management Inc., IMI).
Other hospitalists work Monday to Friday. Wallent says IPC places physicians in posts with “traditional” workweek schedules. “We have a few who do the ‘block model’ or shift work, and there are personalities who love that. They take off and go skiing or surfing. But [many] want a traditional schedule. If you have a family, you’re home every evening, most weekends. You’re going to see your spouse, significant other, kids on a regular basis.”
And some physicians advocate for staggered, flexible shifts tailored to patient volume, in which the hospitalist works more days per year but has the option to leave early on slow days. The bottom line for the hospitalist, Wallent adds, is that he or she can choose “whichever lifestyle fits. And that can change over time.”
A budding trend in hospital medicine is the move toward part-time work. For a variety of reasons, some hospitalists seek reduced hours, and the tough recruiting market means many employers are willing to work with them. In some cases, part-time arrangements can help in retention, says Mathews.
“Burnout is one of the largest challenges facing our specialty,” Mathews says. “The demand [for hospitalists] has simply outstripped the supply, and that’s led to many programs being understaffed” — creating heavy, stressful workloads for many. A Nov. 2008 article in Today’s Hospitalist put the national turnover rate at around 17 percent annually.
“We [at Eagle] have enjoyed lower turnover, but we’ve worked really, really hard at it,” Mathews says. “My philosophy is that you never stop recruiting your physicians. Engage them, listen to them, understand what their concerns are. And continue to listen to them after they’re there.”