Hospital medicine. evolved.
The term “hospitalist” was first coined by Drs. Robert Watcher and Lee Goldman in a 1996 paper in New England Journal of Medicine. Since that time Hospital Medicine has become a fastest growing medical specialty in the US.
First hospitalist groups were organised to help take care of the unassigned patients presenting to the Emergency Departments. As the specialty evolved the hospital leaders realized that having doctor in house has benefits that stretch far beyond simple ED coverage. Many hospitalist groups have consistently demonstrated better outcomes as compared to private physicians in terms of quality and cost of care. This catalyzed the explosive growth of the number of hospitalist programs across the country.
These “first generation” hospitalist programs were extremely diverse in terms of scheduling and responsibilities. Often times they would be comprised of the local PCP who would take turns taking care of the hospitalised patients serving as “hospitalist of the week” etc. Many such programs still preserved Monday to Friday schedule. With these types of schedule after hours and change of shift coverage was often insufficient. Weekend coverage was a nightmare with lack of progression of care and poor continuity. Even with the introduction of the Nocturnist services ED coverage during the busiest time of the day (4P-10P) was challenging. In response to this a traditional 7 day shift was born.
The “second generation” programs required physicians to work longer hours in exchange for working only 14 days every month. At that time a typical hospitals would have a workload of 10-12 patients in the beginning of the shift and would typically take 1-2 admissions from the ED during the day till a cut off time around 6-7 PM. This system remains in wide use even today after 20 years. It provides undisputable benefits of easy scheduling and flexibility with added benefit of having all weekends and holidays covered at no additional cost. Around this time in early 2000 many hospitalist management companies were established in order to address growing need of hospitals across the US. many hospital administrators were eager to outsource their hospitalist service to the likes of Cogent, Sound and others. The idea of having hospitalist service managed by a professional outside company appealed to many. It promised decreased administrative burden on hospital administration as well as access to proprietary IT solutions. As the number of hospitalist management companies and their sites continued to grow exponentially the many problems of such arrangements started to crop up. Poor alignment with hospital and community goals, lack of acceptance by the local medical community, high turnover and low retention and physician satisfaction are just a few common issues with outsourced programs. To save the cost and sometimes due to lack of local leadership these programs commonly utilize a “one size fits all” approach. Even though it may be effective for a while, often times it will backfire few years into a contract. There have a number of hospital that tried to break out from under these types of agreement often resulting in costly legal battles.
Today with the development of “third generation” programs we observe a drift away from the traditional 7 day 12 hours shift mold. The hospital focus on efficiency and quality of care that is truly inseparable from physician satisfaction and low turnover. Many hospitals have developed or attracted the expertise to bring the hospitalist program back home. This allows for a fine alignment of the goals and creation of high functioning teams. It restores and trust between the hospitalist programs and local medical community. Locally managed program is typically best positioned to introduce creative scheduling models including overlapping shift, specialty teams, admission services etc.
At Hospital Medicine Advisors we believe in this change. Our mission is to “...enable our clients to set up and maintain high quality in-house hospitalist programs”. We feel that by doing so we are not only improving the health of the nation but doing it in a responsible and cost effective way.