Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect. Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea. “If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field. “If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting. “The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.” Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say. Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi. “Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says. Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge. And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task. “There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits. “The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.” Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital. “We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

Many hospitalists have added value as local leaders in quality improvement, safety, and innova-tion, but some have functioned more as shift workers. For exam-ple, many community hospital-ists have a 7-days-on, 7-days-off schedule that focuses mainly on high-volume clinical work and sends an unspoken but clear mes-sage that, at the end of an inten-sive clinical “on” stint, one is “off ” and uninvolved. Our impression is that hospitalist programs pro-vide more value when hospital-ists’ inpatient assignments (clini-cal “systole”) are complemented by a systems-oriented “diastole,” dur-ing which clinical activity is limit-ed but they contribute to key in-stitutional programs. Productive diastole is more likely when hos-pitalists have strong leadership, a robust professional-development curriculum, and a mutual hospi-tal–hospitalist commitment to adding value during specified and structured nonclinical time.

The discipline of hospital medicine grew out of the increasing complexity of patients requiring hospital care and the need for dedicated clinicians to oversee their management. The hospitalist model supplanted the traditional method of caring for hospitalized patients, which was often done by clinicians also seeing ambulatory patients or with other clinical obligations that limited their ability to provide the intensity of care often required by these patients. By focusing their practice on this specific group of patients, hospitalists gain specialized knowledge in managing very ill patients and are able to provide high-quality, evidence-based, and efficient patient and family-centered care in hospital settings.

In the academic setting especially, a premium will beplaced on clinical quality improvement, the develop-ment of practice guidelines, and outcomes research,not only to provide the physician with a creative out-let and a potential source of funding during thenonclinical months but also to give the academiccenter a practical research-and-development arm

. The “triple threat” leader— skilled clinician, researcher, and educator — wasthe paradigm of exceptional faculty achievement (orfantasy) for more than a generation. Balancing aproductive research career with teaching and clinicalcare was easier when academic health centers wereless accountable for the quality and cost of clinicalcare than they are now.

As with intensiv-ists, a major challenge is to link the hospitalist rolesuccessfully with other activities.

Conversely, some traditional programs may develophospitalist tracks that emphasize acquisition of theskills most relevant to inpatient practice. If suchtracks are developed, it will be important not to re-duce training in ambulatory care too aggressively,since the competent hospitalist will need a full un-derstanding of what can — and cannot — be donein the outpatient setting

As with anymajor transition, the medical community must con-tinually reevaluate the new approach to ensure thatany possible discontinuity in care is outweighed byimproved clinical outcomes, lower costs, better edu-cation for physicians, and greater satisfaction on thepart of patients.

Oneof the advantages of the hospitalist model is that itcreates a core group of faculty members whose in-patient work is more than a marginal activity andwho are thus committed to quality improvement inthe hospital.

The debate over the role of hospitalists is takingplace against the backdrop of the larger controversyover whether generalists or specialists should pro-vide care for relatively ill patients.11

As hospital stays become shorter and inpatientcare becomes more intensive, a greater premium willbe placed on the skill, experience, and availability ofphysicians caring for inpatients.

First, because of cost pressures,managed-care organizations will reward profession-als who can provide efficient care. In the outpatientsetting, the premium on efficiency requires that thephysician provide care for a large panel of patientsand be available in the office to see them promptlyas required. There is no greater barrier to efficiencyTin outpatient care than the need to go across thestreet (or even worse, across town) to the hospital tosee an unpredictable number of inpatients, some-times several times a day. There are parallel pressuresfor efficiency in the hospital. Since the inpatient set-ting involves the most intensive use of resources, itis the place where the ability to respond quickly tochanges in a patient’s condition and to use resourcesjudiciously will be most highly valued. This shouldprove to be the hospitalists’ forte.

We believe the hospitalist specialty will burgeonfor several reasons.

As a result, we anticipate the rapid growth of anew breed of physicians we call “hospitalists” — spe-cialists in inpatient medicine — who will be respon-sible for managing the care of hospitalized patientsin the same way that primary care physicians are re-sponsible for managing the care of outpatients.

Unfortunately, this approach collides with the re-alities of managed care and its emphasis on efficien-cy.