Hospitalists Must Learn to Adapt if They Want to Thrive in a Rapidly Changing Health Care Landscape

“Marcus Welby isn’t coming back,” and the future of hospital medicine looks bright, said Robert M. Wachter, MD, Professor and Associate Chair of the Department of Medicine at the University of California, San Francisco, as he delivered closing remarks to the plenary session of the 2013 Annual Meeting of the Society for Hospital Medicine, held May 17-19 at the National Harbor, Fort Washington, MD. Wachter, who is credited with coining the term “hospitalist,” is a past president of the Society for Hospital Medicine and current chair of the American Board of Internal Medicine.

Gleaning insights from his longstanding ties to the field and from other presentations at HM13, Wachter cited trends that point to the ongoing health of the profession, even in the face of increasing pressures to provide more and more care in the outpatient setting, as with ACOs, and even to manage more care in the home setting, as the movement toward the “activated patient” capitalizes on telehealth and mobile health advances.

Reminding the audience that hospitalist physicians are fundamentally generalists, Wachter expressed confidence that the “pluripotential nature of hospitalists means that we’ll morph into what’s needed.” Roles in an evolving health care landscape might include co-management, participating in systems improvement and cost reduction efforts, assisting with transitions between different levels of care, and even providing targeted care in skilled nursing facilities. Predicting that the hospitals that will succeed in the future will be robust institutions that are able to demonstrate good efficiency and outcomes, Wachter reminded the audience that a strong hospitalist group has become a necessary component for achieving these quality measures.

Further, increasing pressure to encourage all members of the health care team to practice at the top of their licenses results in a net win for hospital physicians, who are then made more free to accept the most intellectually engaging tasks; for example, in Wachter’s home facility, hospitalists are learning to comfortably co-manage neurosurgery patients, even in the earliest postoperative settings. Such an approach requires effective communication with all members of an organization, patients, and family members; ensuring open lines of communication and a common language are key.

Wachter remarked on trends over the last decade for physicians and institutions to achieve meaningful engagement to improve quality, increase patient safety, and enhance the patient experience. Real work to achieve cost and waste reduction needs to become a primary focus as well, and should involve the same rigorous attention to process and to stakeholder engagement that QI and patient safety have achieved. “The health care delivery system needs to be remade to survive and succeed in the new world,” Wachter said. He recommended that physicians become comfortable with a quality improvement process such as Six Sigma or Lean to help achieve these goals.

Health care is a complex adaptive system; both the system and the external environment are in a continual state of flux, Wachter reminded the audience. In such an environment, mechanistic methods of problem solving are destined to fail; they cannot account for the unpredictability of the environment, nor for the human players within and outside the system. Only solutions which honor individuals as independent and creative decision-makers will succeed‑‑as with the surgical checklists pioneered by Peter Pronovost, MD, and championed by Atul Gawande, MD, the best solutions often emerge from simple rules, and overly lengthy or prescriptive rules can actually impede safety and quality.

Citing the work of authors Daniel Pink and Dan Ariely, Wachter posited that for physicians, the best innovations often come from the bottom up (as with surgical checklists), and the strongest motivators are intrinsic. There is mixed evidence at best that new pay for performance measures will provide the incentive needed to transform healthcare delivery; by contrast, public reporting measures capitalize on intrinsic motivating factors to encourage physicians to compare favorably with peers. Ongoing and meaningful involvement in improving efficiency and quality of hospital care will ensure that hospitalists can continue to shape change. Thus, even as health care evolves to become ever leaner, hospitalists will thrive by continuing to be flexible and engaged participants in a dynamically changing field.