The next 20 years of hospital medicine: Continuing to foster the mind, heart, and soul of our field

In 1995 I took my first job as a hospitalist at a community teaching hospital where hospitalists, though then known as “medical directors,” had been in place for 20 years. Soon afterward, our field gained a name, and my old job no longer was mistaken for a utilization review functionary or lead of a medical unit. I have been lucky enough to have seen the field of hospital medicine grow rapidly in scope and importance. The growth of our specialty in mere numbers alone is a testament to the value we in hospital medicine (MDs, DOs, PAs, NPs) bring to the care of acutely ill patients. We are the front line caring for the elderly and vulnerable, the glue holding transdisciplinary care teams together, and lead hospitals, health systems, and governmental organizations. Hospitalists touch the lives of our patients, and shape the health systems’ practices and health policy on a national and international scale. These are remarkable achievements for a field which, just a few years ago, was concerned about becoming a job equivalent to perpetual residency training (or worse) and gained only grudging acceptance. There is no doubt that the roles of hospitalists will continue to evolve, and whereas hospitalists will be able to shape the debates and development of new programs solving the problems of our health systems, we must take time to foster the mind, heart, and soul of our field. When I speak of the mind of hospital medicine, I am thinking of our field’s contribution to the evidence for how to care for patients’ illnesses, a different body of knowledge than our field’s focus to date on hospitals and health systems. Hospital medicine has been growing research capacity at a rate that is slower than the field overall, a problem in part due to limitations in National Institutes of Health funding for fellowships and early-career awards, which in turn has restricted the pipeline of young and innovative researchers. Slow growth may also be a result of an emphasis on health systems rather than diseases. I and others have written about the need to create mentoring support for junior research faculty as a way to promote success and avoid burnout, and while at least 1 hospital medicine research network exists, there is room for many more. However, at its core, our specialty needs to devote more time and focus to becoming a full scientific partner with our colleagues in cardiology, pulmonary medicine, and critical care, among others. To develop the mind of hospital medicine we will also need to think about our contributions to useful clinical guidelines for care of diseases and patients. Developing trustworthy clinical guidelines can be time consuming but is a key part of ensuring patients and families understand the rationale for changes in clinical care. Hospital medicine as a field has been a leader in programs that develop approaches to implementing evidence and stands in an excellent position to—perhaps in collaboration with other specialties—create the next-generation guidelines that are practically minded, evidence based, and end up being used. The heart I speak of is how we can make sure that the field of hospital medicine is one that is attractive and sustainable as a career. Electronic health records’ impact on day-to-day work is substantial and a large part of the problem, though a more fundamental problem we face is in how to create sustainable jobs at a time where we are going to need to deliver higher-value care to more patients with the same number (or fewer) providers. This is an issue that means we need to settle many important aspects of our work—pay, relationships with our peers, control over our work on a day-to-day basis, hospitalists’ work schedules (such as the 7 days on/7 days off model)—while we also grapple with how to work within a population-health framework. I am not prescient enough to see all the solutions to burnout, but there are at least 2 opportunities hospitalists are perhaps best suited to develop and lead. The first is how we arrange our teams in the hospital and afterward. Recent articles have talked about how medicine needs to be open to Uber-like disruptive models, where labor is deployed in fundamentally different ways. Tools such as e-consults, the application of population health tools to inpatient care, telemedicine, or some forms of predictive analytics may be examples of these tools, which are routes to allowing more care to be delivered more effectively and more efficiently. Another opportunity lies in how we adapt our electronic health records to our work (and vice versa). The perils of “sloppy and paste” documentation are *Address for correspondence and reprint requests: Andrew D. Auerbach, MD, MPH, Department of Medicine, UCSF School of Medicine, 533 Parnassus Avenue, UC Hall, San Francisco, CA 94143-0131; Telephone: 415-502-1412; Fax: 415-514-2094; E-mail: ada@medicine.ucsf.edu