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Richard Gunderman

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What’s ahead for hospitalists?

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What’s ahead for hospitalists?  Two experts on them, Robert Wachter. M.D., and Lee Goldman, M.D.,  discussed in The New England Journal of Medicine the specialty’s rise and  future role.

“Although we continue to believe that the hospitalist model is the best guarantor of high-quality, efficient inpatient care, it’s clear that today’s pressures require innovative approaches around this core,”  Dr. Wachter, of the University of California, San Francisco, and Dr. Goldman, of Columbia University, wrote.

To read their piece in the NEJM, please hit this link.

But  Richard Gunderman, M.D., of the Indiana University School of Medicine, questioned in his own NEJM article hospital medicine’s impact on healthcare overall. “The acute-care focus of hospital medicine may not match the need of many patients for effective disease prevention and health promotion,” he wrote. “I suspect the inherent tensions will remain fundamentally irresolvable.”

“What we don’t yet know sufficiently well is the impact of the rise of hospital medicine on overall health status, total costs, and the well-being of patients and physicians,” Dr. Grunderman wrote.  To read his piece in NEJM, please hit this link.

Modern Healthcare noted: “These questions emerge amid a growing emphasis in medicine on coordinated, integrated care. And while in many ways a hospitalist’s job is to provide precisely that, some see the growing reliance on them as indicative of healthcare becoming too hospital-centric, in a way that hinders comprehensive care.”

“In 2003, when the American Hospital Association first began tracking the specialty, the U.S. had slightly more than 10,000 hospitalists. In 2016, the country had more than 50,000, an increase driven by both economic necessity and a spate of government changes that emphasized efficiency and quality in healthcare. The field’s boom is showing no signs of slowing.”

“We’re seeing many medical students start medical school saying. ‘I want to be a hospitalist,’” Dr. Wachter said, adding that  hospitalists will remain crucial to the healthcare system even as the industry tilts toward population health.

“There are people talking about how we can eventually close down all the hospitals,”  Dr. Wachter said. “That’s not going to happen.”

After all, patients who end up in the hospital tend to be even sicker, with even more complex conditions,   than inpatients tended to be, say, 20 years ago. Many patients who used to be treated in hospitals can now be handled on an outpatient basis. So physicians who specialize in handling the sickest — and thus hospitalized — patients are ever more necessary.

Meanwhile, in recent years, hospitals looking for ways to improve efficiencies and lower costs, have begun outsourcing hospitalists. That’s led some hospitalists to raise concerns about being spread to thin.

“We’re now a mature, really important field,” said  Dr. Wachter. “That’s my biggest worry: that we’ll become old and staid and rest on our laurels.”

For a good overview of the state of hospitalists,  please hit this link.

 


6 bad things in physician-hospital relations

 

Richard Gunderman,  M.D., a  professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department at Indiana University in Bloomington, describes how hospital-physician relationships can go bad.

Becker’s Hospital Review reports on  “six of the most influential things in any hospital-physician relationship and how they can go awry — as inferred by Dr. Gunderman.”

1. Financial support. “When EHRs and billing and coding systems are costly, physician practices have few places to turn. If physicians feel forced to rely on the hospital for financial support and muscled into relationships with hospitals, the relationship can hold resentment and turn sour.”

2. Job security and compensation. “When physicians feel their job security and pay is being toyed with or held over their heads, this undermines confidence and can push physicians to feel beholden to hospital administration.”

3. Decision-making.  “Dr. Gunderman says the best way to discourage a physician is to refer to such their decisions as ‘anecdotal, idiosyncratic, or simply insufficiently evidence-based.’ Hospital administrators are wise to avoid this.”

4. Productivity expectations. “Physicians are not factory workers. Increasing or  establishing exorbitant caseload expectations can wreak havoc. ”

5. Authority. “If physicians actually possess limited control over their work, they may fall victim to ‘learned helplessness,’ which Dr. Gunderman defines as a sense that physicians cannot meaningfully influence healthcare.”

6. Priorities. “Physicians don’t do the work they do for the benefit of the hospital — they do what they do for the patient….When priorities get mixed and hospital interests supersede patient interests, the entire healthcare model gets warped.”


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