Dr. RW provided this link to a John Nelson blog entry.  John is a great guy who help found the organization now known as SHM.  Will the last traditionalist leaving the hospital please turn in your parking pass.

It won’t surprise me if a similar sign appears in hospitals around the US. “Traditionalists,” which I’ll define as doctors with an active outpatient and inpatient practice in the traditional model of the last century, are leaving in droves.

My experience suggests that given the opportunity, a lot (most) doctors in nearly every specialty will choose to leave hospital practice behind. Of course we hospitalists, and other specialties like ER Medicine, will always be there. But most specialties that have historically divided their time between the hospital and outpatient practice have found that the center of gravity of their practice has shifted significantly to the outpatient setting and the hospital work can become increasingly burdensome. While this isn’t really a new trend, it does seem to be accelerating.

Just to make this interesting, let’s assume for a minute that no one believes that a practice focused on a site of care, such as hospitalists, ER doctors, and intensivists, offers no improvement in quality or efficiency. Would ER doctors and hospitalists have still been “invented?”

I’m confident the answer is yes.

As I have written recently, we no longer need to argue about the wisdom of the hospitalist movement.  Whether having hospitalists improves health care and quality has become a moot question.  We have hospitalists, and that trend will expand.

Our job must focus on optimizing care with hospitalists controlling an ever increasing proportion of the overall hospital care.  We can argue about why this has occurred.  We can argue about the wisdom of this trend.  But those arguments have become passe.

Our payment system has dictated the growth of hospital medicine.  It will take many years until we have enough hospitalists to meet the needs of all hospitals.  The supply demand equation of hospitalist groups will remain favorable for the forseeable future.

I believe this trend is good for internal medicine.  If one looks at the Oslerian ideal internist, many hospitalists can practice Oslerian medicine.  Hospitalist jobs follow nicely from the medicine clerkship and the medicine residency.  Newly minted hospitalists understand the patient care aspects and can concentrate on learning the hospital, quality and safety issues relevant to their individual hospital.

Hospital medicine has several very attractive features.  Hospitalists have very low overhead, and need not borrow more money to start a practice.  Hospitalists are mobile, which helps the hospitalists in their negotiations with hospitals.  Since they have not invested in their practice, they are more free to move if they are not treated well.

Certainly, hospital medicine has many lifestyle advantages.  Vacations are easier to plan.  Most mature hospitalist programs provide no call once one leaves the hospital (because a partner is still there.)

Hospital medicine has problems.  The rapid growth has led to an influx of internists, not all of whom are really invested in the field.  Hospitalist Turnover’s a Big Problem – Or is it?

As John Nelson is fond of saying, hospital medicine is a career with low barriers to entry and exit – and individual hospitalist jobs are the same. You can leave a hospitalist practice tomorrow without having to worry about closing up shop and selling your assets or your patient list, choose from a dozen attractive offers, and be fully busy in a new job within a few days. Because the demand for hospitalists is so much greater than the supply, and changing jobs is relatively easy, it seems like turnover is rampant among hospitalist practices.

The best hospitals will treat their hospitalists well.  I doubt this will change in the next 15-20 years.  Only a drastic change in physician payment will impact this relationship.

So hospital medicine will continue to grow because other physicians are delighted to cede the hospital to the hospitalists.  I hope this is good for patients, but I am skeptical.  Having the other physicians leave the hospital has many negative externalities.  But as they say – it is what it is. 

“If life deals you lemons, make lemonade; if it deals you tomatoes, make Bloody Marys”