An ongoing dialogue on HIV/AIDS, infectious diseases,
September 25th, 2016
Is There a Hospitalist “Bounce-Back” to ID?
The New England Journal of Medicine recently published two outstanding pieces on hospitalists, and they had pretty much diametrically opposing perspectives.
Both should be required reading for anyone practicing medicine, and indeed anyone who might know — or be — a patient in a U.S. hospital one day.
In short, everyone.
But since you may not have time, let me give you the condensed versions:
Wachter and Goldman, “Zero to 50,000 — The 20th Anniversary of the Hospitalist”: The hospitalist movement is booming because hospitalists increase the efficiency — and possibly also the quality — of inpatient care.
Gunderman, “Hospitalists and the Decline of Comprehensive Care”: Due to the their limited training, narrow focus, and frequent shift changes, hospitalists inherently weaken the doctor-patient relationship, and may negatively impact patient care.
Both pieces make valid points, and you will probably find yourself nodding with recognition as you read each one. But rather than comprehensively review them, I want to focus first on the issue of greatest relevance to Infectious Diseases, in particular the recruitment of fellowship applicants — money! As creators of the very term “hospitalist” (they should have patented it), Wachter and Goldman provide a concise historical overview of how the field emerged out of multiple aligned forces, the first (and arguably the most important) being financial:
How could hospitalists, then, fashion careers out of a role that was economically unattractive to their colleagues? Once evidence of substantial cost savings had accumulated, health care organizations found it advantageous to have hospitalist programs, and most provided financial support to create appealing jobs with reasonable salaries.
In short, so valuable is a short length of stay to a hospital’s bottom line that essentially all hospitalist positions have subsidized salaries. They also have substantial “time off”, with many positions offering full-time salaries for part-time hours — 7-on, 7-off is a popular (if much-debated) model.
Tough for ID (or any non-procedural specialty) to compete! Indeed, many cite the abundant well-paying hospitalist positions available to internal medicine graduates as the primary driver of the decline in applications to ID and nephrology programs. In an interview I conducted with fellow ID-docs Wendy Armstrong and Mike Edmond recently on Open Forum Infectious Diseases, both brought their A-game (listen!), and what Mike said about hospitalists vs ID positions rings particularly true:
We are seeing an increase in debt burden for students as they complete medical school and go into residency, so that factor is becoming a heavy one on their minds. We have a lack of salary parity with fields that require less training than being a subspecialist in infectious diseases … ID is essentially asking people to do more training in order to make less money, and I think for many residents in internal medicine that’s just a non-starter.
But there’s hope for us yet, and it’s primarily because some of those in hospitalist work are doing so not because of the work itself, but for other reasons.
While I must emphasize that there are many hospitalists who have chosen the field because it’s an excellent way to be directly involved in patient care and, often, quality improvement, teaching, and clinical research, some are doing it primarily for the money because they must — they have too much medical school debt. If so, there’s a decent chance that the hospitalist position will eventually prove something less than career (or soul) nurturing.
For another group, the choice is also expedient — this is good money for part-time work. For this group, it’s not hospitalist work as a career destination, but primarily a way to subsidize their other medical or non-medical activities that are less remunerative — international work, teaching, business start-ups, administrative aspirations, novel-writing.
As an example of the latter, how about U.S. Surgeon General, Dr. Vivek Murthy? He was an excellent hospitalist at the Brigham (brush with greatness, I know) for several years, primarily while pursuing the activities cited in his official biography in his “time off”. It’s either appropriate — or ironic — that he’s cited by Wachter and Goldman as validation for the prestige of the hospitalist position!
Getting back to ID, we’re smack dab in the middle of fellowship interviews, and I’m pleased to report that we still see outstanding applicants to our field — superb clinicians, brilliant researchers, esteemed teachers, thoughtful humanists.
And a substantial number of them have spent the last year or two as hospitalists. They have used those temporary positions to pay-down some of their medical school debt so that they can eventually train in the field that they’ve always loved — ID. They are excited to begin exploring ID in depth, and often somewhat disgruntled by the churn of admissions and discharges that is inpatient medicine in 2016.
Full disclosure, this “hospitalist bounce-back” phenomenon is anecdotal — I don’t have actual numbers to back this up.
But I’m curious to hear if others are experiencing the same thing, both in ID and other fields.
Now for a different kind of “bounce-back”…