September 25th, 2016

Is There a Hospitalist “Bounce-Back” to ID?

53813973 - group of doctors examining a x report in hospital

These actors are supposed to be doctors.

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”…


16 Responses to “Is There a Hospitalist “Bounce-Back” to ID?”

  1. New Hospitalist says:

    This is a great topic! I just finished IM residency and am a new hospitalist. I had long been (and still am) interested in ID but the need to pay down debt was the deciding factor for foregoing fellowship. I’m still considering fellowship, but if compensation/debt were not an issue I would be an ID fellow right now instead of a hospitalist.

  2. Andrea says:

    I think it’s a growing trend and we’ll see more hospitalists go back to fellowship. I’m one of those who did this and I love my career in ID! Your observations are spot on. Love your blog.

  3. Mimi Breed says:

    Thanks for the intro to ZDogg!

    MUCH Funnier than Placebo.

  4. Keith says:

    Anecdotal evidence at one pediatric institution is that the hospitalist group is subsidizing a number of our newly minted Peds ID trainees. Three young trainees have recently finished their ID fellowships and have been hired to stay with a split appointment in ID and hospitalist medicine in order to make the finances work.

  5. MC says:

    To 57% of hospitalists considering a different career & 30% w/ job burnout, CONSIDER ID!

    Here are the refs:

  6. Eric Osgood says:

    Hospitalists are treating cardiac pulmonary GI renal endocrine neurologic rheumatologic hematologic and oncologic conditions, in addition to infections. The vast majority of hospitalists would never take an ID fellowship, irrespective of pay.

  7. Khalid says:

    I was an academic hospitalist for over five years. I never thought of it as a career and worked in ID research in my time off. Now I am an ID fellow and I am absolutely loving it.

  8. Rahul warrier says:

    I think the authors assertion that Internists that choose a career in hospital medicine only do so for financial reasons or to work “part time” grossly undermines the importance of this profession. As a practicing hospitalist/internist I can say without hesitation both patients and hospitals are better off because someone like me exists. The alternative would be either specialists or PCP’s would need to start admitting, I’m not confident for the safety or well being of patients in either scenario. Perhaps the author should spend less critiquing hospitalist’s and more time advocating for his own profession

    • Paul Sax says:

      Indeed, I agree! That’s why I wrote this: “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.”


  9. Rahul warrier says:

    I also take offense to the comment that a board certified internist has “limited” training.

  10. JC says:

    Great post Dr. Sax. You really hit the nail on the head.
    As someone currently interviewing for fellowship in ID, I can tell you this issue has been discussed at many of my interviews.
    You highlight some key points with regards to attracting more residents/medical students to ID: reinvent the passion early on in medical school with microbiology and even delving into some clinical infectious disease; early mentor/mentee partnership in residency; required rotations in ID during residency (some centers do not have this and its rather an elective), showcasing what ID has to offer;; changing compensation (easier said than done); reducing medical school debt burden (easier said than done).

    I always enjoy reading your blog. Thank you.

  11. Vikas Jogi says:

    Hi Dr Sax. I was a hospitalist for five years before turning to ID. Im loving it .
    I make substantially more than the average hospitalist, but im in private practice in the South , which differs substantially in renumeration to the North East.
    Anyways, no comparison in the job satisfaction.

    • Suzy says:

      Hi – I saw your post and feel like I am in a similar situation as your were once in. I’ve been a Hospitalist for about 5yrs and thinking about going back to fellowship in ID. Do you have any advice?

  12. Michael M O'Brien says:

    My recent experience: I’m semiretired, asked to visit -socially-an old patient of mine seen by me for many years, by his son, diagnosed with dehydration, in and out of ER and inpatient cared for by hospitalists for three weeks. From the end of the bed it was obvious he was in CHF. The diagnosis of CHF had been made on an X-Ray on his initial visit to ER three weeks before. NONE of the many hospitalists over the ensuing three weeks had looked at the X-Ray or the results or examined the patient–“he’s been here for three weeks obviously the hospitalist before has properly assessed him” NONE had. This was not an isolated experience.
    The hospitalist programme is an abomination when a series of them are looking after a patient with no proper handover: one MD per admission, regardless of the length of stay and should carry over to subsequent stays. Hospitalists, as they exist in many iterations, are an affront to the basic concept of patient care.

  13. Chris Steevens says:

    I agree that both NEJM articles make valid points. With regard to Gunderman’s comment that hospitalists weaken the doctor patient relationship and can negatively impact care, the alternative no longer seems feasible (that is PCPs caring for their own patients in the hospital), and better communication between PCPs and hospitalists can help to strengthen the relationship. EHRs were supposed to accomplish that, but unfortunately have not lived up to the promise, yet (I’m still hopeful).
    Also, while I can understand the frustration of specialty training programs like ID fellowships losing applicants to hospitalist jobs, I am not sure that training more specialists is necessarily a good thing either. I would point to the Bloomberg report which ranks the US health care system 50th out of 55 for efficiency, and yet we have more specialists than any other system. More specialists may be adding to more fragmentation and less coordination of care, contributing to the lack of efficiency.

  14. Michael Rowe says:

    It’s a historical moment. If you look at academia in general, you see a really similar dynamic with more and more “careerist” decisions being made and fewer and fewer students choosing the Humanities. The hope has to be that sufficient intellectual curiosity remains spread among the current resident and post-residency population to draw an appropriate number of folks into subspecialty fields whether in academia or in the community.

    I think it’s time to stop discussing the “merits” of Hospitalist medicine. The evidence cited now and previously by Wachter, Goldman, and others would be embarrassing even if published in a surgical journal. The samples are small, the studies poor quality, and the differences minor.

    Hospitalists who tout the diversity and breadth of knowledge in hospital practice (which kept me in GIM rather than going into ID also) are either practicing in a privileged, protected practice setting, never seeing their families and staying until 9 at night, or not meeting their productivity targets.

    Nonetheless, Hospital medicine is here to stay for sociological reasons (lifestyle, finances, etc.) which no amount of data is going to reverse. Observing the too frequently poor, disorganized, and often cursory quality of hospital medical care (primarily due to the organization of care and the gradual normalization of the inadequacies not clinician quality) in both academic and community settings for our patients, the current system is disheartening but it is what it is. I don’t expect it to change in my working lifetime and can only hope that something happens before I’m on the other end.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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