Standing in the middle of hospitalist specialization

Dr. John Nelson was at the forefront of the hospitalist movement in the late 1980s and was one of the cofounders of the Society of Hospital Medicine. Today, he is the medical director of the hospitalist program at Overlake Hospital in Bellevue, Wash., and a partner in Nelson Flores Hospital Medicine Consultants in La Quinta, Calif., which specializes in advising organizations on how to make the most of new and existing hospital medicine programs.

But Dr. Nelson is also keeping his eye on a new trend – the expansion of the hospitalist model to new subspecialties. Over the last few years, he’s been bringing physicians together to talk about whether this new model, which would bring the hospitalist practice model to virtually every specialty, is right for patients and how it could work.

In 2011, he worked with leaders in the Society of Hospital Medicine to convene a meeting on the topic in Las Vegas. In an interview with Hospitalist News, Dr. Nelson explained where the model stands today and why he sees it as the right path forward.

Hospitalist News: What kind of activity has transpired since the 2011 meeting in Las Vegas?

Dr. Nelson: Less than I would have predicted. We did a reprisal of that meeting in a shortened form as part of the American Hospital Association’s annual leadership summit last summer. There’s also lots of chatter. Many specialties are continuing to coalesce and mature. The neurologists have a research journal and a society; likewise, the obstetricians have formed a society and are putting out a newsletter. The surgeons – called acute care surgeons – are having their first meeting this May. The snowball has not grown as fast as I would have predicted, but it is still rolling down the hill.

HN: What are some of the issues that have come up as more people have discussed this concept of specialization within hospital medicine?

Dr. Nelson: One thing that comes up a lot is, why is it happening? Another is, how do you do it? The real megatrend to explain why this is happening is that doctors in all specialties have moved the center of gravity of their practices away from the hospital. Twenty or 30 years ago, the hospital was the epicenter of academic, scholarly activity. It’s where the miracles happened; it’s where the doctors coalesced. At the beginning of my career in the 1980s, when we’d have a general medical staff meeting, it was packed. Now, when we have general staff meetings, they have to give away stuff just to get a handful of people to show up. In the case of general surgeons, for example, those who are very good at building a referral pipeline are operating more and more in the outpatient surgery center. To some degree, there’s a flight from the hospital that began with the primary care doctors in the 1990s. Now it’s happening in the other specialties.

HN: This model is taking hold in neurology, obstetrics, and surgery. Will it be confined to those areas or will we see this trend develop in other specialties?

Dr. Nelson: Those are the most visible specialties, but psychiatry, for example, is pretty big across the country. There are few psychiatric inpatients, at least in general medical hospitals. So if you add up all the people who could reasonably be called psychiatric hospitalists today, there’s still not many. But as a penetration of the small universe of hospitalized psychiatric patients, the hospitalist model is very widely adopted. It’s kind of like pediatrics, which was really the first to embrace the hospitalist model but got little attention because there are so few hospitalized children. Psychiatry has embraced this, and gastroenterology to some degree. I’ve heard of a hospitalist in every specialty in medicine, including things like ENT and dermatology.

HN: Is this a divisive issue?

Dr. Nelson: It’s probably less divisive for the specialties thinking about it now than was the case for internal medicine and family medicine in the 1990s. In the ’90s, the casual observer tended to mistakenly conclude that payers were behind all of this. The economic environment was a huge reason to adopt the hospitalist model, but it’s not as though health care executives invented the idea and shoved it down everyone’s throats. But many people thought that. So that led to tension and distress. In most cases now, specialties that are adopting the hospitalist model are doing it because the doctors themselves are demanding it. Our hospital just started an obstetrics hospitalist practice 2 months ago because our obstetricians were pounding their fists, saying, "You’ve got to do it." That didn’t feel contentious. It’s interesting though that, in surgery, it is kind of is contentious.