Why COVID-19 is a threat to hospital medicine

As hospitals everywhere have been using every health care provider available to them in response to COVID-19, the specialty of hospital medicine has shown itself to be uniquely suited for coordinating the effort, to be the front of the frontline responders. I suspect that many people don’t understand what “hospital medicine” is, even though it’s larger than almost any other specialty other than primary-care internal medicine and family practice.

As a hospitalist, a specialist in the field of hospital medicine, I’ve been directly caring for patients with COVID-19 as they’ve been hospitalized. My colleagues and I have also been helping onboard our subspecialist colleagues as they transition from the clinics, catheterization labs, and endoscopy suites and onto the general medical wards. Hospitalists are different than most specialists because what we do is defined by our location of practice, rather than by expertise in a specific organ, a specific kind of disease, or a particular age range of patients.

Hospital medicine is essential in our health care system, especially right now, and it’s likely in danger of being cut back as a result of the COVID-19 pandemic.

The term “hospitalist” was first used in 1996, at a time when hospital care was transitioning in recognition of the changing nature of health care. Managed care systems had made it challenging for primary care providers to continue to see their patients in the hospital setting, especially with the growingly complicated logistics of hospital care, with the involvement of multiple services.

The science of managing health problems in the hospital was itself growing more complicated, with patients often needing to be seen multiple times per day by an available in-house medical provider who is comfortable with inpatient diseases processes. Thus, a new specialty was born, dedicated exclusively to the care of patients in the hospital, with a particular focus on general medical conditions.

Today, there are more than 50,000 hospitalist physicians in America. In addition, about two-thirds of hospitaist groups include nurse practitioners and physician assistants. Studies have shown that patients cared for by hospitalists stay in the hospital an average of up to 0.69 days less than those cared for by non-hospitalists. This might not sound like much, but given that the average length of stay in American hospitals across the board is 4.6 days, this is a significant improvement. Studies have also shown that patients cared by hospitalists have higher quality of care and higher patient satisfaction when compared to those cared for by non-hospitalists.

Disaster response plans in hospitals have traditionally focused on mass traumas — terrorist attacks, mass shootings, natural disasters, etc. — and thus have focused heavily on emergency medicine, critical care, and surgical services. Although hospitals have also prepared for pandemics in light of the 2009 H1N1 pandemic and the Ebola outbreak of the mid-2010s, the unprecedented scale of COVID-19 has shown how invaluable hospitalists are for disaster responses.

We triage and care for patients with complex medical problems. We work closely with nursing units to build inpatient care teams. We work with case management to help arrange comprehensive support services and post-hospital care for our patients. We focus much of our research on improving the quality of the care we provide.

In spite of all of this, hospital medicine is not generally considered as “prestigious” a specialty as many others. There are several reasons for this.

First, our traditionally fee-for-service model of health care has historically rewarded doing procedures: surgeries, cardiac catheterizations, endoscopies, and so forth. Hospitalists often do bedside procedures, but not with the same volume as to generate the kind of revenue hospitals get from full-time proceduralists.

The more revenue a specialty generates for a hospital, the more prominent its role often is for the hospital. In fact, in order to make hospital medicine as profitable as possible, hospitalists often have to carry a large volume of patients and can have a particularly high burden of paperwork.

Second, hospital medicine is still a field dominated by early-career physicians (less than 5 years in practice), many of whom are using it as a “transitional” period between ending residency and starting subspecialty training. It’s also a newer specialty, less than a quarter-century old. The Centers for Medicare and Medicaid did not even recognize “hospital medicine” as a unique specialty for billing purposes until 2017.

Finally, and perhaps most of all, as a primarily clinical specialty, hospital medicine has far less academic support and academic mentorship compared to subspecialties that are flush with research grants and well-established faculty with decades of mentoring experience. As a result, medical education still largely maintains a subspecialty focus, especially at the larger and more prestigious institutions.

Medical training often requires those choosing subspecialties to decide early in their residency, so they can build up the research experience, make professional connections, and then apply to fellowship programs midway through their residency. Only 3 percent of internal medicine residents plan on pursuing a career as a hospitalist during their first year of training. Ultimately, 10 percent do decide to become hospitalists, but two-thirds make that decision during their final year of training.

When the emphasis on COVID-19 subsides — and it will — hospital medicine will be at risk of withering.

COVID-19 has been transforming how we care for patients in the hospital. As hospitals recover from this pandemic, start to take care of patients again who have been missing the care of their chronic conditions, and plan for the next pandemic, they will need hospitalists more than ever.

Unfortunately, as a result of COVID-19, hospitals everywhere are facing severe financial strain. This is going to create more pressure on them to heavily support high-revenue areas of health care, such as surgeries and other procedures, and cut back those areas that do not generate the same kind of revenue, like hospital medicine.

Already, one of the major hospitals in Boston is cutting back pay for their frontline medical staff due to the crisis.

In addition to forced financial cutbacks, there’s a high risk of hospitalists leaving the profession on their own. More than half of hospitalists were experiencing burnout even prior to the COVID crisis. Studies have shown that health care providers taking care of patients with COVID-19 are at especially high risk of burnout, so this problem will only get worse when the crisis abates. Hospital medicine already faces a shortage of providers and has one of the highest rates of turnover among specialties. In the aftermath of the COVID-19 crisis, we are potentially facing very high levels of attrition from hospital medicine, right when we need hospitalists the most.

Hemal Sampat is an internal medicine-pediatrics physician.

Image credit: Shutterstock.com

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