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Hospital Medicine – Now an International Specialty

By Ron Greeno, MD, Senior Advisor for Medical Affairs, President of the Society of Hospital Medicine

This past fall, I was asked to speak at a conference for Japanese hospitalists in Tokyo. They wanted me to speak about the evolution of the hospitalist model in the United States and to begin conversations about getting support from our Society of Hospital Medicine (SHM) for the emerging specialty in their country. The conference was presented by the Japanese Society of Hospital General Medicine and was attended by more than 800 hospitalists including some from other East Asian countries. The JSHGM is seven years old and has 1,400 members; its growth mirrors the growth of practicing hospitalists in Japan, which has been fueled in part by encouragement from the Japanese government.

This emerging partnership of the two societies is only the latest in a growing series of efforts on the part of SHM to support the growth of the hospitalist specialty internationally. It started with Canada, where several years ago a small contingent of hospitalists asked if they could become a chapter of SHM. They wanted to join a group that has now grown to 56 state and regional chapters. Within a few years, the Canadian Chapter evolved to become its own independent and flourishing society. More recently, SHM has helped develop chapters in Brazil and the Middle East with more in the works. The International Special Interest Forum at this year’s annual meeting expects attendees from Holland, Germany, Spain, Taiwan, China and many other nations.

So, why all of this interest in hospital medicine from nations whose health systems are so different from ours? What is it about our new specialty that has captured the interest of physicians, health systems and governments around the globe?

By talking to hospitalists from around the world, the answer is simple: it is cost and quality. It turns out that the American healthcare system is not the only one that struggles with these issues. It seems that healthcare costs are too high everywhere, and the quest for high-quality, low-cost healthcare is a universal struggle. As Scottish healthcare economist Ian Morrison jokes, “Every healthcare system sucks in its own way.”

Let’s take a look at Japan. They have the longest average life expectancy in the world at 84 years, with about a quarter of their population more than 65 years of age. On any given day, almost 14 percent of the population has a physician visit. They also have a historically long length of stay in the hospital with the current average length of stay (ALOS) anywhere between 14 and 21 days. In their single-payer system, the entire cost of this care falls on the Japanese government.

Canada has a different challenge. Also, a single-payer system, their largest issue for the acutely ill is the availability of an open hospital bed. Although the system varies somewhat from province to province, it is typical that hospitals are given a total budget for the year that must cover all expenses. Since most hospitals are full all the time, the discharge of a patient results in another new admission, which actually costs the hospital more money. This perverse incentive keeps their beds full as patients wait for a bed to open, especially for any elective procedure. In addition, physicians are paid fee-for-service and have no incentive to discharge patients. As their citizens clamor for more access to care, the government is looking for ways to lower excessively long length of stays.

It is no wonder physicians and healthcare planners from Japan, Canada and around the world have viewed what hospitalists have accomplished in the American healthcare system with great interest. They recognize the potential of this relatively new model to decrease hospital length of stays, lower healthcare costs and improve outcomes. After all, this is what the hospitalist model was invented to accomplish: to create value not through high production, but by improving the efficiency of care delivery and driving improved hospital operations.

As unrelenting economic forces continue to put pressure on healthcare systems worldwide, it will be fascinating to follow and continue to assess the impact of the hospital medicine model in the nations where it is implemented, including ours.