From Zero to 50,000—The 20th Anniversary of the Hospitalist

Following publication of an article he co-authored in The New England Journal of Medicine, Dr. Goldman discusses how hospitalists contribute to inpatient care, and why there are now more than 50,000 of these medical professionals in hospitals across the country.

Columbia University Medical Center (CUMC): How did the hospitalist movement start?

Lee Goldman, MD (LG): During an earlier part of my career, I had the good fortune to be at UCSF (University of California, San Fransisco), where I collaborated with my good friend and colleague Bob Wachter to create the first academic hospitalist program in the country. Back then, there were almost no hospitalists in the U.S. Now there are 50,000. It's just amazing.

The term ‘hospitalist’ was coined jointly by Bob Wachter and me. We sometimes argue about exactly who thought it up first, but we’ve settled on mutual discovery, if you will. It was defined initially as physicians who spent a majority of their time in the hospital. We didn’t really have a sense at the very beginning that these would be people who would spend essentially 100 percent of their clinical time in the hospital. That evolved over time.

CUMC: What are some of the factors that led to the explosive growth of this field?

LG: In order for hospitalists to go from 0 to 50,000 in 20 years, a lot of stars had to align. Perhaps the most important was the creation of the workforce, people who wanted to do this. There was a tremendous reservoir of people who wanted to be focused on inpatient medicine. They wanted to be generalists, but not office-based generalists, and they saw the inpatient service as a place where they could use the skills they had honed during residency, take care of relatively sick patients, and do it in a better, more coordinated way.

Other things happened as well: pressure to be more efficient in the hospital, to reduce length of stay, to maintain or increase quality. They are not simple tasks. We showed early on that hospitalists reduced length of stay without increasing readmissions, with patients being equally or more happy, with the teaching being as good if not better, and subsequently showing that in some non-teaching settings—community hospitals—hospitalists actually can improve patient outcomes and reduce mortality. This research had a huge impact on the field, and hospitalists spread like wildfire. This movement went viral, so to speak.

CUMC: You mentioned that hospitalists have had a positive impact on outcomes. Can you explain some of the reasons for this success?

LG: The introduction of hospitalists had some really positive, immediate effects. It meant that there were people who built their career around taking care of inpatients. They were in the hospital all the time—a big shift from an era in which individual internists would have maybe one or two patients in the hospital, come to see them at the beginning of the day or at the end of the day, or sometimes even both, but not be there through the course of the day when lots of things happen.

That individual physician with one or two hospitalized patients, on average, was not going to be expert in knowing who to call in radiology to get the right radiologic test, how to find the best consultant for whatever the patient might need. Hospitalists, because they are there all the time, became experts in all the ways that a hospital works on a daily basis. Then you throw in the electronic medical record, and the hospitalists learned how to use it and make it helpful, whereas the individual physician coming from the office found it to be a burden.

CUMC: In which departments do hospitalists participate? Are they seen as medical specialists or generalists?

LG: Hospitalists began on inpatient medical services—services that had a wide enough range of patients that they needed someone with broad general expertise to be able to take care of someone with pneumonia, gastrointestinal bleeding, etc. Since the medical service tends to be the biggest in any hospital, it was the natural place for hospitalists to start. More recently, there has been an explosion of pediatric hospitalists in pediatric non-intensive care settings, neurologic hospitalists for neurology services, and also roles for hospitalists to help care for the medical issues of surgical patients, especially in orthopedics, neurosurgery, and the like.

Another type of hospitalist is the acute care surgeon who takes care of urgent general surgery—appendectomies, gall bladders, things of that sort—and also sees surgical consults and takes care of the general surgery patients on the inpatient service. So it started in internal medicine, but it has really spread. Almost every year, we see another interesting application of the general principle.

When Bob Wachter and I first started the program, we really didn't know how it was going to evolve. Initially, I thought that hospitalists would be overwhelmingly medical subspecialists, like an internal medicine inpatient group practice. I think Bob saw that was not the future, that the people who wanted to do this were more in the general internal medicine mode. Very quickly it shifted from a group of inpatient subspecialists to a group of inpatient generalists.

CUMC: Have there been any concerns about the impact of hospitalists on the quality of patient care? How have hospitalists affected hospital culture?

LG: What got people worried at the beginning, and is still an ongoing concern, is continuity of care. It’s a general truism in medicine that more continuous care from the same physician or a small number of physicians means they are better able to take care of all your problems, and the more comfortable you feel. By definition, hospitalists build in discontinuity. The big challenge was how to overcome this, while simultaneously realizing the tremendous upside potential.

My colleague, Bob Wachter, and others worked hard on issues related to “passing the baton,” both from the outpatient doctor to the hospitalist, and from the hospitalist back to the outpatient doctor. No one should be superior to the other. They have to be colleagues on the same team, in the same relay race.

Early on, some people believed this would just never work. Bob and I always believed it was a challenge, but a challenge that could be overcome.

One of the fears was that these inpatient generalists would almost be too big for their own britches. They would not know when to ask for consultations. They might think they could do more than they really could. Although this was a big concern at the beginning, from a practical perspective it was never a problem because appropriate consultations were still enlisted. If anything, a hospitalist who is physically present all day long can better coordinate any needed consultations.

CUMC: What are some of the biggest challenges that hospitalists face today?

LG: One of the key issues now in going forward is to develop the role of the hospitalist in a teaching hospital or in any hospital that's trying to be as good as it can be. In emergency medicine, physicians often work shifts and then disappear. That's just fine when they're there, but it means those individual physicians really aren't necessarily invested in making the whole system work better. The major concept behind hospitalists was that they would really be invested in making the medical service better. That goal doesn't fit well with a shift work mentality.

One of our beliefs early on was that hospitalists should have what we called a “systole” and a “diastole.” For those of you who know how the heart functions, systole is when the heart works hard to pump blood out. Diastole is when it relaxes and fills up with blood again. Diastole is an active, not passive, relaxation phase, but it's a different kind of work. We believed from the beginning that hospitalists should have some kind of academic diastole, a time when they would contribute to inpatient education, do research, or conduct quality improvement projects to improve the way the hospital works. Their systole—weeks or months on service—is complemented by a diastole—their contribution to the commons. I think that's a very important concept, not only in the academic setting but also in the community hospital setting as well.

“From Zero to 50,000—The 20^th Anniversary of the Hospitalist” was published in The New England Journal of Medicine on Aug. 10, 2016. Robert Wachter, MD, director of the Division of Hospital Medicine at University of California, San Francisco, was a co-author with Dr. Goldman.