Editor’s Note: Listen to Dr. Goldman, Dr. Wachter, Dr. Gandhi, Dr. Bessler, Dr. Gorman, and Dr. Merlino share more of their views on hospital medicine.
When Lee Goldman, MD, became chair of medicine at the University of California at San Francisco (UCSF) in January 1995, the construct of the medical service wasn’t all that different from when he had left as a resident 20 years earlier.
“It was still largely one month a year attending,” he recalls. “A couple of people did two months, I think. Some physicians still took care of their own patients even though there were teaching attending.”
Sure, it was an antiquated way to manage inpatient care, but since it had worked well enough for decades, who was going to change it?
“I got the idea that we could do better than that,” Dr. Goldman says.
He was right.
Dr. Goldman lured a young physician over from San Francisco General Hospital. The guy was a rising star of sorts. Robert Wachter, MD, MHM, had helped run the International AIDS Conference, held in the City by the Bay in 1990. He joined the faculty at San Francisco General that year and two years later became UCSF’s residency program director.
Then, Dr. Goldman asked Dr. Wachter to take on a new role as chief of the medical center at UCSF Medical Center. The charge was simple: “Come up with a new and innovative model by which fewer, selected faculty each spent multiple months as inpatient attendings and teachers.”
The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.
But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.
Until Dr. Wachter and Dr. Goldman.
On Aug. 15, 1996, their article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” was published in the New England Journal of Medicine (NEJM).
A burgeoning specialty was given a name.
Its practitioners were called “hospitalists.”
And the rest, as they say, is history.
The Early Days
The idea of hospital-based physicians seems obvious in the rubric of medical history. There are now an estimated 44,000 hospitalists nationwide. The Society of Hospital Medicine (SHM) bills itself as the fastest-growing specialty in healthcare.
But it wasn’t always this way.
The novelty of hospital-based practitioners taking over care for some or all inpatient admissions wasn’t immediately embraced as a positive paradigm shift. Just ask Rob Bessler, MD, chief executive officer of Sound Physicians of Tacoma, Wash., among the largest hospitalist management groups (HMGs) in the country, with more than 2,200 hospitalists, ED physicians, intensivists, and post-acute-care physicians.
When the NEJM piece bestowing a name on hospitalists was published, Dr. Bessler was just finishing medical school at Case Western Reserve University School of Medicine in Cleveland. He started out in private practice and immediately saw issues in how hospitalized patients were treated.
“As an ED physician, nobody wanted to admit my patients as they were too busy in their office. I felt that those docs that were practicing in the hospital were using evidence that was 15 years old from when they finished their training,” he says. “I raised my hand to the hospital CEO to do things differently.”