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The Rise, Evolution of Hospital-Based Practice


“When the time is ripe for certain things, they appear at different places in the manner of violets coming to light in early spring.” —Farkas Bolyai, to his son, Janos, urging him to claim the invention of non-Euclidean geometry without delay.

In February, I was at a 20th anniversary party for the hospital medicine program from Park Nicollet Methodist Hospital in St Louis Park, Minn., listening to the original founders of the group giving speeches and telling stories of how their program began. For them, it all began at an internal medicine retreat in 1993, with ideas being tossed about on how to be more efficient and deliver better care for their patients. This was three years before Bob Wachter and Lee Goldman delivered their sounding board article to the New England Journal of Medicine describing some early programs and, more importantly, giving those new practitioners a name: “hospitalist.”1 The very same Park Nicollet program I was now helping to celebrate 20 years of success was called out in that article as one of four early groups in our country experimenting with hospitalists.

As I listened to the speeches, it occurred to me that the hospitalists standing up at the front of the room telling their war stories and reminiscing about the early days weren’t actually hospitalists at all back when they were thinking this new model up. They were primary care physicians struggling to meet the demands of the care environment at the time, coming up with unique solutions to the problems of the times without anyone telling them how or showing them the way. Back then, a few brave souls in the group stepped forward and said they would take on the majority of inpatient coverage, and suddenly, just like that, there were hospitalists, their given name still three years in the future, but hospitalists nevertheless.

Now this early program wasn’t the very first program, but it was part of a trend repeating at hospitals and within medical groups all over America. Slowly growing, slowly spreading, and under the radar, a social movement was afoot.

What Is a Social Movement?

Wikipedia says: Social movements are a type of group action. In sociology, a group action is a situation in which a large number of agents take action simultaneously in order to achieve a common goal; their actions are usually coordinated.

In those early days, the proto-hospitalists around the country were not coordinated or acting together, but that would come soon enough.

What were the factors that gave birth to this nascent social movement? Why was the same solution beginning to pop up all over the country in seemingly unconnected instances? The zeitgeist of the times had a lot to do with this, and it can all be boiled down to three things: time, money, and the “X” factor.

Back then, a few brave souls in the group stepped forward and said they would take on the majority of inpatient coverage, and suddenly, just like that, there were hospitalists, their given name still three years in the future, but hospitalists nevertheless.

In the late 1980s and early 90s, managed care was making inroads into healthcare as a struggling country tried to wrestle with exploding costs. Capitated managed care systems attempted to control costs and improve health by managing cases preferentially, using PCPs with a directive to limit resource utilization.2 They were the “gatekeepers” to more expensive care options like specialists and hospitalization. They were tasked with managing larger panels of patients, conducting shorter visits, and seeing more patients per day. In the other type of managed care of the time (non-capitated), physician practices, to stay in the game, were negotiating large discounts for their services. Then, to maintain their income, they had to see larger numbers of patients, either in the same amount of time or, as was usually the case, in time added to their workday.2

Just when the country was starting to count on primary care to be the lynchpin for the new healthcare model, medical students were turning away from primary care in record numbers. Internal-medicine matches were near all-time lows. PCPs in practice were facing growing time and money crunches, and the medical students they were counting on to help out were choosing other fields. The cavalry of new doctors needed to bolster the ranks of those already struggling to keep up simply wasn’t coming.

Finally, unassigned care for hospitalized patients, which had always been a responsibility of local doctors, had frequently been a condition of hospital privileging, and was often seen by the doctors as a way to give back to their hospital and community, was now something that added even more time, work, and financial pressure to their growing burdens.

So, these doctors, just like the doctors in the Park Nicollet Medical Group, began to brainstorm new ways to improve efficiency and see if they could get on top of the changes happening around them. One such idea was to create rounder systems. These systems would have each doctor in the practice take a week away from clinic and care for all of the practice’s patients in the hospital. This way, only one doctor would have to spend time away from those ever-busier clinic practices during the week. By giving up the continuity of the individual rounder and trading it for the continuity of the group, these groups gained efficiencies for everyone in the practice. This was the first small, but critical, step toward hospital medicine. It would have been hard to get to hospitalists without PCPs taking that first mental leap.

Often, it was one or more of these rounders who decided, for various reasons—boredom with ambulatory care, dislike of the more frantic pace of clinic, or simply a realization that they enjoyed or excelled at hospital care—that maybe they would just take on all of the hospital care for their group. This is what happened at Park Nicollet, and what started happening all across the country. The tinder was assembled and stacked, ready for something else to happen.

The Spark

Word of these new types of models and practices began to spread and was even talked about inside the pages of some journals. It took a few years, but somebody noticed and finally put it all together into an article that was published in the most famous medical journal in the world. In that 1996 New England Journal of Medicine article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” Wachter and Goldman gave a name to the strange creatures willingly giving up half of what they had been trained to do and devoting all their time to an inpatient practice.1 “Hospitalists,” they called them, and when the rest of the country read that article, the movement was no longer under the radar; it had a name. The spark had been ignited. What would become the fastest growing medical specialty in history was ready to take off.

But a spark needs more than tinder to truly ignite. Fuel and oxygen are necessary to give it life.

I’ll talk about that in my next column…

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.


  1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. New Engl J Med. 1996;335(7):514-517.
  2. Dugdale DC, Epstein R, Pantilat SZ. Time and the patient-physician relationship. J Gen Intern Med. 1999;14(Suppl 1):S34-S40.

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