History of Pediatric Hospital Medicine

For much of the 20th century, pediatricians often cared for children in both the office and the hospital. A physician might round before clinic, return after outpatient visits, and resume care after discharge. Pediatric training was similarly grounded in hospitals, where residents learned to manage acute illness under the supervision of inpatient faculty.¹

By the final decades of the century, that model was becoming harder to sustain. Outpatient practices were busier, hospitalized patients required more immediate physician availability, and hospitals assumed greater responsibility for quality, safety, and resident supervision. At the same time, advances in pediatrics were changing the characteristics of children admitted to the hospital.

Pediatric hospital medicine developed at the intersection of those changes.

Roberts, Fisher, and Rauch have previously described the organizational history of pediatric hospital medicine, from the hospitalist movement through formal subspecialty certification.² The history can also be understood through the changing needs of hospitalized children and the systems required to care for them.

A New Model for Inpatient Pediatrics

In 1996, Robert Wachter, MD, MHM,  and Lee Goldman, MD, introduced the term “hospitalist” to describe physicians who devoted a substantial portion of their practice to hospitalized patients. They predicted the model would grow as inpatient care became more specialized and outpatient demands made continuous hospital availability difficult.³

Paul Bellet, MD, and Dr. Wachter considered the implications for pediatrics in 1999. They described potential advantages, including greater availability, inpatient experience, efficiency, and resident supervision, while recognizing concerns about disrupting the continuity traditionally provided by community pediatricians.⁴

Pediatric hospitalists ultimately developed a complementary role. The primary pediatrician retained longitudinal knowledge of the child and family, while the hospitalist managed the acute hospitalization, coordinated inpatient teams, and returned care to the community.

Dedicated inpatient pediatric practice predated the word hospitalist, but the term gave an identity to clinicians concentrating their clinical, educational, and scholarly work in hospitals.

At first, the rationale centered on organizing physician work. Hospitalists were present for reassessment, resident supervision, and communication with families and consultants. Over time, the work expanded.

The Changing Hospitalized Child

Advances in neonatal care, critical care, surgery, oncology, transplantation, nutrition, and respiratory support allowed increasing numbers of children with serious illnesses to survive. Many lived with multisystem chronic conditions and depended on feeding tubes, central venous catheters, tracheostomies, ventilators, oxygen, or implanted devices. Others received care from numerous specialists, therapists, home nurses, schools, equipment companies, and public agencies.

National data reflected this transformation. Simon and colleagues found that from 1997 through 2006, children with complex chronic conditions represented increasing proportions of pediatric admissions, hospital days, and charges.⁵ Burns and colleagues similarly reported a growing prevalence of medically complex children in U.S. hospitals.⁶ Later work demonstrated that much of the increase in inpatient resource use was concentrated among children with multiple chronic conditions.⁷

Their hospitalizations involved more than the diagnosis prompting admission. A child with fever might also have intestinal failure, immunodeficiency, limited vascular access, previous resistant infections, and a highly individualized home regimen. A child admitted with respiratory distress might require decisions about airway clearance, ventilator settings, home nursing, equipment, transportation, and caregiver training.

The hospitalist needed to understand the acute illness and the child’s baseline condition while reconciling recommendations from several specialists. A treatment appropriate for one problem could complicate another. A plan that was medically sound might not be feasible at home.

In 2005, Srivastava, Stone, and Murphy described the hospitalist’s role in caring for medically complex children, emphasizing coordination, discharge planning, and partnership with families.⁸ Their article reflected the field’s broadening responsibilities: excellent inpatient care required treating disease while maintaining a view of the whole child.

The Growing Work of Coordination

Children with medical complexity made fragmented care especially visible, but the same problems affected patients throughout the hospital. Communication failures, medication errors, inconsistent practices, delayed recognition of deterioration, and poorly coordinated transitions increasingly came to be understood as failures of healthcare systems rather than isolated individual mistakes.

The Institute of Medicine’s “To Err Is Human” and “Crossing the Quality Chasm” accelerated this change in thinking. The reports challenged hospitals to reduce harm, improve reliability, and redesign care around patients’ needs.^9,10

Pediatric hospitalists encountered these systems every day. Their continuous presence allowed them to recognize recurring patterns across admissions: unnecessary variation in bronchiolitis treatment, inconsistent handoffs, delayed medications, avoidable testing, or gaps between the inpatient plan and the realities of home.

Hospitalists increasingly assumed roles in quality improvement, patient safety, clinical pathway development, utilization stewardship, resident education, surgical co-management, newborn care, and hospital operations. These activities grew from problems encountered in daily care.

Discharge planning became one of the clearest examples. A child could be physiologically ready to leave while the systems needed for a safe discharge remained incomplete. Medications might require authorization. Feeding supplies or respiratory equipment might not have arrived. Home nursing could be unavailable. Several caregivers might require training. Follow-up appointments and transportation needed to be coordinated.

The hospitalist’s work extended beyond treating illness to helping the surrounding system function well enough for a safe return home.

Families as Members of the Care Team

Pediatrics has always required clinicians to care for children within the context of their families. Medical complexity made family expertise even more important.

Caregivers of children dependent on medical technology may learn to operate ventilators, troubleshoot feeding pumps, administer intravenous medications, manage seizure plans, and recognize subtle changes from baseline. They may coordinate multiple specialists across healthcare systems that do not reliably communicate.

When a child is hospitalized, the caregiver may be the person who knows which treatments have worked before, which findings are truly new, and which proposed plans are practical at home. Family participation in rounds and decisions became more than a courtesy; caregiver knowledge was often necessary for accurate assessment and safe care.

This changed communication in pediatric hospitals. Families were not simply recipients of a completed plan. They became participants in developing it.

It also exposed the burdens carried outside the hospital. A discharge plan could appear complete in the medical record yet remain unrealistic for a family without home nursing, reliable transportation, paid leave, stable housing, or access to equipment. Caring for hospitalized children increasingly required attention to the conditions in which recovery would continue.

Building a Field

As pediatric hospital medicine grew, it developed the infrastructure of an established field.

Professional groups within the American Academy of Pediatrics, Society of Hospital Medicine, and Academic Pediatric Association created communities for previously isolated clinicians. Multicenter research networks allowed hospitalists to study common inpatient conditions across institutions, while quality collaboratives supported efforts to reduce unwarranted variation.

The pediatric hospital medicine core competencies, published in 2010, provided a framework for education and professional development. They addressed clinical conditions and procedures as well as communication, transitions, safety, quality improvement, teaching, and healthcare systems.¹¹ Their breadth reflected expanding responsibilities.

The American Academy of Pediatrics’ “Guiding Principles for Pediatric Hospital Medicine Programs” similarly described roles in clinical care, education, quality, safety, scholarship, and leadership.¹² Hospital Pediatrics provided a dedicated scholarly home for the field.

Fellowship programs later formalized advanced training, and the proposal for subspecialty recognition argued that pediatric hospital medicine had developed a distinct scope of practice and body of knowledge.¹³ The American Board of Medical Specialties subsequently recognized pediatric hospital medicine, and the American Board of Pediatrics administered its first certifying examination in 2019.²

Certification did not create pediatric hospital medicine. It acknowledged a field that had already changed substantially.

The Work Ahead

Today, pediatric hospitalists practice in academic medical centers, community hospitals, newborn nurseries, and regional institutions. Their work varies by setting and may include general inpatient care, complex care, surgical co-management, newborn medicine, quality improvement, education, and hospital leadership.

Formal recognition did not resolve the specialty’s challenges. Pediatric inpatient services have become increasingly regionalized. Behavioral health needs consume growing hospital resources. Inequities affect access, communication, discharge readiness, and the availability of home services. Workforce planning must account for specialized children’s hospitals and communities where hospitalists may provide the only available inpatient pediatric expertise.¹⁴

Children with medical complexity remain central to many of these challenges. More are living at home, with technologies and care plans that once existed only in intensive care units. Their hospitalizations cross acute care, chronic disease management, rehabilitation, social services, and community support.

Pediatric hospital medicine has often been described as a specialty defined by where physicians practice. Its history suggests something broader. The field has increasingly been shaped by the children it serves and the systems required to care for them well.

What began as a model for consistent physician availability became a profession integrating acute care, family knowledge, multidisciplinary expertise, quality improvement, and transitions home. Children with medical complexity did not create pediatric hospital medicine, but their care helped reveal what the specialty could contribute.

The history of pediatric hospital medicine is also a history of modern pediatrics adapting to its own success. As more children survived serious and chronic conditions, inpatient care changed. Pediatric hospitalists changed with it. 

Dr. Hairston

Dr. Hairston is an assistant professor of pediatrics in the division of pediatric hospital medicine at the Johns Hopkins University School of Medicine and a pediatric hospitalist at Johns Hopkins Children’s Center, both in Baltimore. He also serves on the editorial board of The Hospitalist.

References

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