Pushback against a new model came from multiple stakeholders. For every Dr. Bessler who was interested in a new way of doing things, there were physicians worried about turf battles.
“Doctors in practice around the county were afraid that these hospitalists would become mandatory,” says Dr. Goldman, who now is Dean of the Faculties of Health Sciences and Medicine, and chief executive at Columbia University Medical Center in New York City. “Some states actually had medical societies that passed resolutions saying they couldn’t become mandatory.”
In the early days, there were more critics than advocates. Critical-care doctors were one group that was, at best, ambivalent about the new model.
“The biggest brush fire in the early days was with critical care, which kind of surprised me,” Dr. Wachter says. “But ICU doctors had spent a huge amount of energy in the prior 20 years establishing their role. When hospitalists came out and often began to manage ICU cases—usually collaboratively with intensivists and partly filling a massive national shortage in intensivists—the leaders of the critical-care field felt like we were encroaching on their turf.”
Perhaps the biggest concerns to hospital medicine in the beginning came from the residents at UCSF. Initially, residents worried—some aloud—that hospitalists would become too controlling and “take away their delegated and graduated autonomy,” Dr. Goldman recalls.
At a meeting with the medical residents, “some actually said this could be awful and maybe they shouldn’t have come here,” he says, “maybe they should tell the internship applicants this would be a bad place to come because they wouldn’t have much autonomy, and I still remember asking a specific question to them. ‘Imagine your mother is admitted to the medical service at the teaching hospital back home where you live. What’s the first question you would ask?’
“And someone raised their hand and said, ‘Who’s the doctor?’
“And I said, ‘You mean who’s the intern?’
“They said, ‘No.’
“I said, ‘Or who’s the ward resident?’
“They said, ‘No.’
“And then, ‘Who is the attending?’
“And they said, ‘Yes.’
“So I said, ‘We have to have a good answer to that question when Mom gets admitted. Now that we’ve figured out how to get Mom the best care, let’s figure out how to make this the best possible teaching service.’”
Dr. Wachter and Dr. Goldman also prepared for some fears that didn’t pan out. One was the clout of specialists who might oppose the new model.
Some “specialists worried that if hospitalists were more knowledgeable than once-a-month-a-year attendings, and knew more about what was going on, they would be less likely to consult a specialist,” Dr. Goldman explains, adding he and Dr. Wachter thought that would be an unintended consequence of HM. “If there was a reduction in requested consults, that expertise would somehow be lost.”
Dr. Wachter and other early leaders also worried that patients, used to continuity of care with their primary-care doctors, would not take well to hospitalists. Would patients revolt against the idea of a new doctor seeing them every day?
“Yes, there were patients who felt that they wanted to see their regular doctor in the hospital. But for every one of them, there was another one or two that said this actually worked better,” Dr. Wachter says.
Community Views
Mary Jo Gorman, MD, MBA, MHM
Of course, the early success and adoption of the model in academic settings didn’t necessarily translate to community settings. Former SHM President Mary Jo Gorman, MD, MBA, MHM, who had just completed her MBA at Washington University in St. Louis when the NEJM article was published, wrote a business plan for her degree on implementing a hospitalist-style program at her institution, SSM DePaul Health Center, also in St. Louis.