She didn’t use the terms “hospital medicine” or “hospitalist.” They didn’t exist yet.
She was writing about what she was witnessing in her hospital: primary-care physicians (PCPs) who no longer wanted to visit hospitals because there simply wasn’t enough to do and make the trip worthwhile. In addition, she saw many of those same doctors no longer wanting to pick up ED calls.
So she pitched a model (same as Dr. Wachter was doing on the West Coast) of having someone in the hospital dedicated to inpatients as their sole responsibility. A “vocal minority” rebelled.
“It was a battlefield,” she recounts. “No other way to describe it. There were multiple hospital committees that reviewed it. There were letters of protest to the hospitals.”
Two major complaints emerged early on, Dr. Gorman says. Number one was the notion that hospitalists were enablers, allowing PCPs to shirk their long-established duty of shepherding their patients’ care through the walls of their local hospital. Number two, ironically, was the opposite: PCPs who didn’t want to cede control of their patients also moonlit taking ED calls that could generate patients for their own practice.
“It didn’t shock me at the time because I had already made major changes in our intensive-care unit at the hospital, which were unpopular,” Dr. Gorman says, adding all of the changes were good for patients and produced “fabulous” results. “But it was new. And it was different. And people don’t like to change the status quo.”
Perfect Timing
The seeds of hospitalist practice were planted before the NEJM article published. But the NEJM audience was nationwide, even beyond American borders. And the playing field was set up particularly well, says James Merlino, MD, president and chief medical officer of Press Ganey’s strategic consulting division. In 1996, the AIDS crisis was full-blown and a particular burden in inpatient wards.
“It was before we really had any of these amazing drugs that have turned HIV/AIDS into a quiet disease as opposed to a killer,” Dr. Merlino says. “At least 50% of the patients on the floors that we were rotating through [then] had patients, unfortunately, who were succumbing to AIDS.”
Dr. Merlino says he’s proud of the specialists who rotated through the hospital rooms of AIDS patients. But so many disparate doctors with no “quarterback” to manage the process holistically meant consistency in treatment was generally lacking.
Tejal Gandhi, MD, MPH, CPPS
“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”
Dr. Merlino has an even blunter viewpoint: “I reflect back on that and think today about what the hospitalist model brings to us; it is an amazing transformation on how the hospitalist model really delivers.”
That type of optimism permeated nascent hospitalist groups. But it was time to start proving the anecdotal stories. Nearly two years to the day after the Wachter/Goldman paper published, a team led by Herbert Diamond, MD, published “The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital” in the Annals of Internal Medicine.1 It was among the first reports to show evidence that hospitalists improved care.
Results published in that article showed median length of stay (LOS) decreased to 5.01 days from 6.01 days (P<0.001). It showed median cost of care decreased to $3,552 from $4,139 (P<0.001), and the 14-day readmission rate decreased to 4.64 readmissions per 100 admissions from 9.9 per 100 (P<0.001). In the comparison groups, LOS decreased, but both cost of care and readmission rates increased.