“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.
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