Even within general pediatrics, there has been a potential further fragmentation by site of care. Perhaps as a form of subspecialization, the hospitalist movement has grown steadily. This too has had and will continue to impact the health care delivery system. The term hospitalist was initially coined in 1996 by Wachter and Goldman.13 The number and demand for hospitalists has been increasing. A survey by the Society for Hospitalist Medicine found that in the last 2 years, there has been a 31% increase in the number of hospitalist groups.14 The impact of hospitalists on health care delivery has steadily evolved, thanks to evidence that suggests that hospitalists can improve efficiency and quality of care through their expertise. Hospitalists function both as inpatient generalists and in subspecialty settings—for example, on a cardiology or oncology inpatient unit. To this point, most have had core residency training in general pediatrics, some in the few existing hospitalist fellowship programs; and others have elected hospital-based practice after subspecialty training.The hospitalist movement adds new challenges to the health care delivery system.15, 16 It creates another point of potential fragmentation of care as a single hospitalist may not stay with an individual patient and family throughout their hospital stay. It is another place where there may be disconnect between the primary care provider and the hospital based provider. Yet on the positive side, hospitalist care may be more efficient and focused on the systems within the hospital and the quality and safety of care. The training of pediatric residents often prepares them for a hospitalist career, and the career is appealing to many because of the flexibility and control of work hours which appear to be important factors in the recent trends in specialty choice of medical students.17

Canada is the first case of the expansion of hospital medicine beyond the United States, and as of 2008, Canada had more than 100 hospital medicine programs.7 Currently, the estimated number of hospitalists in Canada has increased to ~3,000 (Colleen Savage, Administrator, Canadian SHM, personal communication, December 6, 2017). Yousef and Maslowski describe several drivers for the development of the hospitalist model, which are related to physicians, patients, and systems. Work–life balance and the desire for non-hospital work among primary care providers (PCPs) were leading physician factors. Two major patient-related factors were the increasing age and complexity of patients and the increasing number of “unattached” patients. Unattached patients are those who either do not have a PCP or their PCP does not have admitting hospital privileges. System drivers included PCP shortages, reduction in resident duty hours, higher need for health system efficiency, and cost reduction. Further, increasing health system complexity led to PCPs withdrawing from hospital care.7

All in all, the study by Davis et al strengthens the casethat the use of hospitalists improves inpatient efficiencywithout compromising quality or patient satisfaction.The paper is also an interesting case study that debunkssome myths and increases the sophistication and accu-racy of our perceptions of the nation’s fastest growingspecialty

Five years ago, we described a burgeoning model of care in the United States, in which a new breed of physicians, whom we dubbed "hospitalists," provide inpatient care in place of primary care physicians or academic 1-month-per-year attendings.1 We cited numerous forces fomenting this change, including cost pressures on hospitals, physician groups, and managed care organizations; the increased acuity of hospitalized patients and the accelerated pace of their hospitalizations; the time pressures on primary care physicians in the office; the decreasing inpatient volumes of most primary physicians; and the evidence that practice makes perfect in other medical fields. We predicted that the hospitalist movement would grow and ultimately become a, if not the, dominant model for inpatient care in the United States. Finally, we argued that judgments regarding the hospitalist model should be informed by data on cost, quality, education, and patient satisfaction. Our original article generated several negative responses,2-4 largely focused on the purposeful discontinuity in care introduced by the hospitalist model. Later, concerns were raised when a few managed care organizations attempted to mandate the use of hospitalists.5-7 Several medical societies mounted vigorous opposition to mandatory hospitalists, including the National Association of Inpatient Physicians (NAIP), the hospitalists' newly established professional society. Since then, attempts to create mandatory programs by managed care organizations have become unusual,8 and physicians and their societies have increasingly accepted voluntary hospitalist systems.9-11 This acceptance is reflected in the remarkable growth in the hospitalist model over the past several years. By 1999, 65% of internists had hospitalists in their community and 28% reported using them for inpatient care.10 The referral rate was even higher (62%) among primary care physicians in California.11 There are hospitalist programs at many prestigious US hospitals (BOX 1). In its first 3 years, NAIP has grown to more than 2300 members. A recent analysis projected an ultimate US hospitalist workforce of about 19 000 (up from 5000 presently), which would make it comparable in size to cardiology.19

In summary, hospitalists are an important innovation in the delivery ofinpatient care. They appear to reduce costs without compromising qualityorsatisfaction. Further research would assist health plans, hospitals, and medi-cal groups in determining which types of hospitalist interventions are mosteffective and which patients are most likely to benefit from this innovation.Additional research would also enhance knowledge of the characteristicsofhospitalists that enable them to reduce resource use. Researchers shouldusethe strongest feasible research designs to maximize their ability to drawcausalinferences regarding the impact of hospitalists. In addition, more studies ofnonteaching hospitalists are needed to improve the generalizability of findingsto the settings in which most persons in the United States are hospitalized.

In most hospitals, hospitalists typically manage only patients admittedtogeneral medical wards. These are patients who are hospitalized for a medicalcondition, such as persons with acute myocardial infarction, angina, asthma,bronchiolitis, cancer, congestive heart failure, gastroenteritis, infection, pneu-monia, or seizures. Hospitalists may also manage patients in critical carewards in which patients are not managed by intensivists (i.e., physiciansspe-cializing in critical care). Obstetric, psychiatric, and surgical patients are usu-ally managed by physicians in those specialties.Physicians sharply disagree as to the merits of hospitalists. Advocatesassert that hospitalists improve efficiency because they can monitor patientsmore closely and respond more quickly to changes in their condition(Schroeder and Schapiro 1999; Sox 1999). Some advocates maintain that theuse of hospitalists may improve productivity in outpatient care as well,because primary care physicians no longer need to leave the office to visithos-pitalized patients (Wachter and Goldman 1996). In addition, advocatesbelieve that quality of care may improve because hospitalists have more expe-rience in managing inpatient care (Wachter and Goldman 1996).Critics counter that hospitalists may compromise patient care and physi-cian satisfaction. Some critics assert that the lack of continuity between inpa-tient and outpatient care may lead to the loss of valuable information aboutthe patient’s condition, prior medical history, values, and family and socialcircumstances (Schroeder and Schapiro 1999; Wachter 2002). Others are con-cerned that hospitalists may use medical technologies more aggressively(Schroeder and Schapiro 1998). Critics also maintain that patients may not feelcomfortable having their hospital care managed by a physician with whomthey do not have a prior relationship (Sox 1999). In addition, some criticsarguethat limiting primary care physicians to outpatient practice threatens theirprofessional identify and denies them an important source of professionalsatisfaction (Brown 1998; Schroeder and Schapiro 1999; Sox 1999).

patient’s care during the hospital stay. The use of hospitalists represents a dra-matic break with tradition, because U.S. physicians have typically managedtheir patients in both outpatient and inpatient settings.Hospitalist programs were initially established in markets with high ratesof enrollment in health maintenance organizations (HMOs). The first hospi-talist program was established in 1994 by the Park Nicollet Clinic, a large,multisite, multispecialty medical group located in the Minneapolis–St.Paul,Minnesota metropolitan area (Freese 1999, 350). Hospitals owned by KaiserPermanente Northern California, one of the largest HMOs in the UnitedStates, began using hospitalists in 1995 (Craig et al. 1999, 356). Teaching hospi-tals in Boston, San Francisco, and other markets soon implemented similarini-tiatives under which faculty hospitalists led hospitalist teams that includedresidents and medical students (Brown et al. 1999; Wachter et al. 1998).The use of hospitalists has spread rapidly in the ensuing years. Sixty-fivepercent of respondents to a national survey of internists conducted in 1999reported that hospitalist services were available in their communities (Auer-bach et al. 2000). More than 3,000 U.S. physicians belong to the National Asso-ciation of Inpatient Physicians, an association of hospitalists (Wachter2002, 689).Physicians may serve as hospitalists on either a part-time or full-time basis.In some cases, primary care physicians in a medical group take turns manag-ing one another’s hospitalized patients. When physicians rotate into thehospitalist role, they remain in the hospital throughout the day to monitorpatients’ conditions, to adjust treatment plans, and to order diagnostictestsand specialty consultations as needed. In other cases, hospitals or medicalgroups hire physicians to provide inpatient care exclusively. This modelrep-resents an advance over the rotation model, because physicians in the hospi-talist role spend more time in the hospital, which increases their expertise inmanaging inpatient care and communicating with office-based primary carephysicians (Wachter 1998, 2002).In the United States, the use of hospitalists is usually voluntary. SomeHMOs require primary care physicians to use hospitalists, but most have cho-sen not to do so because many physicians object to such mandates (Wachter2002). Most mandatory programs that exist today are in university-affiliatedteaching hospitals in which faculty in certain departments have decided to usehospitalists to manage all of their admissions.

The development of the hospitalist role is one of the most noteworthy inno-vations in the management of hospitalized patients in the United States.Under this new model, a primary care physician “hands off” a patient he orshe admits to the hospital to a hospitalist physician who is responsible for the

Hospitalists need to continue to take C-suite positions at hospitals and policy roles at think tanks and governmental agencies. They need to continue to master technology, clinical care, and the ever-growing importance of where those two intersect. Most of all, the field can’t get lazy. Otherwise, the “better mousetrap” of HM might one day be replaced by the next group of physicians willing to work harder to implement their great idea. “If we continue to be the vanguard of innovation, the vanguard of making the system work better than it ever has before,” Dr. Wachter says, “the field that creates new models of care, that integrates technology in new ways, and that has this can-do attitude and optimism, then the sky is the limit.”

“It doesn’t just help make hospitalists work better. It makes nursing better. It makes surgeons better. It makes pharmacy better.”

In the last 20 years, HM and technology have drastically changed the hospital landscape. But was HM pushed along by generational advances in computing power, smart devices in the shape of phones and tablets, and the software that powered those machines? Or was technology spurred on by having people it could serve directly in the hospital, as opposed to the traditionally fragmented system that preceded HM? “Bob [Wachter] and others used to joke that the only people that actually understand the computer system are the hospitalists,” Dr. Goldman notes. “Chicken or the egg, right?” adds Dr. Merlino of Press Ganey. “Technology is an enabler that helps providers deliver better care. I think healthcare quality in general has been helped by both.

“This has all been an economic move,” she says. “People sort of forget that, I think. It was discovered by some of the HMOs on the West Coast, and it was really not the HMOs, it was the medical groups that were taking risks—economic risks for their group of patients—that figured out if they sent … primary-care people to the hospital and they assigned them on a rotation of a week at a time, that they can bring down the LOS in the hospital. “That meant more money in their own pockets because the medical group was taking the risk.” Once hospitalists set up practice in a hospital, C-suite administrators quickly saw them gaining patient share and began realizing that they could be partners. “They woke up one day, and just like that, they pay attention to how many cases the orthopedist does,” she says. “[They said], ‘Oh, Dr. Smith did 10 cases last week, he did 10 cases this week, then he did no cases or he did two cases. … They started to come to the hospitalists and say, ‘Look, you’re controlling X% of my patients a day. We’re having a length of stay problem; we’re having an early-discharge problem.’ Whatever it was, they were looking for partners to try to solve these issues.” And when hospitalists grew in number again as the model continued to take hold and blossom as an effective care-delivery method, hospitalists again were turned to as partners. “Once you get to that point, that you’re seeing enough patients and you’re enough of a movement,” Dr. Gorman says, “you get asked to be on the pharmacy committee and this committee, and chairman of the medical staff, and all those sort of things, and those evolve over time.”

Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston. “At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”

“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”

“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”

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

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

“My first exposure to hospital medicine was through Drs. Chris Landrigan and Vinny Chiang as an intern in Boston. I was impressed by their clinical mastery and teaching. I then did my first research project with Chris, which led to a publication in Pediatrics. I had previously thought about intensive care or emergency medicine for fellowship, but I was excited about the general nature, growth opportunity, and ability to drive health system change in hospital medicine. I think that growth and ability to drive health system change in hospital medicine has grown exponentially since I finished residency, so the field has more than lived up to its potential and has more room to grow in terms of impact.”

“I’ve been continually surprised at the growth of the field and SHM. My view has evolved from ‘Is this for real?’ to ‘How can hospital medicine make healthcare better for patients on a broad scale?’ The latter view has gone through iterations. We witnessed HM make hospitals more efficient, then we saw hospitalists drive safer, less harmful care. Most recently, hospitalists are embarking on deep change through alternative payment models like bundled payments. In terms of SHM, we endeavored to keep a ‘big tent’ since the many flavors of hospitalists all are united by a deep conviction to make hospitals safer, kinder, and higher-functioning places for the people inhabiting them—patients, caregivers, healthcare professionals. I’m humbled and gratified that we have been able to keep SHM a viable home for all hospitalists after 20 years.”

“I think the future of hospitalists is actually outside of the hospital and helping to keep patients healthy. Hospitalists are really good at taking care of the most sick, complex patients who are at the highest risk of healthcare utilization. While hospitalists predominantly do this for patients in the hospital, hospitalists are starting to play a larger role in post-acute care and trying to target interventions to improve health for high-risk patients. Not surprisingly, we are starting to see extensivist models, including Comprehensive Care Physicians, grow out of existing hospitalist groups.”

“As I was finishing my residency in the mid 1990s, I told folks I wanted to find a job ‘only doing inpatient medicine.’ People laughed at me. Within five years, hospitalist medicine was developing on the East Coast, and people were no longer laughing. … Hospitalists will be at the center of this brave new world [of episodic care] since they assist in the liaising between patient, PCP, specialist, and acute-care provider. It is incumbent upon us to help explain things in a manner easily understood by the patient and to be committed to high-quality care with an eye for value and cost containment.”

“The hospitalist movement has been a remarkable success. I heard of it from my friend Bob Wachter and since then have learned much from him and many others. … Hospitalists have and will continue to play a key role in improving patient safety, quality, patient experience, value, and healthcare equity. SHM has taken a leadership role to help ensure hospitalists have the skills and resources to do this.”

“The emergence of the field of hospital medicine has been one of the most important developments for quality of care in hospitals over the past 20 years. Taking full advantage of this opportunity will require the field to broaden its focus from one that primarily emphasizes the care of patients while they are hospitalized to one that encompasses patients’ full trajectories through the continuum of care. To realize their full potential as quality improvement leaders, hospitalists will need to position themselves as experts in health system quality and safety. Specifically, they will need to take ownership of the vital processes of effectively communicating across transitions of care.”