The History of Pediatric Hospital Medicine in the United States, 1996-2019

In 1996, internists Robert Wachter, MD, and Lee Goldman, MD, MPH, coined the term “hospitalist” and predicted an “emerging role in the American health care system.”¹ Pediatrics was not far behind: In 1999, Dr Wachter joined Paul Bellet, MD, in authoring an article describing the movement within pediatrics.² An accompanying editorial, coauthored by a pediatric hospitalist and an office-based practitioner, attempted to answer which was “better” for a hospitalized child: A practitioner who knew the child and family or a hospitalist who might be more knowledgeable about the disease, its inpatient management, and how to get things done in the hospital?³ The authors could not answer which model was better for an individual child with an invested primary pediatrician, but concluded that hospitalists have the potential to improve care for all children in the hospital—the future promise of Pediatric Hospital Medicine (PHM). This article traces the growth of PHM from 1996 to the present, highlighting developments that fueled the hospital movement in general and PHM in particular (Table).

In the 7 years after the article by Drs Wachter and Goldman, a series of regulations fostered the adoption of hospitalists in teaching hospitals. The first was the reissuance in 1997 of Intermediary Letter 372, which specifies the requirements for attending physicians to bill Medicare.⁴ The common practice of jotting “agree with above” and cosigning resident notes was no longer sufficient: Attendings had to document that they personally provided services to patients beyond those of residents. As a demonstration of enforcement, records at the Hospital of the University of Pennsylvania in Philadelphia were audited, and a bill for $30 million for overpayments and penalties was issued.⁴ Teaching hospitals took notice and instituted mechanisms to assure compliance with IL-372, not limited to patients insured by Medicare. The obvious effect on faculty was the requirement of considerably more time and involvement in direct patient care.

Later in the 1990s, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new direction termed the Outcome Project, which led to two novel trainee competency domains: practice-based improvement and systems-based practice.⁵ The focus on quality improvement, patient safety, and systems was reinforced by two Institute of Medicine publications, To Err Is Human: Building a Safer Health System⁶ and Crossing the Quality Chasm: A New Health Care System for the 21st Century.⁷ Hospitalists had the opportunity to impact both patient care and the education of learners in two ways: Directly, by more actively participating in and closely supervising clinical care (per IL-372) and, indirectly, by improving hospital systems.

In 2003, the ACGME extended work hour restrictions implemented in New York State to the national level.⁸ The new requirements were intended to improve patient safety and increase trainee supervision, but also had the effect of reducing trainees’ clinical experience. While responses of teaching institutions varied, training program changes generated an increased role for hospitalists.⁹

These changes occurred on a backdrop of changing models of healthcare payment that provided incentive to shorten length of stay (LOS) and shift care from inpatient to ambulatory settings, which increased the acuity and complexity of hospitalized patients. The pressure to increase efficiency and decrease LOS affected faculty, residents, and practitioners in the community. Managing care of inpatients from a distance became more difficult; rounding more than once a day was often required and was disruptive and inefficient, particularly for community practitioners who might have only one or two patients in the hospital. Moreover, the hospital electronic medical record (EMR) became an additional barrier for many practitioners to continue to provide hospital-based care. Systems often differed from those used in their offices, and even when this was not the case, using and maintaining efficiency in the different components of the EMR was difficult. The conversion from paper to electronic documentation and ordering may have contributed to some practitioners relinquishing care of their patients to hospitalists.