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

Hospital medicine is the fastest growing specialty in the United States. In 2016, this specialty celebrated the 20th anniversary of the term “hospitalist”.1,2 Current estimates put the number of hospitalists at over 50,000.2 Generalist training including internal medicine, family medicine, medicine-pediatrics, and pediatrics formed the basis of most hospitalist programs during the initial 15 years of the specialty; however, today, several subspecialties are involved in hospitalist programs.3 An interesting aspect of the rapid expansion of hospital medicine is the growth of the field beyond the United States. The Society of Hospital Medicine (SHM) reports more than 15,000 North American members and an additional 126 international hospitalist members (Ethan Gray, Vice President of Membership, SHM, personal communication, August 30, 2017).4 Although the health care systems, regulations, and cultural norms in these nations differ, some of the reasons for the development of hospital medicine internationally are the same as in the United States.1,5 In this article, we focus on adult hospital medicine. We describe some of the drivers for expansion of this field beyond the United States and the challenges faced by these groups. We also speculate on the future of hospital medicine internationally and discuss the role that the United States could play in the continued growth of this specialty beyond its borders.

Hospital medicine is the fastest growing specialty in the United States. An interesting aspect of the rapid expansion of hospital medicine is the expansion of the field beyond the United States. Although the health care systems, regulations, and cultural norms in these nations differ, there are striking similarities in the profession’s development.

Of 25 responding early-career hospitalists, 23 (92%) rated the SCA role as useful to very useful, 20 (80%) reported interactions with the SCA led to at least one change in their diagnostic approach, and 13 (52%) reported calling fewer subspecialty consults as a result of guidance from the SCA. In response to questions about professional development, 18 (72%) felt more comfortable as an independent physician following their interactions with the SCA, and 19 (76%) thought the interactions improved the quality of care they delivered.

o better understand the impact and generalizability of clinical coaching, a larger, longitudinal study is required to look at patient and provider outcomes in detail. Further refinement of the SCA role to meet faculty needs is needed and could include faculty development.

For most physicians, the period of official apprenticeship ends with the completion of residency or fellowship, yet the acquisition of expertise requires ongoing opportunities to practice a given skill and obtain structured feedback on one’s performance.

he hospitalist movement, first described in 1996(1), has grown from several hundred practitionersto more than 4,000 today. The movement’s2-year-old professional association, the National Associ-ation of Inpatient Physicians, enjoys a membership ofmore than 1,500, and is probably the fastest growingmedical society in the United States

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

Without question, much of the growth of the hospital-ist movement has been generated by hospitals anxious tocut inpatient costs. However, the Davis study’s findingsregarding the diverse motivations for these programs aretypical. For example, in the Mississippi hospital, the mo-tivations included a desire to improve outpatient effi-ciency (and ambulatory care efficiency did increase by56%), a motivation shared by many other large multispe-cialty groups. The availability of primary care providersto their outpatients probably improved as well (althoughthese results were not reported). Freese (14) found that asimilar desire to make certain that primary care providerswere predictably available to their office patients was amajor driver of the hospitalist program at the Park Nicol-let clinic, and the program did lead to improved outpa-tient satisfaction. Other common motivations includethe desire to improve physician availability to inpatients,to have hospitalists care for unassigned patients admittedthrough the emergency department, to invest physiciansin hospital quality improvement activities, and to allowprimary care practitioners to have more predictable life-styles (15)

Davis and col-leagues (3) provide useful new data that enhance our un-derstanding of the effects of hospitalists on health sys-tems. In their study of a voluntary hospitalist system at alarge rural nonteaching hospital in Mississippi, theyfound that patients cared for by hospitalists had adjustedhospital stays that were 25% shorter, and costs that were12% less, than patients cared for by nonhospitalist inter-nists. For patients in the highest severity group, these sav-ings were even greater. Annualized, the authors extrapo-late that the hospitalists would have saved $2.5 millionhad they cared for all of the internists’ patients. As withprior studies that found similar reductions in resourceuse (4 –7), these substantial savings were achieved with-out diminishing quality or patient satisfaction. Nor wasthere evidence of cost shifting: hospitalists’ patients wereno less likely to be discharged to home (instead of anotherinstitution such as a skilled nursing facility) than werepatients of primary care internists. We can now state withconsiderable confidence that hospitalists markedly de-crease inpatient costs and lengths of stay with no compro-mise in quality or patient satisfaction.

In summary, the hospitalist model is growing rapidly and appears to have achieved its minimum goal of improving efficiency without adverse effects on quality, teaching, or patient satisfaction. Ongoing larger studies should help determine whether preliminary data suggesting an improvement in some of these outcomes, such as quality and teaching, can be confirmed. The dominant questions no longer relate to whether the hospitalist model is here to stay—even skeptics concede that it is—but rather, the myriad organizational, financial, ethical, educational, and clinical issues that arise with a major change in the organization of US hospital care. We hope that these issues will continue to be settled on the basis of rigorous analysis of the evidence.

The hospitalist movement mirrors the health care trend toward ever-increasing specialization. However, hospitalists are fundamentally generalist physicians who provide and coordinate inpatient care, often aided by myriad subspecialists. How can a generalist be a specialist? Specialties in medicine are traditionally defined by organ (eg, cardiology), disease (oncology), population (pediatrics), or procedure/technology (surgery or radiology). The hospitalist, on the other hand, is a "site-defined generalist specialist" (similar to emergency medicine physicians or critical care specialists), caring for patients with a wide array of organ derangements, illnesses, and ages within a specific location.45 Accordingly, the hospitalist should not be seen as a retreat from generalism and its emphasis on coordination and integration9,77 but rather as an affirmation of these values and as a surrogate for the primary care physician in the hospital. The competing pressures resulting from the distance between office and hospital as well as the requirement of around-the-clock availability make the hospital-based generalist a logical evolution. Hospital medicine has already satisfied many of the requirements of a specialty. A large and enthusiastic group of practitioners identify themselves not according to their training background but as hospitalists. The NAIP is almost certainly the fastest growing physician society in the United States. The field hosts several successful meetings each year and has its own clinical textbook.78 To establish themselves as members of a recognized medical specialty, hospitalists must identify a core skill set or body of knowledge and obtain the approval of credentialing organizations. Advocates of specialty status for hospitalists should be encouraged by the history of 2 other site-defined inpatient specialties: emergency medicine and critical care medicine. Like these relatively young fields, it seems probable that hospitalists will ultimately define a unique set of skills and competencies that will distinguish their field. The identification of practice-training mismatches (Table 2) represents an important first step. Credentialing organizations deliver the final stamp of approval on new specialties by creating a board certification or added qualification. Most new fields quickly agitate for such status, their motivation both practical and visceral. However, for unique reasons, few hospitalists are pressing this point. Many physicians—hospitalists and nonhospitalists—worry that if a credentialing body (such as the American Boards of Internal Medicine or Pediatrics) created a hospital medicine credential, health maintenance organizations might require that physicians possess this credential to care for inpatients. This would be unacceptable to many primary care physicians, who would be excluded from the hospital despite their desire and competence to continue practicing there. For this reason, we expect neither NAIP nor the relevant boards to promote separate credentials in the near future. Nevertheless, as evolutionary forces lead to specialized training, some formal specialty designation may emerge.79

Medical groups, managed care organizations, or, most commonly, hospitals often find it attractive to support hospitalist programs. If hospitalists improve quality, shorten lengths of stay, and decrease costs while satisfying patients and other providers, the return on these organizations' investments in hospitalist programs is highly favorable. Over time, it will be critical that professional fee reimbursement rates be adjusted so that a sustainable hospitalist workload creates sufficient income to support a full salary.

Most early hospitalist groups formed in community hospitals. Over the past 5 years, many academic medical centers have adopted hospitalist models for inpatient care and teaching. Beyond the legitimacy that this expansion into academia affords the movement,68 the 2 greatest effects are on education and research.69 Academic hospitalists are emerging as core teachers of inpatient medicine. For example, at the University of California, San Francisco, 15 faculty hospitalists now staff about two thirds of ward-attending months and all medical consult months. Preliminary evidence indicates that resident teaching evaluations of hospitalists are significantly higher than those of our highly selected nonhospitalist 1-month-per-year ward attendings (K. Hauer, MD, written communication, December 2001), an effect seen elsewhere as well.32 The impact on medical student education has not been empirically studied; we recently described several potential advantages and disadvantages of hospitalists in student education.70 The development of hospitalist groups in academic medical centers may have its most far-reaching effects in defining a new research agenda.69 No longer limiting their research to the impact of the hospitalist model itself, academic hospitalists are now applying the tools of health services and outcomes research, ethics, and clinical epidemiology to critical inpatient issues, such as preventing nosocomial infections,71 end-of-life care,72 and hospital quality measurement.46 Over time, hospitalists are likely to become increasingly engaged in patient-centered research, clinical trials, and genetic epidemiology (BOX 2), taking advantage of their onsite availability and large numbers of potential subjects. Box 2. Clinical Research That Might Be Undertaken by Academic Hospitalists, Beginning With Those Areas Already Under Study 1. Studies of the efficiency, cost, and quality of hospitalist services. 2. Studies of new approaches to systems issues that arise in and around the hospital (eg, medical errors, pain management, palliative care, inpatient-outpatient communication). 3. Clinical trials (single site or multicenter) involving diseases that hospitalists commonly encounter (eg, pneumonia, sepsis, gastrointestinal bleeding, heart failure, thromboembolism, asthma). 4. Multicenter trials involving interventions with smaller expected benefits or less common diseases. 5. Multicenter studies of the etiology of disease and disease susceptibility (eg, genetic analyses of why some patients become severely ill with pneumococcal pneumonia while exposed family members do not).

Collaborative hospitalist-intensivist models will become increasingly important if the projected national shortage of critical care physicians materializes.67 Finally, in many systems hospitalists are moving beyond the traditional role of medical consultant to a new role as physician-of-record for nonmedical inpatients with medical comorbidities. Just as with the primary care physician whose office obligations make inpatient management and discharge planning difficult during daylight hours, the surgeon is similarly obligated in the operating room. In the 1997 NAIP survey, nearly half the hospitalists had added this comanagement role to their repertoire.53 To date, there are no data regarding the impact of hospitalists on the care of surgical patients, making this an important area for future research.

Until recently, there were no specific training programs for hospitalists. Thus, hospitalists have developed from diverse training backgrounds. The 1997 NAIP survey indicated that 90% of hospitalists were internists: 50% general internists and 40% medical subspecialists. Of this latter group, half were pulmonologists and/or critical care specialists.53 The 1999 survey found that the generalist fraction had grown to 75%, while subspecialists fell to 15%.54 Our impression is that early programs often took advantage of the onsite presence of pulmonary physicians, intensivists, and other subspecialists. The recent data indicate that the maturing field is attracting more general internists who view it as a long-term career option. In both surveys, about 3% to 5% of hospitalists were family physicians and another 5% to 7% were pediatricians.58 There are now several early training programs for hospitalists, including a residency track and fellowship program at the University of California, San Francisco.59 In developing training modules for hospitalists, researchers have been guided by a survey in which practicing hospitalists rated areas of importance to their practice and sufficiency of their training (Table 2).60 Interestingly, hospitalists thought that clinical skills (ie, managing heart failure, inserting central lines, interpreting electrocardiograms) were very important and had been well taught during residency. Conversely, they cited major educational deficits in their training regarding communication skills, end-of-life care, quality improvement and patient safety, medical economics, care of surgical patients, and postacute care. These topics are likely to form the core of future hospitalist curricula for both trainees and practicing physicians. Although graduating residents raised concerns about underpreparedeness in some of the same areas, such as in nursing home care and quality improvement, in a recent national survey,61 other educational deficits cited by hospitalists (eg, palliative care) were not raised to the same extent by these graduating residents. Moreover, the illustrative cases and settings used to train future hospitalists would undoubtedly be different than those used to educate outpatient generalists, even within the same general content area, such as pain management or patient safety.

Initial resistance to the hospitalist movement among physicians often focused on the unavoidable discontinuity in care created by the model and the potential loss of information across the hospital threshold.45,49-52 Effective hospitalist programs have created mechanisms to mitigate the impact of this discontinuity, including calling primary care physicians on admission and discharge, faxing daily progress notes, and encouraging primary care physicians to visit or call their hospitalized patients. Though some concerns about information transfer linger, 2 recent surveys suggest that most physicians now accept the hospitalist model. In a national telephone survey of 400 internists, 51% (204) thought hospitalists might provide better care and 46% (184) thought patients might get more cost-effective care. Although 73% were concerned about the impact of hospitalists on continuity, physicians with hospitalists in their community were more approving.10 In a survey of 524 California primary care physicians, physicians perceived hospitalists as increasing (41%) or not changing (44%) the overall quality of care and most (55%) thought that hospitalists increase inpatient efficiency.11 In both surveys, primary care physicians stated their belief that patients generally preferred to be cared for in the hospital by their regular physician. Surveys of both generalists and specialists at Park Nicollet showed high levels of physician satisfaction several years after the implementation of a hospitalist program.28

A major early concern was that patients accustomed to having their primary physician as their inpatient attending would not accept hospitalists.45 In general, however, surveys of patients who were cared for by hospitalists show high levels of satisfaction, no lower than that of similar patients cared for by their own primary physicians28,31,32 or by traditional academic ward attendings.18,21 We have postulated that patients may be willing to trade off the familiarity of their regular physician for the availability of the hospitalist.45

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.”

At a time of once-in-a-generation reform to healthcare in this country, the leaders of HM can’t afford to rest on their laurels, says Dr. Goldman. Three years ago, he wrote a paper for the Journal of Hospital Medicine titled “An Intellectual Agenda for Hospitalists.” In short, Dr. Goldman would like to see hospitalists move more into advancing science themselves rather than implementing the scientific discoveries of others. He cautions anyone against taking that as criticism of the field. “If hospitalists are going to be the people who implement what other people have found, they run the risk of being the ones who make sure everybody gets perioperative beta-blockers even if they don’t really work,” he says. “If you want to take it to the illogical extreme, you could have people who were experts in how most efficiently to do bloodletting. “The future for hospitalists, if they’re going to get to the next level—I think they can and will—is that they have to be in the discovery zone as well as the implementation zone.” Dr. Wachter says it’s about staying ahead of the curve. For 20 years, the field has been on the cutting edge of how hospitals treat patients. To grow even more, it will be crucial to keep that focus.

And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty. “It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”

Dr. Gandhi, who was finishing her second year of residency at Duke Medical Center in Raleigh, N.C., when the NEJM paper was published, sees the acuity of patients getting worse in the coming years as America rapidly ages. Baby boomers will start turning 80 in the next decade, and longer life spans translate to increasing medical problems that will often require hospitalization.

So what now? For all the talk of SHM’s success, HM’s positive impacts, and the specialty’s rocket growth trajectory, the work isn’t done, industry leaders say. Hospitalists are not just working toward a more valuable delivery of care, they’re also increasingly viewed as leaders of projects all around the hospital because, well, they are always there, according to Dr. Gandhi. “Hospitalists really are a leader in the hospital around quality and safety issues because they are there on the wards all the time,” she says. “They really have an interest in being the physician champions around various initiatives, so [in my hospital tenures] I partnered with many of my hospitalist colleagues on ways to improve care, such as test-result management, medication reconciliation, and similar efforts. We often would establish multidisciplinary committees to work on things, and almost always there was a hospitalist who was chairing or co-chairing or participating very actively in that group.”

And earlier this year, CMS announced that by this time next year hospitalists would be assigned their own specialty designation code. SHM’s Public Policy Committee lobbied for the move for more than two years.

By 2007, SHM had launched Project BOOST (Better Outcomes by Optimizing Safe Transitions), an award-winning mentored-implementation program to reduce LOS, adverse events, and unnecessary 30-day readmissions. Other mentored-implementation programs followed. The Glycemic Control Mentored Implementation (GCMI) program focuses on preventing hypoglycemia, while the Venous Thromboembolism Prevention Collaborative (VTE PC) seeks to give practical assistance on how to reduce blood clots via a VTE prevention program

In 2012, SHM earned the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, thanks to its mentored-implementation programs. SHM was the first professional society to earn the award, bestowed by the National Quality Forum (NQF) and The Joint Commission.

By 2003, the term “hospitalist” had become ubiquitous enough that NAIP was renamed the Society of Hospital Medicine

John Nelson, MD, MHM, and Winthrop Whitcomb, MD, MHM, founded the National Association of Inpatient Physicians (NAIP) a year after the NEJM paper, they promoted and held a special session at UCSF’s first “Management of the Hospitalized Patient” conference in April 1997

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future. Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care. BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge. <img class="file media-element file-medstat-image-flush-right" height="220" width="220" alt="Dr. Weiner" typeof="foaf:Image" src="https://www.the-hospitalist.org/sites/default/files/styles/medium/public/images/weinerweb.jpg" title="" />Dr. Weiner “The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon. “The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says. Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge. And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task. “There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits. “The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.” Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Dr. Bessler says that as HMGs continued to focus on improving quality and lowering costs, they had little choice but to get involved in activities outside the hospital. “We got into post-acute medicines because there was an abyss in quality,” he says. “We were accountable to send patients out, and there was nobody to send them to. Or the quality of the facilities was terrible, or the docs or clinicians weren’t going to see those patients regularly. That’s how we got into solving post-acute.”

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

Aside from NPs and PAs, another extension of HM has been the gravitation in recent years of hospitalists into post-acute-care settings, including skilled-nursing facilities (SNFs), long-term care facilities, post-discharge clinics, and patient-centered homes.

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

“Any time when nurse practitioners and other providers get together, there is always this challenge of professions,” he says. “You’re doing this or you’re doing that, and once you get people who understand what the capabilities are past the title name and what you can do, it’s just amazing.”

Recent State of Hospital Medicine surveys showed that 83% of hospitalist groups are utilizing NPs and PAs, and SHM earlier this year added Tracy Cardin, ACNP-BC, SFHM, as its first non-physician voting board member

He and other SHM officials have pushed hospitalists for the past few years to formalize their HIT duties by seeing if they would qualify to take the exam for board certification in medical informatics, which was created in 2013 by the American Board of Medical Specialties (ABMS). Between certification of that skill set and working more with technology vendors and others to improve HIT, Dr. Rogers sees HM being able to help reform much of the current technology woes in just a few years.

“To me, this is the new frontier,” Dr. Wachter says. “If our defining mantra as a field is, ‘How do we make care better for patients, and how do we create a better system?’ … well, I don’t see how you say that without really owning the issue of informatics.”

SHM’s Information Technology Committee, believes that hospitalists have to take ownership of health information technology (HIT) in their own buildings.

Dr. Bessler of Sound Physicians notes that advances in technology have come with their hurdles as well. Take the oft-maligned world of electronic medical records (EMRs). “EMRs are great for data, but they’re not workflow solutions,” Dr. Bessler says. “They don’t tell you what do next.” So Sound Physicians created its own technology platform, dubbed Sound Connect, that interacts with in-place EMRs at hospitals across the country. The in-house system takes the functional documentation of EMRs and overlays productivity protocols, Dr. Bessler says. “It allows us to run a standard workflow and drive reproducible results and put meaningful data in the hands of the docs on a daily basis in the way that an EMR is just not set up to do,” he adds. Technology will continue “to be instrumental, of course, but I think the key thing is interoperability, which plenty has been written on, so we’re not unique in that. The more the public demands and the clinicians demand … the better patient care will be. I think the concept of EMR companies not being easy to work with has to end.”

“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.”

2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.

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.”

Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.

“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.”

The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.

Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing. The impact was profound, and safety initiatives became a focal point of hospitals.

“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

“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 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

“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.”

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.

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?

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.”

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

“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.”

But those efforts were few and far between. And they were nearly all in the community setting. No one had tried to staff inpatient services with committed generalists in an academic setting.

The model Dr. Wachter settled on—internal medicine physicians who practice solely in the hospital—wasn’t entirely novel. He recalled an American College of Physicians (ACP) presentation at 7 a.m. on a Sunday in 1995, the sort of session most conventioneers choose sleep over. Also, some doctors nationwide, in Minnesota and Arizona, for instance, were hospital-based as healthcare maintenance organizations (HMOs) struggled to make care more efficient and less costly to provide.

edical specialization dates back at least to the time of Galen. For most of medicine’s history, however, the boundaries of medical fields have been based on factors such as patient age (pediatrics and geriatrics), ana-tomical and physiological systems (ophthalmology and gastroenter-ology), and the physician’s tool-set (radiology and surgery). Hos-pital medicine, by contrast, is defined by the location in which care is delivered. Whether such delineation is a good or bad sign for physicians, patients, hospitals, and society hinges on how we understand the interests and as-pirations of each of these groups

Others are implementing bedside ultra-sonography for procedures and diagnosis, pioneering methods of making rounds more patient- and family-centric, implementing unit-based leadership teams, or applying process-improvement ap-proaches such as the Toyota Pro-duction System to inpatient care.

Many are developing early-warning pro-tocols in which electronic health record data are used to identify patients who are at risk for prob-lems such as sepsis or falls.

Although we continue to be-lieve that the hospitalist model is the best guarantor of high-quality, efficient inpatient care, it’s clear that today’s pressures require in-novative approaches around this core. In addition to following pa-tients in post–acute care facili-ties, another modified approach is to have a subgroup of hospital-ists function as “comprehensivist” physicians who care for a small panel of the highest-risk, most frequently admitted outpatients and remain involved when hospi-talization is required. This model aims to blend the advantages of the hospitalist model for the vast majority (>95%) of inpatients with the potential advantages of conti-nuity for a small group of patients who are admitted repeatedly.

mentation of quality- and systems-related initiatives. Hospitalists have been slow to pursue sub-stantial inquiry into discovery re-lated to the common inpatient diseases they see or to lead multi-center trials of new diagnostic or therapeutic approaches. This defi-ciency limits hospitalists’ credibil-ity in academia and the advance-ment of the field.

Another problematic, though not unanticipated, consequence of the use of hospitalists has been a diminished role for specialists and researchers on teaching ser-vices. Because specialists are far less likely than they once were to serve as inpatient attendings, trainees have less contact with them and less exposure to basic and translational science

Many hospitalists have added value as local leaders in quality improvement, safety, and innova-tion, but some have functioned more as shift workers. For exam-ple, many community hospital-ists have a 7-days-on, 7-days-off schedule that focuses mainly on high-volume clinical work and sends an unspoken but clear mes-sage that, at the end of an inten-sive clinical “on” stint, one is “off ” and uninvolved. Our impression is that hospitalist programs pro-vide more value when hospital-ists’ inpatient assignments (clini-cal “systole”) are complemented by a systems-oriented “diastole,” dur-ing which clinical activity is limit-ed but they contribute to key in-stitutional programs. Productive diastole is more likely when hos-pitalists have strong leadership, a robust professional-development curriculum, and a mutual hospi-tal–hospitalist commitment to adding value during specified and structured nonclinical time.

Despite the hospitalist field’s unprecedented growth, there have been challenges. The model is based on the premise that the benefits of inpatient specializa-tion and full-time hospital pres-ence outweigh the disadvantages of a purposeful discontinuity of care. Although hospitalists have been leaders in developing sys-tems (e.g., handoff protocols and post-discharge phone calls to pa-tients) to mitigate harm from dis-continuity, it remains the model’s Achilles’ heel.

Finally, financial penalties for readmis-sions have led many hospitalists to staff post–acute care facilities to improve coordination with col-leagues at acute care hospitals.

The field’s rapid growth has both ref lected and contributed to the evolution of clinical practice over the past two decades.

The discipline of hospital medicine grew out of the increasing complexity of patients requiring hospital care and the need for dedicated clinicians to oversee their management. The hospitalist model supplanted the traditional method of caring for hospitalized patients, which was often done by clinicians also seeing ambulatory patients or with other clinical obligations that limited their ability to provide the intensity of care often required by these patients. By focusing their practice on this specific group of patients, hospitalists gain specialized knowledge in managing very ill patients and are able to provide high-quality, evidence-based, and efficient patient and family-centered care in hospital settings.

In the academic setting especially, a premium will beplaced on clinical quality improvement, the develop-ment of practice guidelines, and outcomes research,not only to provide the physician with a creative out-let and a potential source of funding during thenonclinical months but also to give the academiccenter a practical research-and-development arm

on research and clinician-educators concentrating onclinical work and teaching. And the clinician-educa-tors may branch again, with some focusing on out-patients and others on inpatients. We also believethat the relation between quality and volume inthe performance of procedures may lead to anotherschism between medical specialists who primarily per-form procedures and those who do not

Given the parallel pressurefor funding research,32 one can envision fewer triplethreats in the future, with researchers concentrating

. The “triple threat” leader— skilled clinician, researcher, and educator — wasthe paradigm of exceptional faculty achievement (orfantasy) for more than a generation. Balancing aproductive research career with teaching and clinicalcare was easier when academic health centers wereless accountable for the quality and cost of clinicalcare than they are now.

As with intensiv-ists, a major challenge is to link the hospitalist rolesuccessfully with other activities.

Conversely, some traditional programs may develophospitalist tracks that emphasize acquisition of theskills most relevant to inpatient practice. If suchtracks are developed, it will be important not to re-duce training in ambulatory care too aggressively,since the competent hospitalist will need a full un-derstanding of what can — and cannot — be donein the outpatient setting

As with anymajor transition, the medical community must con-tinually reevaluate the new approach to ensure thatany possible discontinuity in care is outweighed byimproved clinical outcomes, lower costs, better edu-cation for physicians, and greater satisfaction on thepart of patients.

For house staff in internal medicine, the introduc-tion of hospitalists may mean a greater likelihood ofbeing supervised by attending physicians who arehighly skilled and experienced in providing inpatientcare. House staff have long enjoyed a certain amountof autonomy, because many of their faculty supervi-sors have been relatively unfamiliar with moderninpatient care. Such autonomy may be diminishedwith the new approach to inpatient care. Althoughthere is bound to be transitional pain, we believethat the potential for improved inpatient teachingwill more than compensate for it. Moreover, thischange will help answer public calls for closer andmore effective faculty oversight of house staff andstudents.34

Oneof the advantages of the hospitalist model is that itcreates a core group of faculty members whose in-patient work is more than a marginal activity andwho are thus committed to quality improvement inthe hospital.

The debate over the role of hospitalists is takingplace against the backdrop of the larger controversyover whether generalists or specialists should pro-vide care for relatively ill patients.11

As hospital stays become shorter and inpatientcare becomes more intensive, a greater premium willbe placed on the skill, experience, and availability ofphysicians caring for inpatients.

First, because of cost pressures,managed-care organizations will reward profession-als who can provide efficient care. In the outpatientsetting, the premium on efficiency requires that thephysician provide care for a large panel of patientsand be available in the office to see them promptlyas required. There is no greater barrier to efficiencyTin outpatient care than the need to go across thestreet (or even worse, across town) to the hospital tosee an unpredictable number of inpatients, some-times several times a day. There are parallel pressuresfor efficiency in the hospital. Since the inpatient set-ting involves the most intensive use of resources, itis the place where the ability to respond quickly tochanges in a patient’s condition and to use resourcesjudiciously will be most highly valued. This shouldprove to be the hospitalists’ forte.

We believe the hospitalist specialty will burgeonfor several reasons.

Equally pressing is the question of value, definedas the quality of care divided by its cost.10

As a result, we anticipate the rapid growth of anew breed of physicians we call “hospitalists” — spe-cialists in inpatient medicine — who will be respon-sible for managing the care of hospitalized patientsin the same way that primary care physicians are re-sponsible for managing the care of outpatients.

Unfortunately, this approach collides with the re-alities of managed care and its emphasis on efficien-cy.

Two of the principles underlying generalism,whether in the form of internal medicine, pediatrics,or family medicine, have been comprehensivenessand continuity.7,8 Ideally, the primary care physicianwould provide all aspects of care, ranging from pre-ventive care to the care of critically ill hospitalizedpatients. This approach, argued the purists, wouldresult in medical care that was more holistic, less frag-mented, and less expensive.9 To its proponents, thenotion was so attractive — the general internist ad-mits the patient to the hospital, directs the inpatientworkup, and arranges for a seamless transition backto the outpatient setting — that questioning it wouldhave seemed sacrilegious merely a few years ago

HE explosive growth of managed care has led toan increased role for general internists and otherprimary care physicians in the American health caresystem.

Polls show that doctors are trusted by the public more than politicians, which means it’s hard for public policy to shape the healthcare system unless medical associations sign off on it.

It’s estimated that unneeded or unproven medical procedures cost us billions each year.

Significant procedures are sometimes not nearly as effective as you might think. “In 2002, the New England Journal of Medicine published a landmark study where they found that this very common knee operation worked no better than a sham procedure in which a surgeon merely pretended to operate,” Patashnik says.

So many medical publications appear worldwide every day that it is no longer possible for an individual medical professional to keep up with the latest state of knowledge. In order to offer support and to encourage new medical research, EBM provides a toolbox of different methods. These tools can be divided into three categories:The first category includes methods that serve to create reliable new knowledge: Someone who would like to compare the advantages and disadvantages of different drugs, for example, will find suitable types of studies here.The second category involves methods that help to summarize the existing knowledge on a subject: They serve to find and select the previously published studies that are best able to answer a particular question. There are now networks of researchers that specialize in looking for the latest research findings and summarizing them to provide easily accessible information.The third category covers methods for presenting information to medical professionals and laypeople in a way that helps them to find, understand and make use of it.The main aim is always to find out what kind of care is most suitable for a particular patient – and how to incorporate their individual preferences and circumstances into the treatment decision.

An evidence-based approach also includes informing patients about the pros and cons of medical options so that they can actively be part of the decision.So making a treatment decision in accordance with EBM means basing it on the best available knowledge from clinical research and medical practice. A number of factors play an important role in the decision. As well as the type and severity of the health problem, these include the person's general life situation, personal values and opinions.

This is the purpose of evidence-based medicine (EBM): to provide healthcare professionals, patients and those close to them with up-to-date and scientifically proven information on the various medical options that are available to them. It can help to find out what sorts of advantages or disadvantages a treatment or test has, when people might benefit from it and whether it might also be harmful.EBM uses special methods that it has developed to find the highest quality evidence for the benefits of a specific medical intervention. This evidence can be found in conclusive scientific studies. EBM also plays a part in making sure that the research that is done can help patients to answer the most important questions. This means that studies look into both the benefits of a treatment as well as how it affects quality of life, for example.

Having initial medical discussions without the family and information filtering are common for LEP patients; filtering may be associated with poorer diagnosis comprehension. Experience with a hospitalized child is associated with increased comprehension among LEP parents.

“It’s about embracing the inscrutable nature of human interactions,” says Chang. Evidence-based medicine was a massive improvement over intuition-based medicine, he says, but it only covers traditionally quantifiable data, or those things that are easy to measure. But we’re now quantifying information that was considered qualitative a generation ago.

“Our biggest opportunity is leaning into that. It’s either embracing the qualitative nature of that and designing systems that can act just on the qualitative nature of their experience, or figuring how to quantitate some of those qualitative measures,” says Chang. “That’ll get us much further, because the real value in health care systems is in the human interactions. My relationship with you as a doctor and a patient is far more valuable than the evidence that some trial suggests.”

Duffy points to the increase in health care interactions online and adds that he would like to see a pervasive culture of in-person care as last resort. “If every organizational decision, technology decision, process decision — assuming all the payment stuff, that’s kind of ticket of entry, transpires — if you view in-person as last resort, that will help pull systems across the country to a more consumer-forward Uber-like experience,” he says

As with other forms of value-based health care, patient-centered care requires a shift in the way provider practices and health systems are designed, managed, and reimbursed. In keeping with the tenets of patient-centeredness, this shift neither happens in a vacuum, it driven by traditional hierarchies in which providers or clinicians are the lone authority. Everyone, from the parking valet and environmental services staff to c-suite members, are engaged in the process, which impacts hiring, training, leadership style, and organizational culture. Patient-centered care also represents a shift in the traditional roles of patients and their families from one of passive “order taker” to one of active “team member.” One of the country’s leading proponents of patient-centered care, Dr. James Rickert, has stated that one of the basic tenets of patient-centered care is that “patients know best how well their health providers are meeting their needs.” To that end, many providers are implementing patient satisfaction surveys, patient and family advisory councils, and focus groups, and using the resulting information to continuously improve the way health care facilities and provider practices are designed, managed, and maintained from both a physical and operational perspective so they become centered more on the individual person than on a checklist of services provided. As the popularity of patient- and family-centered health care increases, it is expected that patients will become more engaged and satisfied with the delivery of their care, and evidence of its clinical efficacy should continue to mount.

The concept of patient-centered care extends to the treatments and therapies clinicians provide. Not only are care plans customized, but medications are often customized as well. A patient’s individual genetics, metabolism, biomarkers, immune system, and other “signatures” can now be harnessed in many disease states — especially cancer — to create personalized medications and therapies, as well as companion diagnostics that help clinicians better predict the best drug for each patient.

Strict visiting hours and visitor restrictions are a thing of the past in a patient-centered care model. Patients are given the authority to identify who can visit and when. Family members (as defined by the patient and not limited to blood relations) are invited to visit during rounding and shift changes so they can be part of the care team, participating in discussions and care decisions. When not in the room with the patient, they are kept informed of their loved one’s progress through direct and timely updates. A patient-centered care hospital’s infrastructure encourages family collaboration through a home-like environment that not only meets the needs of the patient, but also meets the needs of family members. For example, maternity wards are being redesigned with family-friendly postpartum rooms that can accommodate the mom, new baby, and family members, who are encouraged to spend up to 24 hours a day together in the room to foster family bonding.

The primary goal and benefit of patient-centered care is to improve individual health outcomes, not just population health outcomes, although population outcomes may also improve. Not only do patients benefit, but providers and health care systems benefit as well, through: Improved satisfaction scores among patients and their families. Enhanced reputation of providers among health care consumers. Better morale and productivity among clinicians and ancillary staff. Improved resource allocation. Reduced expenses and increased financial margins throughout the continuum of care.

Patient- and family-centered care encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan. Most definitions of patient-centered care have several common elements that affect the way health systems and facilities are designed and managed, and the way care is delivered: The health care system’s mission, vision, values, leadership, and quality-improvement drivers are aligned to patient-centered goals. Care is collaborative, coordinated, and accessible. The right care is provided at the right time and the right place. Care focuses on physical comfort as well as emotional well-being. Patient and family preferences, values, cultural traditions, and socioeconomic conditions are respected. Patients and their families are an expected part of the care team and play a role in decisions at the patient and system level. The presence of family members in the care setting is encouraged and facilitated. Information is shared fully and in a timely manner so that patients and their family members can make informed decisions.

In patient-centered care, an individual’s specific health needs and desired health outcomes are the driving force behind all health care decisions and quality measurements. Patients are partners with their health care providers, and providers treat patients not only from a clinical perspective, but also from an emotional, mental, spiritual, social, and financial perspective.

Family-centered rounds (FCRs) can offer families the opportunity to participate in errorrecovery related to children’s medications

Experts suggest family engagement in care can improve safety for hospitalizedchildren

Poor health literacy is a silent and ubiquitous health care issue, and the field of neurosurgery is particularly prone to the consequent adverse effects. Failure to address low health literacy has several detrimental health and economic consequences, and numerous policies have been initiated to address these. Better facilitating patient understanding of neurosurgical disease, treatment options, and care surrounding the operative period may have a positive impact on the health care economy and ultimately achieve improved outcomes for patients.

Deyo et al. (8) demonstrated a reduction in the adverse impact of inadequate health literacy in the neurosurgical field. The impact of an interactive videodisc program that informs patients of their treatment options for back surgery on patient outcome and surgical choices was evaluated. The program helped facilitate decision making and ensured informed consent. It also reduced surgery rates for patients with herniated disks. The authors of this study also implemented the use of patient-oriented multimedia to augment comprehension and advocated a similar strategy for other clinicians. Further commitment is needed to put health literacy at the forefront of improving health care and reducing health expenditures, especially in neurosurgery.

Paasche-Orlow et al. (18) suggested 3 principles to ameliorate health literacy disparities. The first is to promote productive interactions. Clinicians need to develop better communication abilities and take appropriate measures to ensure adequate comprehension of health information. Educating youth and establishing health literacy standards in the educational system can help improve existing and future health literacy rates. Incorporating health literacy classes as a component of training for health professionals and in studies of preventive services can increase awareness among providers, facilitating better communication and quality of care (19). Additionally, transmitting complex ideas can be aided with the use of technology platforms. Yin et al. (25) investigated the plausibility of a pictogram-based intervention program to reduce medication administration errors. The authors found that when the intervention was used as part of medication counseling, there was a decrease in medication dosage errors compared with standard medication counseling.The second principle is concerned with addressing the organization of health care. Paasche-Orlow et al. advocated patient-centered care, streamlined access to health care, and incentives to promote collaboration to address the needs of the health illiterate population. The U.S. government created and enacted several major policies that address this principle to diminish the adverse effects of poor health literacy. The first is the Affordable Care Act, which stipulates that health plans and insurers must provide understandable and clear health information regarding coverage and benefits (11). Because most Americans receiving coverage through the new legislative act have limited health literacy, standardized information about health care would greatly assist these Americans in making better-informed health decisions (15). Another policy is the National Action Plan to Improve Health Literacy (22). This is the first plan of its kind to create health literacy goals for the entire country. It intends to provide all Americans with access to accurate health information, deliver patient-focused services, and support learning and skills that improve health. All of these acts and policies have the potential to improve 3 keys to health care: access, quality, and cost.The third principle from the study by Paasche-Orlaw et al. involves establishing an objective and sincere voice for better delivery of health information to the community. Individuals may have appropriate health literacy levels, but other personal or environmental factors can contribute to a lower understanding of vital health information. Ito (9) analyzed Vietnamese refugees who tested positive for inactive tuberculosis and their response to prophylactic tuberculosis treatment. Ito found that the immigrants were more hesitant to complete the medication regimen because the side effects were too “hot.” Instead, the immigrants preferred Asian herbal medications as they were considered “cooling.” Von Goeler et al. (23) investigated diabetes self-management among Puerto Rican adults with type 2 diabetes and found that the participants regularly self-monitored their blood glucose levels. However, they did not use that information to control their diabetes properly because of financial and social barriers such as competing family concerns. Situations such as these call for a voice, a cultural broker, who understands the environmental obstacles to comprehending and using health information fully.

Koh et al. (11) detailed a cycle of crisis care elaborating the nature of high medical costs, possibly resulting from fear and denial. First, an individual is in need of medical help, so he or she goes to a physician's office where the staff asks the individual to fill out a complex and confusing form. The physician examines the patient and explains the condition and treatment options using medical jargon. Numerous prescriptions, laboratory tests, and referrals are given without confirmation of the patient's comprehension. The staff sends the patient home with complicated instructions. Inevitably, the patient may consume medication incorrectly or miss follow-up appointments, and his or her condition worsens. Eventually, the patient presents to the emergency department, and the hospital staff develops a new treatment plan. Again, no one confirms the patient's understanding. When the patient is discharged, he or she is likely to get sick again and repeat the cycle (11)