There was a time in the early days of the hospitalist field that my colleagues and I wondered whether the pediatric portion of the field was here to stay. At the first few gatherings of the Society of Hospital Medicine (SHM; then called the National Association of Inpatient Physicians), we organized a pediatric track, but only a few people showed up. One lonely pediatric hospitalist served on the SHM board—he constantly had to remind us to pay attention to the pediatric perspective, and frequently apologized for being a nag. While the early leaders of the hospitalist field were committed to integrating pediatrics, there were times when we wondered whether our efforts were a well-intended act of futility.
Luckily, we persevered, and so did those early pediatric leaders. Today, the annual meeting of SHM has a robust pediatrics track, and so do the meetings of major pediatric specialty societies. There are thriving pediatric hospital medicine programs at virtually every major children's hospital in the United States, and also programs at large and even some not-so-large general hospitals. At my own hospital, UCSF Medical Center, pediatric hospitalists have major leadership roles not only within our children's hospital but also for the entire institution—in areas ranging from performance improvement to medical education to information technology. I am blessed to have several med-peds trained hospitalists in my own adult hospitalist group, and have been pleasantly surprised by the degree to which these individuals serve as bridges between the worlds of adult and pediatric care. While they have taken advances from the adult side to pediatrics, I have found that the arrow usually points in the other direction. For example, our pediatric hospitalists were early adopters of patient- and family-centered rounding, even scheduling appointments on rounds so that families could plan for the team's arrival, and nurses, case managers, and specialists could sometimes attend. We on the adult side have been awed by, and tried to learn from, this effort.
As long as I'm on the subject of leadership, it's worth noting that as of this writing, the top physician at the Centers for Medicare & Medicaid Services—the federal agency that funds more than 40% of US healthcare, to the tune of nearly $1 trillion per year—is Dr Patrick Conway, a pediatric hospitalist.
Since I co-wrote the first article on pediatric hospitalists,1 the growth and success of the field has been astonishing. As in adult medicine, this growth has been fueled by residency duty hour limitations in teaching hospitals, which created a substantial need for physician coverage on services previously supported by trainees. Another driver has been new collaborative arrangements, in which hospitalists have branched out from simply practicing general pediatrics in the hospital to co-managing all sorts of surgical patients, running procedure services, staffing rapid response teams, and serving as leaders in systems improvement work.
It is easy to look at this burgeoning and think that it all was preordained. But it was not. In the late 1990s and the early 2000s, hospitalists were seen by many as an untested innovation; many people were skeptical, even downright hostile, to the model. Given this, the growth in pediatric hospitalists (and leaders) is a testament to the quality and can-do spirit of the early entrants to the field. Former Disney CEO Michael Eisner once observed, “A brand is a living entity—and it is enriched or undermined cumulatively over time, the product of a thousand small gestures.” It is these gestures—making a tricky diagnosis, effectively leading a quality improvement initiative, being an enthusiastic participant in an interdisciplinary team, dealing sensitively with the family of a dying child—that have enhanced our field's brand, and this brand has been the engine fueling our unprecedented growth.
What's in store for the next several years? In the United States, the Affordable Care Act and other payment and structural changes are beginning to transform healthcare. With fewer patients lacking insurance, access has improved (although it is certainly not assured). We are witnessing a greater emphasis on population health and care across the continuum, and experiencing a mandate to improve not only quality and safety but also patient experience. In addition, the pressure to “bend the cost curve” is just beginning to accelerate. This pressure makes it essential that all hospitalists learn to practice in more cost-effective styles, and also assume leadership roles in helping their system identify and root out wasteful care. Federal incentives designed to move healthcare from an analog to a digital industry have been successful in driving the electronic health record adoption curve way up. All of us can expect to practice in a computerized environment for the rest of our careers.
What does all of this mean for pediatric hospitalists? The intense cost pressures will inevitably lead to the closure of some hospitals, but patients in the ones that remain will be even sicker. There will be a premium on delivering demonstrably high quality, safe, and satisfying care at the lowest possible cost. The amount of money available to support pediatric hospitalist programs will be constrained, and so hospitalist programs will be asked to unequivocally demonstrate their value to justify ongoing support. Under the threat of readmission penalties or in the face of new payment models such as Accountable Care Organizations or bundled payments, hospitals will no longer be able to act as silos; there will be much greater emphasis on seamless transitions. Computerized tools will become essential to clinical practice, and good clinical delivery systems will learn to take full advantage of the power of these tools while mitigating some of the awkward workflows and even the harms that are emerging. Just as physicians in small practices are migrating to larger groups, individual hospitals are forging new relationships with others. As hospitalist groups become larger and span multiple institutions, new opportunities but also daunting management challenges will be created.
The pace of change is unlike anything I have experienced in my 30 years of practice and administration. At a departmental meeting not too long ago, a department leader was discussing all of these changes: new regulations and payment systems, public reporting, information technology, and more. I could see the faculty—particularly my senior colleagues—squirming in their chairs. Finally one of our most respected cardiologists, an elder statesman in the department, grabbed the microphone.
“You know,” he said, “this could be worse.”
I found this a very surprising remark from a senior faculty member, particularly one who had clearly thrived under the old rules. But then he finished his thought.
While I still chuckle about this, I have to say that I completely disagree with the message. My own sentiments were well captured in an article by Don Berwick and Jonathan Finkelstein (both pediatricians) in 2010.2 They wrote,
We think that the anxiety, demoralization, and sense of loss of control that afflict all too many healthcare professionals today comes not from finding themselves to be participants in systems of care, but rather from finding themselves lacking the skills and knowledge to thrive as effective, proud, and well-oriented agents of change in those systems…. A physician equipped to help improve healthcare will be not demoralized, but optimistic; not helpless in the face of complexity, but empowered; not frightened by measurement, but made curious and more interested; not forced by culture to wear the mask of the lonely hero, but armed with confidence to make a better contribution to the whole.
This seems right to me. More importantly, when I find myself in a crowd of young pediatric hospitalists, I am quite certain that they see themselves—quite proudly—as leaders of a new, and improved, healthcare system. As well they should.
RM. The hospitalist movement and its implications for the care of hospitalized children. Pediatrics
JA. Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new “public interest”. Acad Med
2010; 85(9 Suppl):S56–65.