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Robert M. Wachter, MD.

Caption: Robert M. Wachter, MD

In 1996, Robert Wachter, MD, and his colleague Lee Goldman, MD, coined the term "hospitalist" in an article they authored for the New England Journal of Medicine.

At the time, Wachter was pretty sure he had discovered a significant trend. But he had no idea he had helped to identify what would become the fastest growing specialty in the history of medicine.

Wachter, a prominent academic physician on the faculty of University of California-San Francisco, is a national leader in the fields of patient safety and quality. He is also a prolific author and blogger. ACPE members will get the opportunity to see him in person when he delivers the keynote speech for the 2014 ACPE Annual Meeting in Chicago, April 25-29.

Wachter's talk is called "If Every Instinct in Health Care is Wrong, then the Opposite Must be Right: Changing our Practice in a Value- Driven World." It's a riff on a classic Seinfeld episode, in which Jerry convinces George to try the opposite of his every instinct.

ACPE sat down with Wachter to find out more about the message he'll be bringing to the Annual Meeting, as well as his concerns about the health care system and his views on the current state of the hospitalist movement. His comments have been edited for length.

The title of your talk is certainly intriguing. Can you describe how you came up with this theme?

It struck me that physicians are under increasing pressure to do exactly the opposite of the way we were trained. We were taught to think the most important thing was the brilliance and the technical skill of the doctor and not at all about the importance of systems of care or teamwork. We were told to focus on the patient like a laser, not so much on populations of patients and how to optimize care for group's of patients.

It's an interesting part of the evolutionary curve of medicine, where you have these extraordinarily well-trained individuals who are schooled and socialized to think about their work in a certain way who are basically being told that it's all wrong. I want to highlight the areas where that's probably right but also give voice to the lament that many physicians have, which is that there were some good things. It's not like I was a terrible doctor 10 years ago. I generally did good things for my patients, and they generally did okay. And this pressure to do exactly the opposite may take us too far in a different direction. The right answer, like most complicated questions in life, will turn out to be somewhere in the middle. There are some areas where we do need to think differently about what we do. But also, it will be important to reflect on the core values that still are quite relevant in today's world.

So what are some of those core values?

The intense focus on the patient as a person. To me, that's very important even as we try to balance this new imperative to think about populations of patients. When you're in the exam room with the patient, telling them about their new diagnosis of cancer or the surgery you have to do on them, you don't want them believing you're distracted by thinking about what you are going to do for these 100,000 patients in your ACO. I believe quite strongly in the importance of systems and teamwork. But the risk is we may forget that the skill and knowledge and commitment of the individual physician still matters quite a bit. I'll highlight a few areas where that's particularly crucial, and the main ones are related to technical skill and diagnostic reasoning, where all of the pressures to think in a more system-like way don't get at the issue of making sure your doctor is smart enough to make the right diagnosis and has the technical skill to do the procedure safely and correctly. The bottom line is, and this is no shock to anyone, medicine is a complex field and the answer is usually 'and' rather than 'or.' Yes, we need better systems, yes we need a population focus, yes we need a new payment system, but let's not forget about some of the old things we used to pay a lot of attention to because some of them had a lot of merit to them.

The same can be said for physician leaders, who may not see as many individual patients as regular clinicians, but still feel the pull between focusing on patients and creating new systems of care.

It's equal if not more relevant to people in leadership positions because they're the ones who have to figure out how to create a culture and a structure in which we effectively walk on this tightrope. Their delivery system is saying to them, get the docs to pay more attention to populations and yet don't let them lose focus on the fact that there's a scared person in their office. Get the docs to be better team players and think about organizing systems of care, yet we don't want to turn them into automatons or create a level of learned helplessness where they believe they have no role because it's all taken care of by the system. Those are real risks. We hear that all the time from physicians who say, 'I've become a cog in a machine.'

I spent a year in the United Kingdom, and I went there expecting to love the National Health Service because it really is a national system of care and everybody has insurance. But I was also struck by the degree to which the management is very top down and the individual physician doesn't think he or she can change things all that much because they're part of this big bureaucracy. That's the job of physician leaders: How do we get the best of both worlds? How do we practice in a much more systematic way in better-functioning teams, to think about populations of patients without causing everybody to forget about what was good and noble about the Marcus Welbys of the world. Marcus Welby was not a bad doctor. He didn't have a computer, he didn't think much about teamwork, but there were certain things he did for his patients that we have patients lamenting today because they're being lost.

Part of the reason why the message is important is that when someone who spent years training and then practicing in the old model is told 'everything you've learned and everything you think is wrong,' their instinct is to get up on their hind legs and fight it. Whereas if the message is, there are certain new competencies and new perspectives that are really going to be important to meet a set of goals we now have as a health care industry, that's easier to swallow. It creates much more engagement among physicians. It's not just marketing--it happens to be truth.

You've spent a lot of time observing and writing about the health care system. What do you feel are the biggest challenges today?

I'm afraid the most pressing one is the cost. The costs of health care are really going to bankrupt our country. I'm a big believer that safety needs to be improved and care needs to be better integrated and all that stuff, but if we can't get a handle on the cost, the rest of it may not matter. I think we will be in dire straits as a profession and as a society. Of course, once you say that, you haven't made life any simpler. There are a hundred different things that need to happen in order to get a handle on the cost.

I think the most striking trend that I've been amazed by, but hasn't been emphasized sufficiently, is the degree to which we are very rapidly transforming from an analog into a digital industry. We spent a very long time--decades and decades--waiting for computerization to happen in medicine. Really, over the course of about four or five years, because of the federal incentives, we have flipped a switch and gone from a non computerized industry to a completely computerized one, at least in most big hospitals and most big doctors' offices. I've just signed a book contract to write about this, about how it is changing everything. Not in the ways that people are generally talking about--how wonderful it is and getting rid of doctors' terrible handwriting. But how it is transforming the way doctors and patients talk to each other, the way doctors and doctors talk to each other.

Everywhere you look, you see how it is massively transforming workflow and relationships - and not all for the better. We really didn't appreciate the degree to which the computer systems really change everything about the sociology of medicine and the way we think and communicate. We need to be much more thoughtful about it or there are going to be all these unanticipated consequences--very spiffy computers but the doctors and the patients both hate it.

So what can be done to correct this?

The ultimate solution may be another technology. Some combination of voice recognition and Google Glass. But we didn't give this any thought; we just put in the computers. In the first line of the book, I make it very clear that I'm not a Luddite. I love my iPhone and I love my iPad. I believe that we have to computerize health care, no question about it. But we have to do it with our eyes open.

You are often referred to as the academic father of the hospitalist movement. What do you see when you look at the movement today?

The biggest and most obvious change is unprecedented growth. The next time I coin a term, remind me to trademark it. I'd be on my yacht right now (laughs).

I noticed that this was happening, and I began hearing about it in lots of different places when I wrote the article for the New England Journal. I thought it was going to be big, but I didn't anticipate it would be the fastest growing specialty in the history of medicine. I kind of got a sense I was on to something when the article came out and I started getting calls from hospital leaders who were saying, 'We want to do this, show us how.' Of course, I had no idea, but I winged it. But more importantly, I started getting calls from docs from various parts of the country who were saying, 'I've been doing this job for five years and I thought I was the only one in the country.' No one realized there was a megatrend going on. That was very exciting to be a part of the early, heady years of something that you knew was going to grow big.

I think the most exciting part of it for me was that the timing couldn't have been better to create a new specialty of generalists who would manage all sorts of different patients as well as interact with surgeons and ER docs and primary care docs in this complex ecosystem we call the hospital in the late '90s. As the new pressures on medicine began to grow, it became quite logical that we needed a new kind of doctor.

Any system is only as good as the way it's structured and the quality of the people. But by and large, I'm very proud of it, and I think on average it has made care better.

ACPE Participates in American Medical Student Association Conference

For the second year, ACPE will have a significant presence at the American Medical Student Association (AMSA) annual conference.

Taped interviews will allow pre-med and medical school students to voice their thoughts, concerns and opinions regarding the industry. Their remarks will be uploaded for viewing on LeadDoc (, ACPE's online journal for medical students, residents and early careerists.

ACPE will also lead four educational sessions at the conference, focusing on personality types as identified by the Myers-Briggs Type Indicator assessment, ethical behavior in health care leadership and a forum for female medical students seeking to solidify their leadership identities.

The commitment to work closely with AMSA is reflective of ACPE's strategic goal to support physicians throughout all stages of their careers and is just one example of the inroads the organization has made. The number of LeadDoc subscribers continues to grow--it has now surpassed 1,100--and the numbers of submissions from residents and early careerists is also steadily increasing.

ACPE continues to provide professional development opportunities to the resident community as well, collaborating with individual residency programs as well as membership organizations.

ACPE Forms New Partnership with ACP to Create Leadership Academy

ACPE is pleased to partner with the American College of Physicians to deliver the American College of Physicians Leadership Academy.

The ACP Leadership Academy provides early career internists with training and resources to prepare them for leadership roles in the healthcare setting by offering a variety of options for formal leadership development. The Leadership Academy will kick off with a two-day face-to- face program taught by ACPE faculty at ACP's Internal Medicine 2014 in Orlando, FL, April 10-12.

Highlights of the Academy include ACPE courses on Strategic Thinking, Financial Decision Making, Managing Physician Performance, Marketing, Negotiation and Ethical Challenges. ACP members can roll their course work into a master's program in medical management from one of ACPE's four prestigious universities or be used toward becoming a Certified Physician Executive (CPE). ACP Certificates of Completion are given for completed courses.

ACPE welcomes this partnership with ACP and is pleased to give internists the leadership skills necessary to navigate the health care system of tomorrow.

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Title Annotation:services and management
Author:Wachter, Robert M.
Publication:Physician Executive
Article Type:Interview
Geographic Code:1USA
Date:Mar 1, 2014
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