Welcome to Wachter’s World

Photographs by Susan Merrell

Robert M. Wachter, M.D. ’83, an internist and hospitalist, thinks he doesn’t take himself too seriously. 

Some self-deprecating presentations bear him out.

At the national convention of the Society of Hospitalist Medicine last year, he donned a costume and wig, sat at a piano, and belted out his own words to the tune of Elton John’s “Your Song.” (“Sometime in the ’90s, / A new field was born, / Docs lived in the building / From nighttime ’til morn. / They called themselves ‘hospitalists’ — / Oh god, what a name! / But once they took over, / Nothing was the same.”) 

The audience of some 3,600 gave him a standing ovation. 

When he received the Perelman School of Medicine’s Distinguished Graduate Award in June, he spoke about how his own medical students gave him a comeuppance last year when he thought he’d shake them up a bit. 

“You folks,” he intoned to them, “are entering a profession that will be profoundly different from when I entered medical school because you will be under relentless, unremitting pres­sure to deliver care of the highest quality, the highest safety, the highest patient satisfaction, and the lowest cost.” 

Whereupon one of his charges raised his hand and said, “What exactly were you trying to do?”

He also recalled, three months into his own medical school career, meeting his first patient, at the Veterans Administration Hospital: “So I said to the patient, ‘Why are you here?’ and he said, ‘I have gout,’ and I said, ‘What’s that?’”

His alumni audience roared at both stories. 

 In his blog, Wachter’s World, he summed himself up by recalling his undergraduate stint (B.A. ’79) as the Penn Quaker, mascot of the University of Pennsylvania: “I needed to be funny, quirky, ungraceful, and utterly without shame,” he wrote, adding, “These skills have served me well through my subsequent career.”

The Other Side

Wachter does, however, take medicine seriously — “our sa­cred charge,” he called it when receiving the alumni award. He is one of the creators of the term hospitalist, giving impetus to a nascent movement that has been hailed as the fastest-grow­ing specialty in medical history. 

He edits two web sites for the Agency for Healthcare Research and Quality — AHRQ WebM&M, on confidentially reported medical errors, with commentary, and AHRQ PSNet, on pa­tient safety. 

He is a professor of medicine at the University of California at San Francisco, where he holds the Marc and Lynne Benioff Chair in Hospital Medicine, serves as associate department chair (and interim chair, as of July), and heads both the medical service at the UCSF Medical Center and the 60-plus-member Division of Hospital Medicine. 

He was the first elected president of the Society of Hospital Medicine (1999-2000) and chaired the American Board of In­ternal Medicine from 2012 to 2013.

For these efforts, most others take his work – and him – seriously as well. He has won the nation’s top honor in patient safety, the John M. Eisenberg Award, from the National Qual­ity Forum, which serves to improve health care, and the Joint Commission, the U.S. accrediting organization for health care. 

For seven years, Modern Healthcare magazine included him among the 50 most influential physician-executives in United States. In 2015, the magazine named him number one. A web site for health-care executives called him one of the “10 health-care bloggers we’re thankful for.” 

In retrospect, Wachter’s career looks coherent, but it took him a while to discover how to integrate his interests in patients, their care, health policy, systems thinking, and informatics. Happenstance often led him. Even he laughs and apologizes when interviewing job candidates and asking about their five-year plans. He never had one.

Doctor and Systems

Growing up on Long Island, N.Y., Wachter knew his parents would be proud if he became a physician, but he worried about that motivation. And despite volunteering at a local hospital, he felt he hardly knew what it was to be a doctor. His parents, who socialized with doctors, admired them but also saw through them: “My dad would get dressed up for a cocktail party, and he’d look perfectly normal and about to go out, but he’d have his garage-door opener on his belt” — fitting in with, yet laughing at, the doctors, who had beepers.

As an undergraduate, Wachter took the science courses that medical schools required, but his intellectual heart was in his major, political science. He was drawn to “politics and the way systems worked and people thought and organizations did their thing.” 

He credits John Eisenberg, M.D., G.M.E. ’77, for showing him how to weave these interests together. Eisenberg taught and practiced at Penn Med from 1975 to 1992, founded and led the Division of General Internal Medicine, and later headed AHRQ. In his work on physician practice patterns, patient safety, and health-care effectiveness, Wachter explains, he saw a way “to being a really good doctor and thinking about the way the system works.”

Even so, Wachter’s career started in a routine way. He vis­ited UCSF for a residency on a whim (Eastern Airlines had a $600 fly-anywhere-in-the-U.S.-for-a-month promotion); liked the more casual style of the West Coast; resisted the pull from his mother, “who thought even Philly was a little far”; and, in his fellowship period as a Robert Wood Johnson Clinical Scholar, began to think of fundable research projects and publications.

With a résumé that included peer-reviewed articles on the treatment of AIDS patients, he was appointed program direc­tor of the Sixth International Conference on AIDS, which UCSF hosted in 1990. Senior faculty members told him he’d learn “how the world works and how policy and politics work.” 

He did learn that, but not because his advisers were prescient. 

AIDS activists, moved in part by the social advocate Larry Kramer’s “Call to Riot,” descended upon the conference with “die-in” street protests. They heckled speakers and challenged the sedate expectations of the scientists and clinicians in at­tendance. The activists sought to change both attitudes about and government regulations against people with AIDS – and demanded to be included in the discovery processes toward treatment. 

During the conference, Wachter kept notes, which he orga­nized into the 1991 book Fragile Coalition: Scientists, Activ­ists, and AIDS. Looking back, he calls it “an amazing and ulti­mately important story about this tension between experts and science and the community that’s affected by it and their efforts essentially to morph into one.” 

Reviewers credited Wachter for forging a relationship, how­ever tenuous, among the groups and pointing the way to non-adversarial health policy that includes patients.

Meanwhile, he turned his back on the standard research track, “the job you’re supposed to want,” he says. Ironically, it helped that a major proposal of his was turned down. It helped, too, that he felt “too social” to isolate himself while generating fundable ideas; he also realized he had organiza­tional skills. In 1992, he was made director of the residency program, yet he was feeling, in his words, “a little bit adrift.”

The Hospitalist “Thing”

“Then the hospitalist thing happened,” he says. In 1995, his new department chairman, Lee Goldman, M.D., M.P.H. (now head of the Columbia University Medical Center), appointed him to run the inpatient service at UCSF’s medical center and in particular to figure out how to re-organize it. 

Goldman’s rationale: It hadn’t changed since he had been a resident there 20 years earlier, a sure sign of stagnancy. 

In calls and conferences and visits to hospitals across the country, Wachter found an emerging model — an in-house doctor was taking over patient care. He thought it made sense, a generalist who was a specialist in care at one place. 

When a UCSF colleague left to become a “hospital man­ager” across town, Wachter, struck by the odd title, inter­viewed him, then wrote about it and his other findings for the house-staff newsletter. Encouraged to redo the piece for a journal, he engaged Goldman as a co-author, and their semi­nal article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” appeared in The New England Journal of Medicine in 1996.

The response was immediate – and sharply divided. Hospi­tal CEOs asked how to develop such a program. Doctors called, saying they had been doing the work for many years and thought they were the only ones. A group of family physicians in Florida frankly didn’t want to manage their hospitalized patients and had just hired a young internist for that responsibility. 

^{A physician and a blogger, Wachter encourages “a thoughtful use of technology.”}

Among critics, primary-care doctors feared that patients would not want to be cared for by a physician they’d never seen, or the physicians simply wanted to continue caring for their hospitalized patients as in the past. Critical-care physicians saw a threat to their turf. Specialists feared fewer consultations. 

Others worried that, without providing inpatient care, in­ternists would be indistinguishable from family physicians and nurse practitioners. Some suggested that hospitalists would become insular and miss advances emerging in medical specialties. Some worried about the continuity of care when patients left the hospital.

Wachter’s father happened to sum up the opposition’s bit­terness. As Wachter told Modern HealthCare, his proud fa­ther phoned to tell him excitedly about his tennis partner, a doctor: “He’d heard of you!” The senior Wachter paused, then added, “He hates you.”

“The article just gave voice to the idea that a trend was hap­pening,” says Bob Wachter. Primary-care doctors had little time to tend to their hospitalized patients; the worry about patients’ preferences “turned out not to be a big deal,” he says, although it’s still argued. Hospital administrators were trying to reduce length-of-stays and costs. Residents were less avail­able because their hours were being cut.

In early 1997, Wachter and others sketched out a specialty, with its own organization, journal, training programs, text­books, and conferences. “It just grew. I knew it would,” he says. But the field had to offer physicians something more lofty and inspiring than saving money. “I really worried quite deeply about that.” 

The answer came when the Institute of Medicine, in 1999, issued To Err is Human: Building a Safer Health Care System. The report estimated that medical errors cause as many as 98,000 deaths in the United States annually. 

“We need to own this,” Wachter recalls thinking. “We have the opportunity: a brand-new field — in hospitals, which are going to be the epicenters of improving quality and safety and where the hazards are the greatest. We have the opportunity to brand our field as being about improvement.” 

The mantra became: “We have two sick patients: the person you take care of in the building and the system you’re in.” As Wachter observes, “That turned out to be a good call.” 

When he was doing his study, there were an estimated 500 hospitalists. Today, according to the American Hospital Association, the number now approaches 50,000, defined in Wachter’s words as “physicians whose main professional focus is inpatient care.” 

Some are well-placed, such as Patrick Conway, M.D., the chief medical officer of the Centers for Medicare & Medicaid Services (who earned an M.Sc. degree in health services re­search from Penn In 2007); and the U.S. Surgeon General, Vice Admiral Vivek H. Murthy, M.D. “And,” Wachter points out, “this is a pretty young field.”

According to Wachter, there is substantial evidence that care has become safer in the past several years, demonstrated by fewer adverse events; falling mortality rates in hospitals; and marked improvements in certain safety targets such as central line infections, sepsis, and falls. “I don’t know how much of that is due to hospitalists,” he adds, “but I think they have had a role — and they increasingly are taking on leader­ship roles in safety and quality because of their work in these areas.”  At UCSF, for example, the chief quality officer, the chief patient-experience officer, the chief medical officer for adult care, and the chief medical information officer – four of the senior physician leaders in quality/safety/IT – are hospi­talists.

Yet the field hasn’t finished evolving and most likely won’t. For instance, Wachter still hears criticism that hospitalists create a “discontinuity” between patients and their prima­ry-care doctors. Wachter’s response: “You have to figure out how to make the communication work – but people who crit­icize it, I’m always fine with that, because it’s not perfect.”

“To me,” he says, “the touchstone is value. I’m relatively ag­nostic on whether it’s hospitalists or something else. It’s what system delivers the best care at the lowest cost. And that should win. Right now, hospitalists do that better than the old system. Will it be that way forever? Who knows?”

^{A professor of medicine at UCSF, Wachter also heads the medical service at its Medical Center.}

Becoming a Better Writer 

Since then, Wachter has mined the essentials of the spe­cialty. He served as lead editor of the text Hospital Medicine in 2005; wrote Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes (2005; with Kaveh G. Shojania, M.D.); and wrote both the primer Understanding Patient Safety (2007, 2012) and The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (2015). 

His topics are urgent, but even more, his writing is compel­ling (the word Terrifying was supplied by publisher). He draws from many fields, writes directly, and has an eye for everyday examples and an ear for humor and irony. He generalizes convincingly. 

He understands sentence rhythms and plays them sharply or lyrically (or ornately, in a self-mocking way). He has a brawny ego yet is upfront about his shortcomings. An insider, he doesn’t write like one. He assumes that the physician reader appreci­ates good prose and the lay reader is intelligent – and both audiences respond. 

He’s also open to advice. In 2002, The New York Times wrote about “The Wrong Patient,” a series on medical mis­takes that he edited for the Annals of Internal Medicine. A publisher called Wachter to propose a book on the subject. Wachter wrote three chapters in what he felt was honest and flowing prose on interesting cases. 

The publisher replied in an e-mail with “I hope you’re sit­ting down” in the subject line. Over three pages, he faulted Wachter’s lack of candor. He found the text “dripping with caution.” He figured that Wachter didn’t want to annoy doc­tors or nurses or administrative leaders and concluded, “Ei­ther do this right or get out of my face.” 

Wachter winced. “I haven’t been talked to that way very of­ten,” he says. Colleagues were only partly consoling. “He’s an ass,” they told him, “and he’s completely right.” Wachter dropped the caution. The result was Internal Bleeding, which readers praised for its style, warmth, and frankness (the au­thors described their own mistakes), as well as its message.

For The Digital Doctor, Wachter received sage guidance from his wife, Katie Hafner, who has written even more books than he (six) and who writes on health care for The New York Times. When he told her his idea, she replied, “The only way you’re going to get this story right, the only way it’s going to be interesting, is to go out and talk to people.” 

“As soon as I started doing that,” he acknowledges, “it was immediately obvious that she was right.”

He interviewed 94 people (listed in the book), quarried his own experience, consulted history (tracing patient notes from their Greek origin to the present), and visited computer and other companies, physician practices, and hospitals, including his own, where the book’s centerpiece patient error occurred because of, not despite, the latest technology. 

Computers, Wachter concludes in The Digital Doctor, pre­vent some mistakes of the past but create new ones. The error he explores was the result of bad software and a glut of false alerts to patients’ situations, which lulled hospital personnel from paying proper attention to genuine crises. Computers have also distanced doctors from patients as well as from each other.

He argues for “a thoughtful use of technology.” For instance, better communication with software engineers for “user-cen­tered design.” Most people are good people trying to do the right thing, he says, but things can go wrong when those in­volved see only through their own lens. Another recommen­dation: doctors should get their heads out of their computer screens and back to facing their patients.

Enabling him to investigate and discuss a near-fatal error was “an act of incredible organizational bravery” on UCSF’s part, he says, and the feedback “has been universally good. It was the right thing to do.”

“On the other hand,” he adds, “we got a letter from the Joint Commission saying, ‘Can you tell us a little more about it?’ — as if UCSF’s actions and standards were problematic. 

The Commission’s response “is a little disappointing,” Wachter says. “I would hope that the incentive system out there would be one in which this kind of thing is praised, be­cause that’s the way we’re going to get better.”