Doctor Q&A: Bob Wachter

Dr. Bob Wachter, UCSF's chief of Medical Service, is credited with helping create a new specialty in medicine: hospitalists, doctors charged both with caring for hospitalized patients and making hospitals work better. In Internal Bleeding, his 2004 book with fellow hospitalist Dr. Kaveh Shojania, Wachter pulled back the curtain on the world of medical errors and discussed the latest thinking on how to prevent them. He also blogs about hospitals, patient safety and care quality on Wachter's World.

Photo by Tom Seawell

I'm curious what you think of the health care reform debate. Do you see any major opportunities for improving patient safety, or any major potential pitfalls?

I find the debate disheartening, mainly because there are so many important issues to be addressed but the politics tends to overwhelm, and caricaturize, everything. That said, I do think that some of the changes in health care reform — specifically the ones that create real incentives for quality, safety and value — have the potential to transform the health care system in a positive way.

It is clear that the great hospital of the future will need to truly demonstrate that it achieves better outcomes for patients, and that will require new kinds of thinking, teaching, teamwork and technology. That's really exciting, and I think we're well positioned at UCSF to thrive in this new world.

What drove you to help found this new specialty of hospitalists?

I was a political science major in college and have always tried to think about organizational models to improve care. In 1995, I became chief of the medical service at UCSF Medical Center and my boss charged me to "come up with a new way of delivering inpatient care." The hospitalist idea was just beginning to emerge, and so I articulated a vision for this new way of organizing hospital care in an article in the New England Journal of Medicine, which coined the term "hospitalist" and is generally credited with launching the field.

Why has the specialty taken off so fast?

It became the fastest growing specialty in modern medical history because it filled so many needs: to provide high quality and well-coordinated inpatient care, to improve efficiency, to help educate new generations of trainees, to be leaders in quality and safety improvement activities, to care for patients in the face of housestaff duty hour limits.

When new needs arise, it seems like the first question always is: "Can the hospitalists do that?" I like that.

What are the main ways hospitalists have helped change health care at UCSF?

I see our contribution on two levels: what our folks do in caring for individual patients, and what they do in transforming the systems of care. Every day, our hospitalists participate in the care of about 200 patients — nearly half of the adult census at UCSF — in myriad ways: direct care, supervising trainees of all stripes, consultative care, co-management of patients on several specialized services, palliative care, performing and supervising complex procedures and more.

But probably more distinctively, we are leaders in making the hospital system work better, and many of our faculty have assumed leadership roles in areas related to quality, safety, medical education and information technology because of this. It would be hard to fathom what UCSF would look like today without hospitalists.

What changes would you like to see made in the future, both at UCSF and other hospitals?

Simple. I would like a system that is organized to reliably deliver high quality, safe, efficient and satisfying care to every patient we see, to educate the next generation in the competencies needed to do that, and to innovate, both in the traditional scientific realm as well as the newer domain of improving the delivery of health care. That shouldn't be too hard, don't you think?

What can patients and their families do to help prevent medical errors?

I wish there was a simple answer to that. I do believe that vigilance is a good idea, checking to be sure that caregivers clean their hands, ask you for your name before giving you a medicine, that sort of thing. But I also know that when I get on an airplane, I need to trust that the system has done all it can to ensure my safety. In health care, we need to have the same goal.

At UCSF, we're not quite there yet, but I think we're as good as any place in the world and I am completely comfortable being a patient there myself or recommending it to a family member or close friend.

You're on sabbatical in London, but it's a working sabbatical - you're on a Fulbright grant. What are you up to?

I'm focusing on a few things. I'm based at Imperial College with the top patient safety group in Europe, so I'm exploring how they think about patient safety. I've also become intrigued by the way they organize hospital care, which has some similarities to and some major differences with our hospitalist model.

I've just finished the second edition of my patient safety book, and am blogging away. But I'm also taking plenty of time to smell the roses, get in shape, travel to the rest of Europe and enjoy some down time. I've been meeting lots of wonderful people — what a joy when they ask, "Can you get together next Monday?" and my calendar is absolutely blank. At home, I'd be looking for time two months from now.

If you weren't a doctor, what would be your dream alternate career?

Maybe a news analyst on TV. I thought about trying to be a golf pro for a while — I'm not bad (I'm a 5 handicap), but the three-footers are just too much pressure. I choke.

What would your patients be surprised to learn about you?

I am the answer to a trivia question: Who was the school mascot for the last Ivy League college basketball team to reach the Final Four? The answer: me in 1979, as the Penn Quaker (yes, I wore a tricornered hat, bifocals, a ruffled shirt and knickers).

We were this Cinderella team, a Team of Destiny, and we all felt like we were going to go all the way after we beat some mighty teams, including UNC and Syracuse, in the run-up to the Final Four. Then we ran into a team that had this guy named Magic Johnson, and that was that. But it was great fun.

Any personal heroes? Who are they?

Sure. The late John Eisenberg, who showed me that one could combine a career as a physician with one as a health policy leader, and be good at both. Atul Gawande — I find his writing simply astounding. Bruce Springsteen, for his honesty and integrity. And my kids, who have blossomed into amazing young men, each their own person without a hint of arrogance or artifice. They're great.

November 2011

Interviewed by Sierra Tzoore.

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Robert Wachter
Dr. Robert Wachter,