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Ahead of the Curve


 

Twenty years before the term “hospitalist” was coined, and not long after serving as a battlefield surgeon in Vietnam, Tracy Spencer III, MD, selected a path few—if any—had chosen before.

Fresh from his combat experience, he became chief resident at the University of Colorado School of Medicine in Denver in 1975. He dreaded clinic hours but enjoyed the hospital. The flash, dash, and adrenaline of battlefield medicine were still in his blood; he wanted challenges.

“I didn’t want an outpatient practice with the overhead of an office,” says Dr. Spencer, 63, “I wanted to do internal medicine in a hospital setting. I had tons of energy to deal with the unassigned patients who came in the ER, and [I liked] the idea of being a hospital-based physician.”

He began searching for the right setting for his skills and temperament. Eventually, the third-generation physician made a bold leap—he started a hospital-based internal medicine practice in Everett, Wash.

Grass-roots Campaign

In 1976, Dr. Spencer knocked on lots of doors and convinced scores of Everett’s primary care physicians that his caring for their hospitalized patients would free them to build their practices. Although many of those physicians thought it bizarre that Dr. Spencer had no outpatients, they readily turned over their inpatients to him.

“I believe he was one of the first, if not the first, hospitalist in the state of Washington, and perhaps the country,” says John Cramer, MD, MBA, an intern at the University of Colorado 1974-1975 when Dr. Spencer was chief resident. Their relationship has endured more than three decades—with a twist. Now the former intern, who joined Dr. Spencer as a hospitalist in 1979, supervises his former boss in the growing 32-physician hospitalist group at Providence Everett Medical Center.

“Tracy is a member of the team, dispensing wisdom to the younger docs,” says Dr. Cramer. “I have never seen him happier professionally than he is now.”

Early Influence

Dr. Spencer’s medical training and early experiences shed light on how he came to be an inpatient physician two decades before hospitalist medicine formally emerged.

Theodore Woodward, MD, nominated for a Nobel Prize in 1948 for his work on typhus and typhoid, was Dr. Spencer’s professor at the University of Maryland, Baltimore. He impressed Dr. Woodward with “an old-fashioned, knowledge-based, and holistic approach to patients.”

Later, Thomas Petty, MD, an eminent pulmonologist who headed a respiratory team at the University of Colorado Medical Center and became chairman of the National Lung Educational Program, introduced the young physician to a team-based approach to hospital care. During his 1968-1969 internship at the University of Colorado under Dr. Petty, Dr. Spencer found he enjoyed working on a hospital team and the discipline of the hospital hierarchy.

After graduating from medical school, Dr. Spencer was drafted in 1970 by the Marines and was sent to Dà Nang, Vietnam. As a regimental doctor, he worked alone—and didn’t like it. “There was no collegiality for field combat docs,” he recalls. “There were ship-based specialists who didn’t even talk to us. The most serious cases we triaged were [taken] to the ship, and I didn’t see them again. I was dissatisfied and felt that the doctors in the field deserved more respect.”

Maurice Ramirez, DO, an emergency physician and federal medical officer with the Department of Homeland Security, suggests the military’s command structure may have influenced Dr. Spencer more than he realizes. “Before hospitalist medicine, physicians were like British aristocrats in their fiefdoms, ordering their lessers about,” explains Dr. Ramirez. “[The] hospitalist movement has changed all that.”

Turning Point

Dr. Spencer returned from his tour of duty and began his chief resident stint at the University of Colorado in 1975.

That year, Boyd Bigelow, MD, “a maverick with a plane” by Dr. Spencer’s account, hired him to admit and manage patients at Denver’s St. Anthony’s Central Hospital, which had no house staff. “To compete with big hospitals, we’d fly referrals into Stapleton [Air Force Base],” Dr. Spencer says. Dr. Bigelow became medical director of Flight for Life, the first civilian airborne emergency medical service, which has flown more than 65,000 patients to critical care facilities. He would swoop down from the sky through Colorado’s whirling snow, delivering patients to Dr. Spencer.

In 1976 Dr. Spencer took stock of his career and recognized he wanted to be a hospital-based physician. He contacted John Hoidal, MD, from his University of Colorado days, expecting to buddy up, move both of their families to Everett, and cover inpatients at two hospitals 24/7. But Dr. Hoidal chose not to go.

“It would have been easier if the two of us had started the hospitalist practice together, but it wasn’t right for him,” says Dr. Spencer. “I saw that I could do it on my own. I had energy to burn and ambition to succeed.”

Undaunted, he soldiered on to Everett.

“It is an absolutely gorgeous place to live,” he says. “When we arrived I found Everett loaded with GPs in their busy offices, and I had the expertise they needed to manage their inpatients. I hooked them with my three A’s: availability, affability, and ability.”

Everett Hospital hired him to provide 24/7 coverage for respiratory care, the intensive care unit, medical/surgical consults, and overall inpatient management. He worked solo for more than a year and grew exhausted. He hired a second physician in 1977, then Dr. Cramer in 1979.

Also in 1977, Dr. Spencer forged what has become a 30-year professional relationship with Eric Larson, MD, MPH, executive director of the Center for Health Studies Group in Everett.

“In 1977 I was chief resident at Providence General [which merged with Everett Hospital to become Providence Everett Medical Center in 1994],” Dr. Larson says. “Tracy introduced himself as a hospitalist and said he took care of patients in the hospital for GPs. It seemed like an interesting solo practice model.”

What struck Dr. Larson at the time was the contrast between the commotion of a teaching hospital with medical students, interns, residents, and attendings “tripping all over each other” and Dr. Spencer’s approach.

“He embodied the principle of keeping things simple and was organized and methodical in his approach to patients,” Dr. Larson says. “He was superb in pulmonary medicine and the ICU.”

Challenging Times

The hospitalist practice and Everett’s medical community kept growing through the early ’80s, with specialists joining general practitioners in using Dr. Spencer’s group for consults and co-management. Then came managed care in the mid-’80s, and the hospitalists’ gains seemed threatened. “Managed care’s tight controls and preauthorizes of inpatient services were terribly frustrating,” says Dr. Larson. Dr. Spencer found himself competing for managed-care contracts rather than seeing patients.

By the time managed care loosened its grip in the 1990s and the hospitalist movement was officially launched, there were new challenges and frustrations. Dr. Spencer felt worn out administrating rather than doctoring. Dr. Larson felt something else: futility. “One of the hardest things about being a hospitalist is dealing with the futility of treating old people with multiple co-morbidities who shouldn’t even be in a hospital,” explains Dr. Larson. “Hospitals are now so protocolized. Once a patient gets in the hospital he’s almost on automatic.”

Frustrated and tired 25 years after becoming the first hospitalist, Dr. Spencer retired in April 2001. Then he realized he wasn’t finished with medicine. Six months later he joined the hospitalist cadre led by his former intern, Dr. Cramer, at the Everett Clinic, a multispecialty group with 250 physicians and 65 midlevel providers.

Putting 30 years of hospitalist experience to work, Dr. Spencer recruits young hospitalists, teaches best practices, and continues to build relationships with general practitioners and specialists. From his unique vantage point, he sees hospital medicine as a maturing discipline gone mainstream.

“There’s still so much to do,” he says. He plans to explore a variety of hospitalist growth areas, such as efficient use of diagnostic testing, higher intensity medicine with patients of markedly higher acuity, step-down cardiac telemetry, more involvement with ICUs, and managing complex patients living with multiple co-morbidities.

But Dr. Ramirez says that with all he’s already accomplished, Dr. Spencer has earned a place of note: “I hope that hospitalists recognize he was three decades and six generations of physicians ahead of his time.” TH

Marlene Piturro is a medical writer based in New York.

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