“Each generation goes further than the generation preceding it, because it stands on the shoulders of that generation. You will have opportunities beyond anything we've ever known.”
—Former U.S. President Ronald Reagan
In the April 2014 issue of The Hospitalist, I began the tale of our specialty and the beginning of our evolution into a social movement. A social movement occurs when a large number of agents take coordinated action simultaneously.1 In the early days, managed care and other factors began driving doctors to try new, more efficient ways to practice, including early hospitalist practices, but usually these practices were one-offs and uncoordinated in their actions. Additionally, small numbers of doctors, perhaps a few hundred, focused their practice in the hospital. Drs. Wachter and Goldman published their “Sounding Board” article in the New England Journal of Medicine and, suddenly, hospital doctors across the country had a common identity: hospitalists.2 The specialty was poised for growth, but who would fill the need to come?
We should back up a few years to the dawn of the hospitalist movement in the late 1980s and early 1990s. For 20 years, Baby Boomers had been matriculating and graduating from medical school. The last Baby Boomers would graduate as the 1990s were just beginning. Baby Boomers were raised in the post-war era, largely by intact families with working fathers and stay-at-home mothers. They grew up in a competitive school environment—fueled by Sputnik—with a focus on success and working hard as the means to achieve that success. They were raised to be idealists and to question authority—remember Vietnam protests? These traits served the Baby Boomers well when managed care began to exert its pressure on physician practices. It was these physicians who figured out a new way to succeed in an altered landscape. It was either them or the big payers; their competitive nature was funneled into trying new, efficient practice models, to maintain income and control over their practices. Hospitalist systems were the most visible new practice model created in this era.
Fast forward a few years to the mid 1990s. A demographic shift was occurring. A new generation of Americans arrived on the scene of modern medicine—Generation X. The first Gen-X physicians graduated from medical school in 1991 and began moving into internship. They would graduate from residency in 1994, just as the early HM groups were starting to build a quiet but critical mass. This was a generation raised as latchkey kids in a time of rising divorce rates and working mothers. These kids were often home alone and grew up with more freedom and independence than any recent generation in history. Gen-X kids learned how to function on their own. Resourceful and self-reliant, they took on responsibility, but, conversely, did not appreciate being watched over. They liked to work at their own pace and valued work-life balance in a way that was foreign to the Baby Boomers. They weren’t born with keyboards in their cradles, but this was the first generation raised with technology—and they embraced it.
As these Generation X’ers came out of residency looking for the right fit in a specialty, trying creative ways of doing things, and seeking balance in their lives, they saw the early hospitalist programs the Boomer pioneers had created and started to join. They saw in these early hospitalist programs all that they were looking for in a practice. In many programs, the first hospitalists were lonely souls—but lonely by choice, usually left to their own devices. Their partners in the clinic stopped coming to the hospital, and their administrative leaders focused on the engine of running the clinic and managing the capitated and non-capitated costs of care.
Hospitalist practices became bastions of independence and freedom. No longer were these physicians chained down to their small area in one hallway of the clinic, nor did they cling to the metaphor of the fast-moving production line. Hospitalists could roam the hospital at will, from inpatient unit to ED to ICU. Hospitalists could eat lunch when they wanted to! Gen-X physicians flocked to this model of independence that so aligned with their own inner desire to work at their own pace and in their own way.
These early hospitalist programs, still trying to find their way in a complicated and changing healthcare environment, necessitated continued resourcefulness. We saw creative approaches to scheduling that favored continuity (seven on/seven off), transitions to hospitalists as teaching attendings, and early attempts at night coverage. The transition from at-home call or coverage by residents to in-house shifts to nocturnists could fill its own column. The creative opportunities offered by these early practices strongly appealed to the Gen-X sensibilities and values.3
Lastly, work-life balance strongly resonated with Gen-X physicians. Many of the Boomer physicians of the time were content to stay in the clinic and “run faster” to keep up with the demands of managed care; however, the Boomers who migrated to the hospital and the early Gen-X physicians seemed to have a different mindset. They relished the opportunity to work in the new hybrid model. I say hybrid because it certainly wasn’t the ongoing continuity model that it originated from in primary care, but neither was it pure shift work like in the ED. It had the element of daily shifts—but clustered together in five to 14 day runs, often with an equal amount of time away from work. Additionally, nobody was taking work home—at least not until EMR. Work-life balance was the recruiting “pitch” during the late 90s and early 2000s.
So, after the creation of the field by Baby Boomers, the Gen-X doctors were the fuel needed to grow the specialty at a pace never before seen in medicine. Wachter and Goldman’s article opened the floodgates. Between 1997 and 2006, the number of hospitalists grew by 29%—not in total, but 29% per year!
Gen-X physicians latched onto the idea created and publicized by the Boomers, but the movement needed more to sustain, even accelerate, that early growth than just an interesting new idea for how to see hospital patients. What was the oxygen? What gave the HM social movement its purpose?
In my August column, I will explore what came next to propel HM from a new area of practice, an offshoot of primary care, into a full-fledged movement. It was that next thing that made our field “go viral.”
Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.
- Lancaster LC, Stillman D. When Generations Collide. Who They Are. Why They Clash. How to Solve the Generational Puzzle at Work. New York: HarperCollins; 2002.
- Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. New Engl J Med. 1996;335(7):514-517.
- Wachter R. Today’s NEJM hospitalist study: what’s the news? Available at: http://community.the-hospitalist.org/2009/03/13/today-s-nejm-hospitalist-study-what-s-the-news/. Accessed May 11, 2014.