“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.