The Year Ahead: Preparing the DOM for the Next Phase of Clinical Growth

As we begin 2026, we do so after a year that tested academic health care systems and the people who make them work in profound ways. Across the country, health systems have grappled with layoffs, hiring freezes, and sustained budget cuts, all while asking faculty and staff to do more with fewer resources. Productivity expectations have risen even as administrative burden, regulatory complexity, and uncertainty about the federal policy environment have intensified. These realities have asked much of faculty and staff, and that effort has taken its toll.

At UCSF, while we have so far avoided some of the most severe federal actions facing other institutions, we have nonetheless felt the strain of a challenging national and local environment. Our faculty at the VA are confronting a painful hiring freeze that directly impacts clinical care. Those at ZSFG continue to carry the weight of last year's violence while preparing for likely budget cuts. These experiences shape the context in which we look ahead to the coming year. Detailed updates from ZSFG and the VA were covered in our previous newsletters.

Against this backdrop, as I look ahead, 2026 marks an important moment of transition for the DOM. The UCSF Health five-year strategic plan, also referred to as the clinical enterprise plan (CEP), is still under active development, with continued input from chairs and other stakeholders. As its broad direction comes into focus, we are beginning to implement the clinical growth framework that I co-led in developing.

This effort is not unique to UCSF but reflects a broader transformation in American healthcare. As private practice continues to recede in major urban markets, more physicians are being hired by or affiliated with large, integrated health systems and academic medical centers (AMCs). To remain competitive in this environment, AMCs have rapidly expanded their clinical footprint beyond the traditional 10–20 mile radius of a flagship hospital, moving decisively into secondary care and geographically distributed outpatient services. UCSF Health entered this phase of expansion later than some of its peers, but doing so is essential to serving patients across the Bay Area and sustaining its academic missions. All our academic sites stand to benefit from this growth, as it will strengthen our research and educational missions. At the same time, it will require us, collectively, to grapple with what this shift in focus means for our department and for what it means to be faculty at UCSF.

The Strategic Imperative

If there is one theme that unites the strategic plan, it is the need to expand access to our services across the Bay Area's geographies, and to do so in a way that allows patients to receive comprehensive, coordinated care within a single system. In an increasingly competitive healthcare market, systems like Kaiser and Sutter have set a clear expectation for patients: that primary care, secondary care, and even subspecialty services are accessible, timely, and integrated. This is something patients have long sought from UCSF, and something we must now deliver to remain viable and relevant as a regional health system.

While our safety-net and federal partners, ZSFG and the VA, have long provided robust secondary care to their communities, UCSF Health has historically struggled in this space. Too often, our own patients who require secondary care have been referred outside of UCSF, not because the care did not exist, but because it was not accessible with the timeliness or in the geography patients need. Addressing this gap represents an important opportunity for patients seeking continuity, for clinicians trying to deliver coordinated care, and for the health system itself in an era where retaining patients within a single system is increasingly critical to financial sustainability.

To do so, the strategic plan calls for a significant expansion of our presence across the nine-county Bay Area, particularly in the East Bay, which has the largest patient population that is potentially recruitable to UCSF for their healthcare. To deliver on this promise, we need to increase the sites where patients can access UCSF care, streamline our processes, and leverage technology more effectively. And critically, we need to shift our center of gravity toward outpatient care, where most of this expansion will occur.

One premise of the strategic plan is that we need more full-time clinical physicians to solve this problem – doctors who can provide high-quality care without the competing demands of research programs or extensive teaching responsibilities that characterize our traditional faculty model. Meeting the scale of this challenge will require new thinking about how we staff, support, and integrate clinical faculty into the life of the department. If we need 150 new clinical FTEs of DOM physicians (perhaps 50 new primary care doctors and 100 specialists), we will be far more successful hiring 150 nearly full-time clinicians than 750 physicians who see patients in ambulatory practice one day a week.

Key Questions Ahead

The shift described above creates a cascade of questions that we have not previously had to fully grapple with as a department. At its core, it challenges long-standing assumptions about compensation, career pathways, and academic identity within the DOM. These questions reflect deeply held values around fairness, professional development, and what it means to be part of an academic community.

• Compensation: If we are to hire physicians who are essentially full-time clinicians, we will need to compete with institutions offering clinical market salaries that will be significantly higher than our academic benchmarks. Can we sustain a model in which faculty work side by side clinically but earn markedly different salaries?
• Career pathways: Our traditional academic model assumes that faculty evolve over time, often beginning with substantial clinical effort and gradually buying down that time through leadership, education, or research roles. How does this model change if we expect some faculty to remain primarily or entirely clinical?
• Academic identity: UCSF’s HS Clinical series allows promotion for primarily clinical faculty, with a relatively modest requirement for creative activity. As we consider hiring large numbers of full-time clinicians, how do we ensure they feel fully welcomed as faculty, and how does their presence reshape our departmental and school culture?

Where We Go from Here

As you can see, solving this complex equation will, I suspect, be a challenge we face as a department over the coming year. I don't believe there's a single "right" answer; in fact, the answers may differ from division to division.

Before making any major decisions, we plan to discuss these questions at several leadership meetings and at one or more town halls. As we work through them, I encourage you to send me a note with your thoughts or perspectives that you believe should inform this discussion. Your perspectives will be essential as we work through these issues together.

Our decisions will shape the future of our department for years to come. By approaching them with openness, care, and collaboration, we can ensure that our path forward reflects both our values and our shared commitment to excellence across all our missions. Let's get it right together.

Robert Wachter, MD
Professor and Chair, Department of Medicine