‘You’re doing a wonderful job; we have a lot of work left to do’
A speech by Darrell Kirch, president and CEO of the AAMC
Delivered at the College of Medicine’s 10th-anniversary celebration
Oct. 7, 2010
We’ve all been basking in the glow of what you’ve accomplished in the last 10 years. And you should have your buttons just bursting with pride about that. But the last time I checked, we have 90 years to go in this century. (Laughter) And while I may not enjoy quite seeing all of it, I think we face some huge challenges. Some huge challenges for medical schools and academic medicine in general, and some huge challenges as a nation. And while you should take pride in where you’ve gotten, I hope you leave here this evening thinking about where you want to go. I want to share with you some ideas I have about where I think we can go.
In my job, those of you who work in the Legislature, those of you who are going to be my doctor someday, we all have our work cut out for us. Sometimes it’s really most productive when you’re thinking about the future to remember where you’ve come from. And while you’re very appropriately focused these days on your 10th anniversary, I don’t know how many of you realize that this is the centennial, the 100th anniversary, of another big event for medical schools. And that was that 100 years ago this year, the famous Flexner Report was published.
Medical education in the United States before 1910 was, in general, a mess. Literally you could go to cities in this country and get a medical degree delivered with almost no teaching from a storefront medical school, many of them for-profit enterprises simply there to generate a little income, not to really create a doctor. The AAMC, my organization, and the AMA knew this was a disgrace, and they partnered together with the Carnegie Foundation to do a report on medical education, which became the famous Flexner Report. And that report 100 years ago – it was a revolution. It changed medical education totally in this country, and it built a model that was very different from those storefront medical schools and that has persisted for much of the century. I’m going to talk about that model, and I’m going to talk about what it built. Then we’re going to talk about where you fit in it, and in particular your role, key role, going forward from that model.
Now the key tenet of the Flexner criticisms was that medical schools were out there in these fly-by-night operations, and they belonged in the university. You want a doctor who understands science. You want a doctor who’s a scholar. And not only should it be in the university, it should be closely connected to the real world of the best clinical practice you can find. That was Flexner’s concept. It was absolutely necessary at that time. I’m not faulting what he said or what we did with it. But like most good ideas, some things can head in directions we wouldn’t necessarily have wanted. And that happened with Flexner.
Because if you think about it – many of you are members of this university community, or affiliated with other universities, and you know there’s a kind of culture to the university, right? Basically it’s the culture of experts. It’s also a very hierarchical kind of culture, right? I go from instructor to assistant professor to associate professor. It’s a very independent culture. If any of you have ever worked with faculty members – they don’t exactly view themselves as employees. They view themselves as autonomous experts, with some good reason.
So Flexner did that. He said you need to get back to the scholarly roots of the university. That’s what we did. And we also adopted that culture of the university. Now, it created a lot of great scholarship, but we’re also going to see how it came together with a couple other forces in the century that followed -- to take that university-based medical school, which is pretty much what we all became after the Flexner report, and then something happened after World War II.
What happened was that we built what is arguably the greatest research institution the planet has ever seen. It’s called the National Institutes of Health, and it is a wonderful thing. I was privileged to work there. But it added its own culture to medical schools and their world. And the way it did it was fascinating. They decided that the way they could best support research was to go find those experts in the universities and give them grants. Those of you who know our world know they call them even R01s – project grants that were given to an individual, for their expertise in a particular area of science. This also is good. We would not have the treatments we have for a broad range of diseases if it wasn’t for that kind of investigator-initiated research. But it also reinforced that culture of independence. If it was all about me, as an independent scientist, and all about my grants, it didn’t exactly engender a spirit of collegiality or teamwork. So it produced great science, without question, but it reinforced the sense that we were just a collection of independent faculty members.
It also injected a new element in the education program. Because if I’m busy with my next grant deadline due, I may be less inclined to want to spend time talking with you about the pharmacology of this or that class of drugs as a medical student. So inadvertently, while it took medical schools in the direction of even better science and even better treatments and even cures in some cases, it also tended, without anyone’s intention, to sometimes put students a bit out to the margins. Many of us can remember times in medical school when we thought, “I’m not sure this lecturer would really like to be here today. I have a feeling they might rather be in their laboratory.” So we had what Flexner did in 1910 and then the NIH did right after World War II coming together in a very subtle but very powerful way.
But then something else happened. Added to the legacy of Abraham Flexner and the NIH is the legacy of Lyndon B. Johnson. I don’t know, if you were old enough, what you remember LBJ for – I actually mainly remember that day he showed his gallbladder scar. (Laughter) Does anybody remember that? But what most of us actually remember him for is Medicare. Lyndon Johnson understood that we had WAY too many elderly people in this country with no health insurance coverage whatsoever. He felt it was a national tragedy. And with the help of some like-minded members of Congress, he established Medicare as a health insurance program for the elderly. Anybody here think it isn’t a good thing to give the elderly health insurance? Of course it is. But something else went along with that, because they established a way of paying for those services in Medicare that was firmly based in traditional fee-for-service medicine. Now what that meant was Medicare, like those growing employee insurance plans at the time, would pay me as a doctor piece by piece for every visit, every procedure I did. Think about it for a second. If I’m in academic medicine, and I’m a faculty member, it’s all about me as an independent expert. If I also am a researcher, it’s all about me as an independent investigator. And suddenly, as a clinician, it became all about me as an independent biller for physician services.
Get a sense of the kind of confluence here? … There are a lot of problems associated with that traditional fee-for-service reimbursement that rear their ugly head at times. But for us in medical schools, in the now 45 years since Medicare passed, it created an additional trend, which was we got bigger and bigger clinically. So those traditional academic medical centers that you saw referenced in the [College of Medicine’s 10th-anniversary] film tended to take on a certain character. The character they took on – this is just a bit of an overstatement – was you had a small core medical school, with its classrooms, its laboratories, your lockers, your library, somewhere, if you could find it, in the middle of enormous research laboratories and institutes, side-by-side with an even more enormous health system complex. In the last 50 years in the United States, the number of medical students has doubled; the number of clinical faculty has increased 14-fold! That wasn’t because medical students became harder to teach. It was because we became very focused, working in the world of fee-for-service medicine, on building large clinical systems. And we did good things in those systems. I’m not debating that. I’ve been a patient at an academic medical center. Many of you have. It’s not a question of whether we were doing good things. For me, the question that was generated out of all of that was, “What was the culture we created, what did it mean for medical students, what did it mean for American health care?”
As I said earlier, the culture we created has some interesting traits. It is very individualistic. Even in medicine, in general practice, the majority of physicians still are in individual practices or in very small group practices. It was very much focused on individual effort. It was very autonomous. It was very hierarchical. In traditional medical schools, it was down to when you could go from a short coat to a long coat, when you got promoted through the ranks of the professorship. It also tended to be very expert-centric. I remember when I first became dean at my first medical school and I was walking through the clinics one afternoon about 12:30…, and they were bursting at the seams. There were patients everywhere. They were sitting on the floor; they were standing outside. I said, “Why is this going on?” And they said, “Well, we have our clinic this afternoon.” I said, “But you can’t see all of these patients.” And they said, “No, this is the entire afternoon schedule. We tell them all to get here at 12:30 so we don’t have to wait for any of them.” So was that clinic centered on the patient or was it centered on the expert? I’m glad to say that was one of the things my colleagues and I had the courage to change there. But you see the culture it represented?
This became very pervasive in academic medical schools. But I just illustrated, and I think you know, that that may not be the culture that you or I want when we enter a hospital or walk into a doctor’s office. We’re all patients. Let’s be honest with each other. Do you go to your doctor and announce at the beginning of your appointment, “I’m going to depend on you to be an absolute expert and very smart; therefore, I’m not going to ask any questions. I want you to assure me you’re not going to talk to any other doctors taking care of me; I want you to operate totally independently and autonomously. I want you to treat me like a number or a lab test and not a person. And I want you to be distracted because you’re worried about other things, such as your clinical billings....” We don’t want that as patients. The more I, as an aging baby boomer, become a patient, the more I know that I want a different culture. I want a culture that isn’t centered on the expert but is centered on me as a patient. I don’t want a bunch of specialists each acting like an independent agent. I want a team taking care of me. I want that team to communicate with each other. I want that team --regardless of who they are, what degree they have, what specialty they have – I want them all to feel that they are equally accountable for my health and my outcomes in this system. That’s the culture we want. And this was our failing in academic medicine. We had drifted and reinforced the culture that wasn’t meeting the basic needs of patients.
That’s a huge event. In and of itself, that would be enough of an argument to fix not just American academic medicine, but that culture has permeated all of health care – the expert-centric, non-patient-centered culture. It’s an argument for fixing that. But then there are two other huge forces out there today, this year, that make me feel a real sense of urgency.
The first one is – you may not have noticed, but there was a health-care bill passed in Washington this year. (Laughter) Now, I respect whatever opinion you have on either side of the aisle about the health-care legislation. Actually, there’s no one I can find who believes it’s perfect. Everyone sees the flaws in it, and I can enumerate some of the flaws in it for you. However, we’ve had a major flaw – I would even view it as a national failing – and that is: How can we consider ourselves a highly developed nation when we have now, TODAY, 50 million Americans without health-insurance coverage whatsoever? In my view, that flaw trumps the flaws we need to deal with in a bill that will give more Americans health insurance. My regret about that debate and the legislation that came out of it was where we started and where we got. Can anybody even remember the 2008 election? (Laughter) Doesn’t it seem like it was decades ago? And do you remember how suddenly every candidate said, “I’m the candidate of change”? They’d hold those change signs up, and we’d all imagine the kind of change that we wanted, and then we elected a number of them and they started making changes, and we said, “No, that wasn’t the change I had in mind!” (Laughter) And that played out in the health-care reform debate, too. The presidential candidates, many of the candidates for Congress and Senate from both parties argued strongly for sweeping health-care reform. They didn’t just argue to insure more Americans. They said, “Many parts of our health-care system are broken, and we need to fix them.” But when it got ugly, as it sometimes can get in politics, their focus got more and more narrow. And in the end, the only thing that could squeak through legislatively isn’t a health-care reform bill; it’s an insurance-expansion bill. Not much more than that, quite honestly. It doesn’t really fix the parts of the health-care system that don’t work. It does very little to increase the health-care workforce, which was the reason for your founding.
So, that bill that was passed deepens our problem, because while we’ve given more people an insurance card, an insurance card won’t help you much if all you can get when you need a doctor is an answering machine. We have [to do] a lot of other things in order to train the workforce we need and to fix the flaws in our system. So, we’ve got the culture we built up under Flexner. We’ve got the limits of the health-care bill – and believe me, I don’t think there’s anybody who’s in Washington or who’s going to be elected to come to Washington who’s going to want to pass another health-care bill in their lifetime. So we’ve got to live with the limits of what we have for right now.
And there’s a third thing. Did any of you ever imagine we’d be in the economic situation we’re in? As a baby boomer, I didn’t live in the Depression, but my parents sure talked about it. And I am constantly struck to hear conversations today that seem a lot like those conversations they had, about the way it felt in the Depression, about really wondering if there was going to be future economic security. Now you might say, “That’s real, but what does this have to do with our topic today?” I’ll tell you. The problems of our health-care system, including what we spend on health care, lie smack-dab in the middle of our economic situation. We all hear constantly, on a daily basis, about the threat of the national debt. Everybody running for office now talks about it on the federal level as a real problem. What is the biggest single driver of the growing national debt? Medicare spending. Medicare’s a good idea. Medicare’s a critical idea. But we are driving it to the limits of unaffordability. And then for those of you in state government, … what is the biggest driver of problems for state budgets right now? Medicaid. What is the biggest reason American businesses seem to have such a struggle being competitive? Health-insurance costs. We’ve loaded them with the issues of employee health insurance in a way many other nations haven’t, and it’s breaking their competitiveness globally.
I’m a psychiatrist, and – believe me – the last thing I want to do is depress you. (Laughter) This is actually a good situation. Sometimes you need a real sense of urgency. You need somebody to light a fire, and we’ve got it in health care and we’ve got it in medical schools. In medical schools we have this culture that hasn’t been as patient-centered as it needs to be. It absolutely has to change if we’re going to meet the needs of our patients. In the health-care bill we went part way but left some of the biggest problems unsolved. Nationally we need to change our habits, and we need to change our spending patterns, and we especially need to do it around health care. Who is going to fix this? Who can take on all those things at once? Call me cynical, but – for all the great things they do – I don’t think health-insurance companies can do this. I don’t think the pharmaceutical industry can fix it. They are private businesses with well-defined agendas. I don’t think a struggling group of primary-care doctors in a small Florida town can fix it. And I don’t think a rural hospital that can barely staff itself or maintain its … budgets can fix it. Somewhere you need to have some of the best minds in the nation who understand how you deliver health care, how you educate health professionals and how you study – do research on what works and doesn’t. You need to have those come together, and they come together in academic medicine.
You’ve started this kind of journey with what you’ve done here. There are three kinds of change. You have revolutions. You know, we’re an interesting country. We were founded on a revolution, right? I think we scared ourselves because we then immediately established a form of government that assures that very little can get done. (Laughter) So we went from revolution, one kind of change, to the other end of the spectrum of change, which is incrementalism. We actually saw this in academic medicine and health care. Flexner was a revolution, right? But then, in health care and in medical schools, we’ve been about smaller change.
You’ve shown the middle kind of change. It’s transformational change. It’s where you say, “There’s a lot of good here. We don’t want to sweep away the old order” – but where you have the courage to admit that the old order isn’t going to meet our future needs, and you make big change. You sometimes do it in the face of skepticism from a lot of people around you. Sometimes you may get tortured by an accrediting body. (Laughter) But you persevere because you believe the time has come for transformational change. This is what we need in America’s medical schools, teaching hospitals, in our health system as a whole.
I think you have done it on the educational front, and I can’t say enough good things about what you’ve accomplished in that regard. The problem is now we need to extend it to other medical schools and to the entire health-care system.
I’m just going to close with what I think a few of the active ingredients are. And in my two days here, I’ve seen them in action here. These are the ingredients, the key things to bake this cake. You tell me what you think about whether you’ve really demonstrated them.
1. The first is you have to have a mission statement that you actually intend to fulfill. Every medical school, every university has a mission statement. They’re all aspirational. Yours is focused, and you’ve been deadly serious about meeting it. You have the most focused mission statement I’ve ever seen for a medical school. And you’ve been relentless in every one of your programs to line up your activities with that mission statement. That’s the key ingredient. That’s the flour in this cake, right?
2. The next thing you need is a different kind of leadership. For a long time we believed great leaders were like Patton, right? Standing on the tank with chrome pistols, you know? (Laughter) In command! The leadership today is very different. It’s integrated leadership. It’s highly, highly interactive. It’s servant leadership. I spent a lot of time with the leaders – not just here in Tallahassee, but I had a chance to video with the regional campus deans and others, some of whom I know are watching. You are displaying integrated leadership. Dean Fogarty is a very, very talented person, but he could never get that mission fulfilled as a commander. He could only do it surrounded by a group of like-minded leaders. I saw leadership from the students today when I saw some of the things that they do in your outreach programs. It’s not a single leader; it’s widely distributed leadership. So that’s the second ingredient.
3. The third one is teamwork. Health care and medicine have not figured out that it’s a team sport…. When you’re a patient, you want a team. You don’t want a bunch of rugged individualists. We’re still struggling to find that. Everywhere I’ve looked in this College of Medicine, I’ve seen teams. Your Learning Communities are teams, right? As students. It permeates the curriculum. Your outreach programs are team-based. You understand it’s the power of the team, it’s the wisdom of the team. None of us, as an individual, can get it done.
4. The film really illustrated the fourth ingredient I would mention, and that’s a focus on results. And it isn’t that you’re the only person around measuring your outcomes and your results. What I’m impressed by is you’re actually saying not just, “Are we doing good things?” but “Are we really delivering on what we promised – what we promised when we were established and what we say in our mission statement, what we say to our students when they apply?” You’re measuring your results in line with your promises.
5. The fifth one is a little – you might say softer; I would actually say it’s one of the most important. It’s this: Don’t ever, ever think this is about politics. I know it took a political process to establish this school, but once you are established it’s about ethics. I’ve taught ethics. It’s about the only subject I’ve taught consistently through my medical career. And I love medical ethics because it’s one of the few things in medicine that is simple. There are only four principles: You always do good for the patient (we call it beneficence); always avoid harming the patient (we call it non-maleficence); always respect the autonomy of the patient; but we’ve struggled in American health care and medicine with the fourth one, which is called justice. When you have expansive areas of Florida where people can’t even get to health care, when you have people searching in vain for decent primary-care homes, that’s not a just health-care system. So it isn’t a political issue; it is an ethical issue for any of us who have any concern about health care.
6. And that leads me to the final active ingredient. There are a whole lot of people in this country who are just standing by and watching. There actually are a whole lot of people in this country who are just angry. I was talking with one of your colleagues earlier and I said, “You know, anger is not a national strategy.” (Laughter) What do we need right now? We need some courage. You know, some of you as med students – especially those in the early years – showed some real courage coming to a start-up medical school. The faculty who came here showed some real courage. President D’Alemberte clearly was a courageous leader. You [pointing to Sen. Durell Peaden] showed courage with an idea that was swimming against the stream of the times, Senator, when you developed the legislation. We’re at a time in our country when I fear courage is in short supply. But I know where we need it most is in fixing our health-care system and training the next generation of physicians to be our partners in doing that.
You’re doing a wonderful job; we have a lot of work left to do. I really look forward to joining you in that task. Thank you.