Articles, Blog

Dr. Catherine Lucey A Life in Medicine People Shaping Healthcare Today

March 11, 2020


(calming music) – This is another in our
series of fireside chats. Probably about the 10th
or so that we’ve done. And these are just an opportunity for us to get to know better some of
the remarkable people at UCSF. And lucky enough to have
one of the most remarkable, Catherine Lucey, who is the
dean for medical education and the executive vice dean. And we will talk about that
and what those titles mean a little bit later. But thank you for coming. – Thank you. – Tell us your origin story. Where were you born and
how did you become you? – I am the oldest of five. I was born in Edwardsville, Illinois. Actually in East Saint Louis. And then lived in Edwardsville, Illinois. And my parents are both chemists. They met at Purdue in graduate school. My mother was the first
chemistry graduate student to earn a masters degree at Purdue. And she had five kids. And, when. I was in middle school, actually, when she went back to teaching. She went back, first, as my substitute teacher in Earth science, which was almost a social disaster for me. And really taught me to
compartmentalize my life. Which has turned to be a
very important aspect of it. – What do you mean by that? – If you know someone
in one part of your life and you don’t want to
know them in another part, you don’t actually have to. You can pretend. So, it’s good. You can sort of say, “Oh, Mrs. Renes.” You should never, ever
call your mother “Mom” in Earth science class. It’s just was a bad idea. But, actually, when she went back to work. I said I’m the oldest of five. And there’s five of us in about six years. So, it was pretty quick succession. Four girls, one boy. I actually ended up taking on most of the dinner responsibilities. So, I learned very quickly to also learn how to manage your time so that you can go to school and study well and cook dinner and be
on the swimming team. And I actually went to. When I started in high school, I thought about going into medicine. Actually, I thought about being a nurse. And none of you in this
room are quite that old, except for Bobby. Bobby and I are in the same generation. But, back when I was trying
to figure out a career, there really weren’t a lot of role models in professions other than nursing. And I knew I wanted to do science. I love science. And I spent a lot of my
time as a child reading. And reading books like
Sue Barton: Rural Nurse and Cherry Ames: The Visiting Nurse. And I thought “This would be
a cool thing to do things.” And so, a very interesting turn of events. My father came home one day and said, “I heard about this great new career. You can go to school just two years longer than it would take you to be a nurse and you can be this thing
called a physician’s assistant.” So, I’m like, “Okay.” At that time, my father still
was somebody who was smart. When you’re a teenager, at some point, your parents become dumb. And then they can become smart again when you’re in your 20s. But I still sort of thought of him as somebody who had good sense. And so, I thought, “Okay,
well, I can do that. We’ll start looking to these PA programs.” And then I came home about
three months later and said, “I found another good thing. You can go to school the
same number of years as a PA, but you can be a doctor.” Because they have these
accelerated programs. Six year medical programs. So, I said, “Okay, well, let’s try that.” And so, lo and behold, after spending a lot
of time in high school doing the usual things, I applied to and got
accepted at Northwestern. So, I went to a six year medical program. And that turned out to be a tremendously positive experience, but also different than
a lot of people I know. Peter I see over here. He was in a six year medical program, too. I think at Brown. But it really made me think
a little bit differently about education. That was sort of the first
competency-based education that I think I was a participant in. Although I didn’t really
understand that was the case at that time. But, looking back on
it, it really did shape my understanding of what is needed to succeed in medical school. And what’s needed may not
always be what we insist on. – So, the fact that the
normal time course for this is eight years and you did it in six. That’s carried with you and
caused you to ask questions about how long does it need to be and what are people learning? – Yeah, and I think that there’s
a lot of things that we do in higher education and in
medical education, in particular, that people hold fast to as being the absolute best way to do things. But, in fact, there’s
very little evidence. There’s no evidence whatsoever for any of the duration
of residency programs that we choose. There’s no real evidence that you need four years of college before you go into medical school. And there’s no evidence that, actually, every single person has to follow the same pathway. And so, as I’ve thought through a lot of the innovations
we’ve tried to do here, that level of flexibility, and also challenging
the dominant paradigm, has been some of the guiding strategies that I’ve used in thinking about medical education reform, redesign, whatever you want to call it. – We’ll get into some of
the things you’ve worked on. But, in terms of your upbringing and then your commitment to
social justice and diversity, where did that come from in terms of your family upbringing, what you saw? – Yeah, what’s fascinating to me is that, in high school, I decided, as I said, to go into the health
professions as a real strategy. And I specifically didn’t
think I was gonna be a teacher. My mother was a chemistry teacher. She was very beloved. And, like most teenage girls, you don’t necessarily wanna follow in the footsteps of your mother. At least when you’re in high school. But then it very quickly
became apparent to me when I was in medical
school, then in residency, that I really enjoyed teaching. I loved the challenge of
taking a complex topic and converting it into something others could understand. And so, I was first a gross anatomy TA and then I was a psych TA. And then I was chief resident
here at San Francisco General after being a resident. And I really loved my
opportunities to teach. But I really come at education more from the perspective of trying to advance healthcare for others. And that has. I think it factors into. And I’ll get there in just a second. The issue of social justice. So, throughout my career, I’ve really loved clinical diagnosis. I love clinical reasoning. It’s been one of the things
I’ve taught most about and thought most about. Both as a chief resident. Then eventually as a program director in a hospital in Washington, DC. And then into undergraduate
medical education, which started at Ohio State. But my experience as an educator really comes out of a desire to help make sure that everyone has access to the type of doctors we would choose for
somebody that we cared for. All of my siblings have been the victims of medical misdiagnosis. Some to very horrendous results. A lost child, almost a
near death experience. And it really became apparent to me that one of the things we need
to work on in education and in the health professions
in general is reliability. You shouldn’t really have to
have a sister who’s a doctor in order to be appropriately
diagnosed with HELLP syndrome or epiglottitis or avascular necrosis or a brain stem stroke. Those should not be diagnoses that are elusive to large numbers of faculty in academic medical
centers across the country. – Are all those the
examples in your family? – Those are examples of all my siblings. And each one of them. You get this call in
the middle of the night and someone says, “I have these symptoms. Should I worry about them?” And your answer is “Go
back to the emergency room and I will be there as soon
as I can get on a plane.” But it required listening
and trusting the individuals. That the story that they’re telling and the concern they’re showing is something worth paying attention to. And it feels to me that one
of our biggest challenges in medical education today. And I mean that across the continuum. From UME to GME. Is what I would call
consistent excellence. And I think there’s three
areas of consistent excellence. One is universal excellence
of all clinicians. Medicine is a deep bench sport. It doesn’t really matter how
good your best player is. It matters how good your worst player. And so, it really
shouldn’t be the case that people can’t just open a phone book and sort of say, “This person is a doctor. They have an MD. They’re board certified as
an internal medicine person. I can be confident in going to them.” The second is excellence regardless of who you are and who you know. And that’s where a lot of the social justice issues come from. You know, I was chief
resident here at UCSF in San Francisco General. My clinic was there. And I think began realizing how very inequitable our
system is at that point. And, throughout most of my career, I’ve worked in safety net hospitals. With the exception of
when I was at Ohio State. And that idea that people
are treated differently based on the color of their
skin or their last name or their gender. For example, the situation we see in terms of women’s misdiagnosis around cardiovascular disease and the epidemic of maternal
morbidity and mortality here. Have primed me to sort
of think about this. And I have to congratulate
our students for, I think, catalyzing us
to be more aggressive. It’s not just sufficient to say, “I’m gonna create an environment where all doctors are excellent.” But you have to say, “And we’re
gonna create an environment where the medical profession seeks to reverse or mitigate or eliminate all of the inequity that stems from centuries of structural
racism and oppression.” And, if K through 16
education didn’t do it, then we have an obligation to
do it in our own profession. So, those are the things
that I think about. – One more background question. So, you mentioned you came
out here for your residency. I think you started a year before I did. So, the AIDS epidemic was exploding. And you were chief resident of the county. What did you learn from that experience? – That was transformative. At the time, it was. I’m not sure I really understood how transformative it was going to be. It was exhaustive. It was harrowing. It was eternally sad to see this incredible generation of young men, people who were the same
age as myself or as you. They look like my brother. And they would come in and they would have run the beta breakers on Sunday. And, by that following
Sunday, they’d be dead. And it happened time
and time and time again. The most common community-acquired
pneumonia at that time was pneumocystiasis pneumonia. Forget about pneumococcal pneumonia. It was pneumocystiasis pneumonia. And one of the things that
I realized, in retrospect. One was how remarkable
an institution UCSF is. Because, when faced with
this horrible epidemic that was affecting people who had historically been
marginalized by medicine, gay individuals, IV drug abusers, people who were immigrants, UCSF sort of took on the challenge. Not 100% of UCSF. But they took on the challenge. And they took on the challenge in a way that has really impacted the way I look at other big problems. Big problems like healthcare disparities or equality and safety
or the opioid epidemic. And that is they said, “We’re not gonna solve this
just by going into the lab. We need to go into the lab. But we also need to go into the community. We need to sort of put our
best basic scientists to work. We also need to have our best
clinicians working on it. And we need to actually work with people who are experiencing this illness so that the design and
the strategies we use are going to be feasible, acceptable, and positive for the people for whom we’re making these decisions.” And so, that idea of the
comprehensive suite of sciences needed to solve a complex problem is one of the reasons we
designed the Bridges curriculum as we did. Which says that there are more
than foundational sciences that were around with Abraham Flexner. You have to understand education. You have to understand policy. You have to understand culture change. And social and psychologic
sciences, as well. And so, it was really transformative. It was also really
interesting to contrast. After I left here at the end
of my chief resident year, I went to Boston. And Boston was quite different
from the HIV epidemic. First off, there were very
few people who were experts. And so, as a general internist who had just spent four years here, three as a resident in internal medicine and one as the chief resident, I was one of the more knowledgeable people in the organization that I worked for. And I did a lot of HIV care those first couple years
when I was in Boston. Secondly, the community
support was almost nonexistent. And so, there was no real
community engagement. The community was shunned. There was no Shanti Project. There were no nurses
advocating for people. And so, that just sort of
cemented my understanding of what was necessary
to solve the problem. And the fact that this was
not a universal strategy that all medical centers did. There was something unique about UCSF. – Something, sounds like, about
co-creation of the agenda. That embracing, even
if it’s uncomfortable, the idea the people that are gonna be impacted by what you’re
doing need to be involved in the planning of it
and the execution of it. – That’s a good word. I hadn’t thought about that. But it definitely is a
co-creation strategy. – So, you wandered out in the wilderness for a decade or two. And then you came back here. Why’d you come back? – Aw, man. I ask myself that a lot. No. And I’m thrilled I came back. At the time that this
position came available, I had a unique position at Ohio State. I was kind of a last leader standing. So, I was the interim dean there. And I had been vice
dean for education there for about maybe five years. The new dean had appointed me. And then a new CEO for the
health system came into play who had been a dean at another school. And the two of them could not get along. It was really astonishing. Leaders behaving badly. I mean, they would bicker over
who sat where at graduation. And who got to greet who first. It was astonishing. And, you know, I spent a lot of time funneling back and forth and trying to sort of
do shuttle diplomacy. And, in the end, the dean left. And several other people left. And there was sort of a gap. And they said, “Why don’t you do this? You’ve been doing this sort
of de facto for 18 months.” And so, I was interim dean. And, at the same time, I was on the American Board of Internal Medicine with Bob, Tomage, Neil, Cohh. Was there any other UCSF? There was quite a cabal of UCSF. – I don’t think there
was any non-UCSF people. – There were none non-UCSF people. And so, I decided. I was vying for the permanent
dean position there. So, I was the single internal candidate. They were down to three. There was a single internal
candidate in a search there. I had had my doubts about
whether I wanted to stay there. Largely because it was really challenging to work with the CEO of the health system. I could do it. But it took a lot of energy
and effort to manage up. Which is a skill that I think all of you probably learned to do at some level. Not with Bob, of course. Bob could never need to be managed up. – Thank you. – Yes, I just had to say that. We’ll talk later. And people actually really. Bob and Talmage came and said, “You should look at this job. Dave Irby’s stepping down.” And my first instinct was I
was not qualified for the job. Said, “You know, there’s
plenty of people at UCSF who are much greater scholars than I am. And I don’t think this
is the right job for me.” And they said, “No, no, no, we
think you should look at it.” And then I started looking at it. And one of my strategies
in leadership positions is you should take a leadership position if you think you can contribute something that isn’t there already. And the second is you should
take a leadership position if it’s the type of people
you want to work with and you think you can
continue to learn from. So, it came down to it. I came out. I said, “Okay, finally, I’ll come up. I’m probably not gonna stay in the race.” And then, of course, you
arrive here on a November day and it’s sunny and it’s beautiful. And you spend the whole day talking to really brilliant people who
are just genuinely excited about sharing their ideas and helping make the world better. And I went back. And I’m like, “Wow, this is
gonna be a tough decision. What if I’m offered both positions?” Let’s not be arrogant. But what would be the case? And I talked to a lot of people I respect. There were lots of people who said, “You should stay in the
dean’s race at Ohio State, because we need more women deans.” Which is, by the way, true. And then. But I kept saying, “But I don’t want to.” A part of me kept saying. I kept talking to more people to have someone tell
me what I knew inside. Which was UCSF would meet the criteria that I set out myself. Some place where I thought
I could contribute, add something to the excellence
that was already here, and I thought I would
continue to learn here from people that I wanted to learn from. And, in the end, that
was the choice I made is to accept the position here before they made the decision
about the dean there. Because, in the end, I
realized all these people who are urging me to stay in the race to be another woman dean
were not gonna be around when I was the woman dean. I was gonna have to do the job. And I didn’t really want to do the job with the people that were there then. Since that time, they’ve
turned over several times. And so, I think that it turned
out to be a wise decision. I know it was great for me, because I have found this
to be an incredible place for continued learning and the ability to impact
things beyond the walls of UCSF. UCSF has a great reputation as being an innovative place where people, when you talk, want to listen. And the ability to sort of
work with creative students and residents and faculty to really tackle some
of those big problems that I talked about has been
extremely meaningful for me. And I’ve loved every day. Not every minute. But every day I’ve loved. – Every day’s okay. – Every day, yes. – That’s not bad. So, one of the biggest things
you did, maybe the biggest, was revamp the curriculum. So, that’s sort of a
traditional thing that a new dean for education comes and does. And, often, it goes badly. How did you position yourself? How did you try to
understand the environment to increase the probability that you’ll get the outcome that you wanted? – So, an important thing that we. What I thought I could
contribute here was. Dave Irby was an incredible
educational scholar and had created this amazing
cadre of educational experts. And that was essential. It was sort of the launch of the Academy of Medical Educators and the professionalization
of medical education here. And it was because of his work that I was able to come in
with a different lens. And the different lens I had
was as a treating clinician. As I had mentioned, that
drives all of my work. – Dave was a PhD. – Yes, Dave was a PhD in education. And I was a treating clinician. And what I realized, part
through that ABIM work and part work that I’d done
with other organizations, is that we were in the midst of a strategic inflection point in medicine. That it wasn’t going to be sufficient to just continue to tweak
the way we educated. We actually had to aspire to
educate a different physician. The way medicine is practiced now. This sounds not novel. Is much different than the
way it was practiced in 1910 when Flexner walked the Earth. And yet people were still
sort of rigidly holding on to the Flexnerian physician
and the Flexnerian strategy. And so, we started by asking people, “What are your experiences
with the healthcare system? Personal and professionally? What needs to be different? And what type of skillsets
would be evident?” And so, we started not with
how does the curriculum change? We started with how do
doctors need to change? And we did so in a very deliberate way. Going around and engaging
multiple different individuals in this community
and outside this community. Tapping into both what I
would call hearts and minds. Which has been a strategy that’s worked really well for me, as a leader, is to make sure that data is present. Very critical here. You have to know data. But that also that you
get the stories, too. And so, we tapped into amazing stories in town halls and workshops
and things like that. And, really importantly, people were very quickly able to say, “The health system we have
right now is in transition and it’s also not very good for everyone.” And we had people tell stories
that brought others to tears. That brought them to tears. About problems they had had
with the healthcare system with loved ones. Or disappointments they had
as a professional in that. And so, we started from a very high level. Not should we change the number
of hours of biochemistry? Which we did. But that tactical level is
where people tend to squabble. If you start with a really high level. How can we create the type of workforce that will meet all of the needs
of everyone in our country regardless of where they
come from or who they know? People can get behind that. And then I think the other thing is that you always, as a leader, have
an idea of where you wanna go. What’s the direction? You have a directional concept. And you also may have some
strategic concepts, as well. But you have to be willing
to socialize those. And not just to convince people that what you are thinking about is right. But to actually really
hear from them genuinely. To alter the plans in a way that meets the organization’s needs, taps into unique characteristics
of the institution, and creates buy-in along the way. – Can you give an example of an area where you had a pretty firmly set belief on we need to do X and you
chose to do Y based on input? – Yeah, so I will say that, when we first started
redesigning the curriculum, our focus was really on expanding the types of clinical skills that the 21st century physician needs. I wrote an article
called Medical Education: Part of the Problem and
Part of the Solution. And sort of laid out this idea that there was a new 21st century
set of clinical skills. That it was not sufficient
just to be individually expert. You had to be collectively expert, too. And that required systems thinking, quality and safety work,
population management. And we sort of laid
out this whole diagram. And so, our initial focus was on expanding the authentic teaching and early teaching on
quality and safety strategies and systems thinking. And we socialized this for about a year. And people were enthusiastic about it. And then there was what
we lovingly referred to as Propane Tuesday. And Propane Tuesday came about a year into the curriculum redesign. I think I told you about this at this recent workshop we did. When there was a bunch
of physician scientists who were sitting in the room talking about the new curriculum
and essentially revolted. And they revolted in very vocal ways. Basically saying they
did not see themselves in this curriculum. That they thought we were leaning too heavily towards
redefining clinical skills without sustaining the enduring excellence that is the UCSF basic science mission. And it was like an uprising. You know, if you’ve ever watched. What is that? Beauty and the Beast. And they’re going after kill the Beast. All like Gaston. It felt like that. – You had to know some
piece of that was coming. – I thought we had managed it well. I thought we had actually gotten by. Because we had met with
all of these people. Individually and collectively. But, when they aggregated. I actually don’t know. ‘Cause I wasn’t at the meeting. But two of my deans called me
up that night and they said, “We have a big problem.” I’m like, “Well, okay.” And so, what we did worked extremely well. We just confronted the dissent. And we asked to meet
with every single person who was in that room and
who was upset about that. And we met with them one
on one or one on two. However they wanted. And we said, “Tell us
what you’re worried about. Help us fix this. If you don’t see yourself
in this, that’s bad for us. Because one of our principles was that you should recognize a UCSF graduate by the way they approach patients and problems and populations.” And we had our commitment to science right there in one of our core principles. But they didn’t see it in
the way we had designed it. And so, we met with them individually. Heard a lot of love for their fields that needed to be respected. And a lot of excitement about thinking about doing things differently. And then we recruited
about half a dozen of them who had never worked in medical education to help us design the inquiry thread. And that’s how we ended
up with an inquiry thread in the curriculum. That starts with the first
year of medical school and then it ends up
with a capstone project. It was all designed by physician
scientists out of that. And I think it actually really
strengthened the curriculum. It’s never perfect. Some students like one or the other. And some think you could do X or Y. But it’s an example of another thing that I thought I would be able
to contribute to UCSF. And this gave me the opportunity to try different ways of doing that. And that is to make medical education something everyone owns. Not just the educator owns. I think, whenever you have a new field, like patient safety and quality, it always starts with a core of experts who become, really, like Bob,
the national figures in this. But, for it to really work
in all medical centers, everyone has to have a level of expertise. You can design the field
using elite approaches. I mean, just these people
are gonna be in the academy. Just these people are gonna
do quality and safety. But, in the end, to be successful, everyone has to have an
understanding of what’s happening and a willingness to row
in the right direction. And so, we benefited from the fact that the elite phase came before I got here. And I was able to actually expand to make it more inclusive. And I think we are better for it. – So, looking back now,
three, four years later, what did you get right? And are there any things you got wrong? – One of the things that I
think is important is that you’re never 100% right when
you launch a curriculum. You have to sort of launch
with about 75% belief that things at 75% are gonna be fine. – But you have to tell people 100, right? – We tell people that
you are in the middle of a very exciting, pioneering experiment. (laughter) And everyone, let me tell you, when you interview them
for medical school, everyone signs on like, “Yes,
I want to be a pioneer.” – Really? They’re not worried
about being a guinea pig that first class or two? – No, I think part of it is
that’s also being at UCSF. You get a little pass for that. Once they’re here, they worry
about being guinea pigs. But, when they’re interviewing, no. It’s like how everybody who interviews in the primary care tract says they want to be a primary care doctor. Or every dermatologist says they want to take care of patients with skin cancer. And then, somehow, we end up with a lot of plastic surgery dermatologists. We put challenges in front
of very bright people. And they figure out how to navigate them. And, if that means telling
us the answer to a question that we want to hear, we incentivize that. So, I think one of the biggest things that we found challenging was we
redesigned the curriculum to be fully integrated. Meaning we wanted to extend basic science. This was part of the
physician scientists’ work. We wanted to extend basic science through the clinical years. Because we really felt that,
in the current environment. And I will use a phrase that I’ve used. There was a little bit more focus on the mechanics of discharge than the mechanisms of disease. And we really want to somehow
restore deeper conversations about what was happening to cause these disease manifestations in the clerkship environment. And so, we designed this curriculum to be fully integrated
for the first two phases. Foundations one and foundations two. So that there would be
early clinical exposure and late basic science exposure. The balance of that has been the most challenging aspect of it. First, from the early clinical exposure. In general, people like this. But it causes a different
pace of the curriculum. So, you have to actually
pace the basic science a little bit faster. Lots of others schools have done that. I’m doing a review at Duke tomorrow. They’ve historically done
one year of basic science. Then one year of clerkships. But we had to stop and sort of back away from some of the speed and redesign even within the first year and within the second
year of the curriculum. So, we’re still working on that. And John Davis is actually got some interesting thoughts on that. The other thing is it’s been harder than we really anticipated to get people to buy into the basic science
in the clerkship years. And students have struggled a little bit with feeling torn about leaving
their clinical environment and revisiting basic science constructs. So, we’ve tried different things. We’ve iterated each year. Next year will be a third iteration. I’m not willing to give up, because I think it’s really important. The empiric data on the
value of understanding foundational science to being
a good clinical diagnostician is very strong. And we can’t actually have students who don’t remember that basic science is the foundation to all we do. But we’re still working on it. Those are the two biggest areas. – Okay, one of the
maybe more controversial issues in the last year or two has been the decision to
not give letter grades out during the clerkship. So, tell us how that happened and what your overall
thoughts about grades. – Grades. – You’re the person who once told me that maybe your kid’s elementary
school had A and not yet A. – Not yet A. Yes, A and not yet A were the two grades. Which I actually laughed at
mockingly when I was there. But I’ve really come to believe in it. So, two things. One is it goes back to this idea of graduating a workforce
that is universally excellent. And really defining what excellence means and how we measure that excellence. You know, a lot of the
strategies we use grades for are not in alignment with that. We don’t use them to make sure everyone is universally excellent. We use them to find the top
10 from every medical school. And then we heap rewards and opportunities on those individuals. Maybe 10 is too small. We’ll say the top 20. And we do so using flawed metrics. We use standardized exams that were never designed for
assessment for ranking. Which is what I will call that. Assessment for sorting
would be another term. We use that despite the fact that we know that those exam scores have very little correlation with anything other than
subsequent exam scores. And I’m saying this as somebody who spent several years as the chair of the American Board of Internal Medicine Test Writing Committee for
the internal medicine boards. Which, interestingly,
are graded pass/fail. And we started looking at a
number of different things. One is, first, we found that there was substantial population group differences between minority and not minority students in the clerkships. And small differences
in assessed performance. Meaning the difference between someone getting an average
Likert scale grade of 3.4 and someone getting an
average Likert scale of 3.3 would translate into
substantial differences and the likelihood of getting honors. Now, I would defy anyone in this room or in this university to tell me what’s the difference between somebody who performs at a 3.4 and someone who performs at a 3.3. This is not like the Olympics where we have a really precise timer. So, that was very disturbing. The other thing is the amount of stress on everyone in the
environment was creating a problem for learning. The relationship between
students and their faculty was deteriorating such that the students would
basically begin lobbying. They would send their notes
to the faculty sort of saying, “You know, if you want me to get honors, you have to give me all fours. Are you sure you meant to give me a 3.9?” And then they would fight with the faculty about whether the faculty
gave them a 3.5 or a 3.4. – You said deteriorated. You think this was
getting worse over time? – I think it was getting worse. I think it was getting worse because of the competitiveness
of the residency landscape. And that has a lot to do with what I think is inappropriate
messaging from the AAMC. And I was on the board of the AAMC. So, I’m looking at myself,
as well, with that. Where the failure to expand
residency positions was greeted. While we were expanding
medical school positions. Was greeted by the AAMC
as a point for them to lobby for teaching hospitals. And that created this environment where they kept warning students. “We don’t have enough residency positions in the United States. You’ve got to apply to a
lot of residency positions.” So, at this point, in 2019, 2018, the average number of residency programs that a US graduate applied
to across the board was 60. 60. Now, there’s all sorts of
downstream consequences of that. Because if every residency program is receiving thousands of applications, they have to sort somehow. And so, they sort on number of honors or they sort on USMLA or both. And so, people are then being rejected from potentially wonderful
educational opportunities based on metrics that really don’t have a lot of predictive ability
about their likelihood of being a successful resident. And so, we looked at equity. We looked at learning environment. The students were afraid to ask questions that they didn’t know, because they thought they
would be graded down. And we found some evidence of that. And then the phrase
“Responds well to feedback,” when we queried people in the environment, was found to be a marker of
a student with a problem. When everybody should
respond well to feedback. Everybody needs feedback. So, then we undertook an experiment to see if we could change the inequity. We raised the cap on honors. We moved to all grading committees. We did all sorts of things. And then we relooked at our equity issues and found they were no better. And so, once you identified that your system has a
structural inequity in it, you really can’t keep
doing the same thing. And we talked with
people around the country who have pass/fail grading. We asked them about their
students’ success in the match. We know that people, institutions, sometimes move back and forth. But we felt that the primary
responsibility for assessment was to help learners improve. Secondary responsibility
was to ensure that people are able to move to
the next level of performance. And this idea that assessment should be primarily driven by the need to help residency programs identify who’s the top doctor in the
country based on exam scores seemed to be much less
important than those two. But we were committed, when we went around and
talked to all the chairs and talked to the program
directors, we said, “We understand we have to do something to help residency programs determine whether this student is a
good fit for their program.” We’re not gonna say the best fit. But a good fit for their program. So, we have to work on
both sides of the equation. But, as an educational
institution committed to equity, we can’t leave things the way they are. And so, that’s why we
moved to pass/fail grading. – So, what do you tell
a residency director now who’s reviewing the
record of a UCSF student? – Yeah, so, a couple
of interesting things. One is we’re still in the
process of reshaping the MSPE, the Medical Student
Performance Evaluation, to be more reflective of
what makes the student particularly unique. That’s another thing where
we’ve been doing things the same way forever and ever. The same narrative paragraphs. The same code word adjectives. And there’s a lot of evidence
that nobody reads them. And people put a lot of work on them. So, we’re trying to experiment with a much more concise
executive summary of the MSPE. Secondly, we’re encouraging departments to do exactly what medicine does. In all honesty, what’s
really much more relevant to a surgical residency is
what the surgical department thinks of that student. Or what the medical department
thinks of that student. Rather than what the
school thinks of them. And so, you all use a departmental letter. Not everyone uses departmental level. But that, we think, is
really an important thing. You know the people well. And you know where they sit in comparison to the other people going into that field. And then the third thing we have planned is actually a broader
communication strategy with the residency
program directors to say, “We’ve moved to this for these reasons. We’ll pledge to be honest with you about our students’ strengths,
as well as their challenges. And we are reaching out to you to make sure that this doesn’t
disadvantage our students.” – So, too early to tell. – Too early to tell. It’s actually the class
that’s graduating in 2021 will be the first pass/fail class. – Got it. A couple more questions. Then I’ll open it up. You wrote an article. As I was looking through your CV, probably the most interesting title was Rock Stars in Academic Medicine. Who are they, why did you
care, and what did you learn? – Yeah, that was a fun. That was really an educational article. So, I was interim dean at the time. And I had this really
challenging basic scientist who’s turned out to be very
challenging to everyone and has subsequently left the institution. But he was really. You know, he’s one of these
people who has won a Lasker and will probably win a Nobel. And everybody always wants
to keep the Lasker winners in their institution
because they really hate it when the Lasker winner moves and then gets Nobel at
another institution. So, I was really
conscious of the fact that deans have lost their
jobs for failing to retain somebody that is that impressive. But he was a pain in the neck. And he would. Every week, he came by and
wanted yet another perk. And one of the perks that almost broke the proverbial camel’s
back was he wanted a shower installed in his office. – Sounds reasonable. – Yes, reasonable. I didn’t even have a
bathroom in my office. I had to use the generic
bathroom down the street. And so, I just kept trying to figure out what makes a person be like this? And it felt like the rock star who only wants green
M&Ms and want someone to pull out the green M&Ms. So, I decided I would
start looking into this. And so, I started reading the organizational psychology literature. And I interviewed a bunch of people. And what was really surprising to me was, in writing this article, which started out from a
position of frustration, I actually grew more
understanding of rock stars. They are who they are
because that allows them to dedicate all of their intellectual time to the pursuit of the scientific goal. And, while I still. Again, I grew up as the oldest of five. If you didn’t get a pork
chop, that was just too bad. Everybody else got it ahead of you. So, there’s a lot of sharing. This idea of demanding was not really part of my ethos growing up. But they just had this relentless focus on what they needed to
do to get their job done. And, while it didn’t
make them a good citizen, a lot of them were
extraordinarily successful. And so, it just reminded me. Writing that article just reminded me that you have to be curious
about people in these jobs. You have to sort of figure
out what makes them tick. You don’t have to compromise your values. But, sometimes, approaching
people who are difficult with empathy and a curiosity about that, you can actually get them to sort of redirect their efforts. And some of what this guy just wanted was constant reinforcement
that we valued him. And that we valued him more than whoever was the next in line
trying to recruit him away. – How do you manage,
psychologically and in real life, the kind of Venn diagram
of gender and rock star? I’m assuming that most of the rock stars who were making a fuss were men. Maybe that’s not right. – Well, at Ohio State,
almost everybody was a man. Except for me. I was the only. I was the only woman in
the whole leadership team. It was very interesting. – But the question of whether. The squeaky wheel issue. Whether people are getting
something more than they deserve because they’re making a fuss. – The gender issues are real. And I think people take
rock stars who are men with a much more generous eye
than rock stars who are women. Rock stars who are women tend to be viewed as not nice people. But I think they’re the same. And I think actually having
more women in leadership to understand that demanding
women sometimes are demanding because that’s how they
need to get their work done. Just like the demanding
men are demanding men because they need to get their work done. But our job, as leaders,
is to make it easier for everyone to get their work done. And not necessarily have to have people ask for special privileges. He didn’t get his bathroom, by the way. He did get some M&Ms. But not his bathroom. – Give you a chance to
talk for one more minute. And then we’ll open it up. About your philosophy of leadership. I think you are generally seen as, appropriately, a really
extraordinary leader. And kind of what are the. Are there tips that you have that you would want to bestow upon people? – Thank you for that compliment. There’s a lot of really
effective leaders here. And I’ve really benefited from working with tremendous people. Sam hired me. Sam Hawgood hired me. Talmage, Bruce, Bob, a lot of the chairs. I think the number one
thing I’ve learned is that you have to lead from the middle. The higher you go in academic medicine, the less control you have over things. You have an expanded circle of influence. So, I talk about the circle of control and the circle of influence. You have an expanded circle of influence. You can influence a lot of people. But you really don’t control much. You don’t control hiring
and firing of faculty. You don’t control, to a large
extent, space decisions. You don’t control money
in every department. Bob has a lot more money than I do in the Department of Medicine. He has a lot more control over money than the dean’s office does, in many ways. So, you have to learn to. – Remind her that every time I ask for something from the dean’s office. – Yes, Bob keeps saying,
“Can I have some money?” I’m like, “Sure, you got a bank account. Go ahead and write the check.” So, you have to learn
to work with influence. And you can only work with influence if you are curious about people. And so, I think understanding that your job is to influence people. And you can influence them both by being curious about who they are. But being curious about the environment that you find yourself in. I talk to people a lot about the importance of leaders understanding the full landscape of what’s happening so that you can help people make sense out of changes that are
happening in the environment. Whether it’s in medical
education, in healthcare delivery, in technology. You have to, in some
ways, be curious about all of these things. So, I think the key to
influence is curiosity. The key to curiosity is preparation. You have to constantly be reading. Fortunately, my reputation as a child was I was always the young girl
who would pray for rain so I could stay inside and read. Rather than being forced to
go outside in the sunshine. (laughter) But that’s actually created
a good lifelong habit. There’s so much now that we have at our fingertips in terms
of helping you understand the dynamics of the
broader societal things. The social justice issues that are happening in the environment have been a particular focus of my reading in the last five years. As has technology. The impact of technology. Where they coalesce. So, I think the other thing, too, is that you should always lead from a perspective of broad vision. And be willing to be firm
in principles and vision. And flexible on tactics. I think that you can’t possibly know what the right way to do things is in every single unit or
every single institution. But you can sort of know
what the right thing to try and do is from a
principle-based perspective. And so, I guess those would be. Those are sort of my leadership positions. Lead from principles. Be flexible with people and tactics. And be open to ideas that come at you either from the individuals
in your environment or from other disciplines. I think I’ve gotten a lot of use out of crossing the disciplinary borders between medicine, business, psychology. That, I think, builds
resiliency as a leader. To have an understanding
of how different fields look at similar problems. – Great. Throw it open to folks in the audience. – [Woman] I’m the Internal Medicine Residency Program director. I do read every word of those MSPEs. And I’m curious. One thing I think you really captured is this breakdown in trust between undergraduate medical education and graduate medical education. And I am guilty of this from
residency to fellowship. And I think part of it is
actually changing the culture to accept that all people
have strengths and weaknesses. And so, honesty involves sharing both strengths and weaknesses. And I’m curious. I think it’s very brave to
be a leader in that and say, “We will share with you
our students’ strengths and their weaknesses. And we want you to understand that all humans have strengths and weaknesses.” How do you do that in a way that kind of gets everybody else
to buy into that immediately and doesn’t disadvantage your own? – Yeah, it’s a really
interesting question. And there’s no short answer to it. I think you have to continuously work. And I feel like, right now, we’re in an era where people are beginning to think about it. I was just. It’s interesting to me. For the first time in all the years I’ve been in medical education, deans are saying we should not be using Step One scores to select residents. I mean, there are some schools
who have taken the stance. For example, Northwestern,
which was my alma mater, said, “We are no longer
going to use Step One scores in any of our programs
to screen applications.” I mean, Larry Jameson at Penn,
who’s on the AAMC board now, has really been pushing them to move. To push the MBME to go
to a pass/fail system. Strangely enough, the medical
schools that resist this are medical schools that
are newer, up and coming, who feel that their students getting a 270 will help them get into
a residency program. And, for us, that’s shame on us. Because that doesn’t. A 270 is no better than a 240. Even psychometrically. And yet we use the
America’s Top Model approach to managing the selection. So, I think you have to
keep working on this. What is excellence? Somebody at the national organization which shall remain nameless, said to me, “Do you know what they
call someone who graduates in the lower 50% of the
class from Stanford?” I said, “I don’t know. Is this like a joke? Is this a question or a quiz?” He said, “They call them excellent.” To which I said, “Maybe
they are excellent.” He said, “What do you mean? They’re in the bottom half of the class.” I’m like, “But they competed successfully to be one of 100 students
out of 40,000 applicants in the country each year
to get into Stanford. That’s pretty excellent there. Then they navigated Stanford. All they did as a mistake
is they chose to go to a very competitive medical school. And the fact that they are lower than 50% is a statistical inevitability. Somebody has to be in the
lower half of the class. It doesn’t work the other way.” And so, this idea that,
somehow, you’re flawed if you’re not at the top of your class I think is something we
have to get away from. And we just have to keep talking about it. And we have to mean it from
our own institution, as well. And so, working on our own institution is probably the number one thing to do. I think showing success and, as you said, showing real concerns
when they exist so that people don’t believe that they had something withheld from them. Challenge, though, is that, you know, residency training occurs at a very dynamic developmental time. Lots of things are happening. You could be a wonderful
student, very successful, and then you travel across
the country and stuff happens. Your parents get sick. You lose your spouse. Any number of things can happen. Can interfere with optimum performance. Not the least of which is you’re thrust into a whole new system at a very developmentally
shaky time of your career and have to learn to work in that system with different supports. So, I think we just need a
broader conversation about it. And it’s going to. It’s not going to happen overnight. It will probably take, I think, the better part of a decade to get people to shift their idea of what is excellence and what are we capable of training. Who are we capable of training. – [Bobby] I’m Bobby Baron. I’m associate dean for
graduate medical education and continuing medical education. You talked a lot about the vision of the collective nature of medicine rather than the prior, more individual. But we don’t do a terrific job with the other health professionals with whom we study or work. And I’m wondering what
your vision would be for the next half decade or so of how do we really build a collaborative clinical learning environment
that’s interprofessional and not as siloed as it is. – That’s been probably the
surprisingly thorniest problem, I think, in health professions education. Because everyone sort of agrees team-based care is where it’s at. Everyone recognizes that
you can’t take care of an individual with multiple,
complex, chronic diseases. And we’re willing to sort of work across our own disciplines to do so. We don’t do it well. I think that’s part of our
challenge in healthcare quality. The balls get dropped between specialist and specialist and
specialist and generalist. Even here, I think
interprofessional education has been the toughest nut to crack. Even being a health sciences campus that has four health profession schools. And that has a lot of reasons. Some it is what I call academic
dust that clogs the system. I’m on semesters. You’re on quarters. My students are free on Tuesdays. Yours are free on Thursdays. If that was only the
problem, we could fix that. More of the challenge is that there’s not enough high-functioning,
interprofessional teams in the clinical environment
in which to educate people. And so, you can do it all
you want in the classroom. Teach about conflict
management and role respecting and relational coordination as a team-based communication strategy. If people don’t see it functioning in the clinical environment
that way, it doesn’t stick. I mean, the tacit lessons
in the clinical environment are some of the most powerful
in medical education. They have the highest impact. And so, if we really want interprofessional,
team-based care to work, we actually have to
redesign the health system so interprofessional, team-based care works in the health system. We have some shining lights. Transplant team, geriatrics, some ICUs. Not all ICUs. But, pretty much on
general medicine wards, it’s still parallel play. And we are going to have to, if we really want to redesign
the working environment so no one gets burned out and we’re not having
redundant documentation, we have to change the
clinical care environment. And we also have to advocate nationally for reversal of ridiculous strategies that require a physician to be the only one to document something
worthwhile of paying for. I mean, there’s lots of
structural issues that feed into the challenge
that you’re outlining. So, it is probably a
decade-long period of work that has to be fought at every level from reimbursement down to
autonomy around deciding how rounds are done and where patients go and who gets to contribute to their care. – Well, plenty more to do. Thank you, Catherine. That was fantastic. Really appreciate it. – Thank you. (applause) (relaxing music)

2 Comments

  • Reply randall2020 January 17, 2020 at 8:30 am

    Unfortunately, the people shaping healthcare today are the corrupt insurance and pharma companies, with the aid of their bought-off politicians.

  • Reply Farhad Mardan Medical tutorial January 17, 2020 at 1:38 pm

    Thanks for subscription

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