Faces of Medicine, Part II

This second installment of our two-part Faces of Medicine series looks at the achievements of four remarkable individuals who are dedicated to improving healthcare through their leadership in the areas of medical education, humanitarianism, Internet medicine, and healthcare administration.

HEALTHCARE ADMINISTRATIONDavid Fine

David Fine is the President and Chief Executive Officer of St. Luke’s Episcopal Health System. He has spent the last 30 years working as a healthcare executive, including 22 years as chief executive officer of university hospitals, multi-hospital systems, medical groups, and managed care organizations. He has also been a tenured professor in healthcare administration, public health, and pharmacy at the University of Alabama at Birmingham, Tulane University, University of Cincinnati, and West Virginia University.

MDNG: You served as CEO of university hospitals, multi-hospital systems, medical groups, and managed care organizations for 22 years. What are the primary responsibilities for a CEO in such systems?

DF: You need to prepare yourself to enter the career of a healthcare administrator by learning a variety of personal skills. The skills required for success in this field are quite diverse. It’s important to act as a cheerleader for your executive team, staff employees, and staff members, and it’s also important to be able to focus internally, maintain great communication with your entire staff, establish values, and demonstrate these values. A CEO in this field will typically find that the job involves a substantial amount of time and energy spent in determining the appropriate strategic direction; deciding which way to go and how to go about doing it; defin[ing] community needs; and determin[ing] how to meet those needs.

MDNG: Can you describe the bond between clinical medicine and the management of healthcare facilities and explain how it affects the quality of care patients receive?

DF: It has been a good 60 years since healthcare administration became its own separate field and there became a distinct need for non-physicians to serve as chief executives. It is critical that we reach a full understanding of what it takes to manage healthcare enterprises. The key issue is to avoid medical errors. A senior healthcare executive must make reasonable allocation decisions and must determine course and quality of care. He or she has to decide how many nurses should work on a given shift; how much freedom pharmacists should be permitted; how to budget for quality services; how to measure the quality of the clinical services you provide; and how to organize these improvements. And all of these interplay with the core of what executives do in healthcare administration, such as planning how demographics guide divisional services and planning services to improve the health of the population in your community. We’re reactive. We react when a person is ill, but how do we charter the course toward wellness?

MDNG: How important do you think it is for healthcare leaders to be involved in civic and professional organizations?

DF: I think that it is essential to represent your organization in the civic arena, both in social and government affairs. On the professional side, I’ve had tremendous fulfillment from serving in several professional organizations. Participating in these kinds of activities helps executives develop the skills they need to demonstrate while on the job.It can be challenging because it means time away from home and even from work, but making this kind of commitment is how you will eventually advance in your profession.

MDNG: What are, or should be, the most important goals in healthcare administration and public health today?

DF: I feel that if we’re talking about public policy, the most critical issue we face today is how much of the gross domestic product we’re prepared to spend on healthcare. This country spends twice what other countries spend, but we’re not getting a healthier population. What are we getting? No issue is more important to the future of healthcare in the United States than this. This is a question that demands an answer. We need better preventative health and we need to address epidemics like obesity and diabetes. We have to change our ways. Healthcare executives and professionals have to be informed and active in policymaking. The government has to do a better job of responding to what people say, need, and want in terms of healthcare. We can’t keep on the way we’re going. Various interventions have been tried by both political parties. The Nixon administration tried cost control, and the Clinton administration launched healthcare re-form. I think that any future direction could come as an intervention by Demo-crats or Republicans. But no matter who starts it, there must be changes.

To read the full interview, go to www.mdng.com

HUMANITARIANISMJoia Mukherjee, MD, MPH

Dr. Joia Mukherjee is an infectious disease doctor and public health specialist, board certified in Internal Medicine and Pediatrics, who is committed to improving basic human rights through healthcare equity. Since 2000, she has served as the Medical Director of the Boston-based charity Partners In Health where she oversees projects in Haiti, Peru, Russia, Rwanda, and Mexico.

MDNG: What project are you currently working on while in Santo Domingo?

JM: I’m actually working in Haiti, but because of the lack of security in Port-au-Prince, we’re coming in through the Dominican Republic and leaving through the Dominican Republic. I spent the last couple weeks in Haiti.

I’m the Medical Director of Partners In Health, a charity that has projects in Haiti, Peru, Russia, Mexico, and now Rwanda. Since mid-2002—through money that we received from the Global Fund to Fight AIDS, Tuberculosis, and Malaria—we have been expanding our HIV treatment, which began in our large charity hospital, to six more public clinics throughout central Haiti. I was going to work with the team there at different sites and then spend some time at our newest site in a very rural town close to the Dominican Republic where we were trying to get the system in place and set up the Internet to make sure our team has the kind of working conditions it needs to deliver care.

MDNG: What is your reaction on being named our Face of humanitarianism in regards to the fact that bringing health to the poor and underprivileged requires the work of so many clinicians?

JM: I think it’s teamwork; it’s never one person. Of course, I’m honored…but I feel that I’m a foot soldier in a much larger battle. The people who are really leading this are those on the ground: patients of ours who have become well from being treated and are now community health workers, mothers who are organizing mothers’ groups so they can support other families, farmers who are trying to organize so that they can plant crops together and improve the level of nutrition in the community. So, as far as our team in Haiti, we would all say that those are the people we most respect and admire. We take our lead from their analysis of the situation. In public health, you need to do a needs assessment from the outside, rather than to just go into the communities and see what their needs are. I also have many really wonderful colleagues in all the countries that I work in who are doctors and nurses who—though they also come from a middle-class background like I do—have chosen to work in very poor areas. For them, it’s even more of a sacrifice, because often their families can’t live in the areas where they work, and they end up in situations where they only get to see their families on weekends. So, there’s a huge structure of people who are making this happen everywhere in the world, and I think it’s very important to highlight that fact.

MDNG: What are the biggest obstacles that you and others working with Partners In Health have to overcome in bringing healthcare to these populations?

JM: Poverty. Poverty and everything related to poverty. It’s shocking; I just left Haiti and came to the Dominican Republic. The difference between these two countries is so striking. Pretty much everyone who we see in rural Haiti has some degree of hunger and malnutrition. So many of the diseases that we are treating are either directly caused by poverty, as is the case with tuberculosis, which affects people with weak immune systems, or indirectly caused by poverty. We certainly think the AIDS epidemic has been fomented by people not having jobs, men having to migrate for work, and women having to exchange sex for food or security. Getting people food and getting people jobs—these are critical elements to delivering good healthcare. A health group can do some of that; we certainly provide food for a lot of needy families, and we provide a lot of jobs. Employed on our staff are 2,000 Haitians, for example. Very few Americans work in Haiti for us; about 70% of our staff are local people. The professional staff generally comes from the capital city. Without addressing those issues of food and housing and jobs, it is very difficult to deliver only medicines because you see people going back to the same situations they were in before. I think delivering good healthcare has a role in addressing poverty, but we also want to work towards pointing out the links between poverty and ill health and, through advocacy, try to address some of these underlying issues of poverty.

To read the full interview, go to www.mdng.com

INTERNET MEDICINEDaniel Sands, MD, MPH, FACMI

Dr. Daniel Z. Sands is a primary care practitioner and an Assistant Clinical Professor of Medicine at Harvard Medical School, in addition to serving as Chief Medical Officer and Vice President for Clinical Strategies for Zix Corporation. He is a member of MD Net Guide’s Editorial Board, and has received several awards in recognition of his leadership in the field of health IT, including the President’s Award from the American Medical Informatics Association and an IT Innovator award by Healthcare Informatics magazine, and he was elected to the American College of Medical Informatics.

MDNG: Why do you think the healthcare industry has been slow to embrace information technology?

DS: Doctors typically have incredible time pressures in the office. They have less and less time to take care of more and more patients, and the patients we’re seeing in the outpatient setting are increasingly complex. The only way that doctors survive from day to day is by being creatures of habit; they’re managing the craziness in their lives by doing things a certain way. The other problem is that the time it takes for reimbursement has put the squeeze on doctor’s offices. A lot of them are losing money. The primary beneficiaries of the use of clinical IT are people other than doctors. If a doctor uses an EMR, for example, just about 90% of the benefit is accrued to other people, including the patients, the insurance companies, and others. Doctors do benefit, but not directly and not in ways that are always easy to see. For example, if doctors benefit in terms of efficiency, then it doesn’t accrue until maybe six months down the pike, maybe even a year in some practices. But there are some efficiency benefits to the doctor and to the practice, like getting rid of paper records, for example.

MDNG: What is it going to take for more physicians and insurance com-panies to accept and adapt to patient—physician e-mail consultations? What can physicians do, if anything, to accelerate this process?

DS: If you talk to most small businesses, they’re focused on the customer. We don’t generally do that in healthcare, and I think that’s a big problem. We need to offer the best service we can. It helps for patient recruitment and patient retention, and it needs to become the norm that we provide good service. Some of that service is going to be online. We know that the majority of US households have access to the Internet, and we know that roughly 70%-80% of those online are looking for health information. And these are people who would like to go online to make appointments, request prescriptions, get health information from their doctor, look at their records, and communicate with their healthcare providers. It is a growing demographic and we need to be appealing to those people. We can’t get rid of the telephone yet, but we can minimize the use of the telephone. So much of what we do in our practice is done the same way it was done 100 years ago. We really haven’t changed a bit.

MDNG: Do you think patients should have access to all of their health records?

DS: Just like the notion that doctors know everything and patients know nothing has to go away, patients need to have access to their information. If someone came into my office and we did a pap smear, it’s her body. We took her tissue and ran a test on it. She should have access to that information immediately; she shouldn’t have to fret about whether it’s normal or abnormal and wait two, three, or five weeks until she gets a notice from me. Or worse, many doctors tell patients, “If you don’t hear back from me, it was normal.” That has to go away. Patients have a right to see their records. We shouldn’t be keeping secrets from patients; we have the technological capability to share information with them. Allowing patients see notes from our office visit is slightly different; I think that there will be additional resistance to this idea. To get a pap smear result online is one thing, but for pa-tients to see the notes we write about them is somewhat different. I still think patients have a right to see them, but there is going to be resistance, mainly because doctors don’t write their notes with the patient in mind. Doctors write their notes for the sake of communicating with other providers; so that they won’t get sued; and so that they can get paid. There are three purposes, but none of them is communicating with patients. For us to let patients see the notes, we the doctors need to have an understanding that one of the audiences now is going to be the patient. Certainly, how we write our notes needs to change and that’s going to be uncomfortable and a little bit difficult for physicians to adapt to.

To read the full interview, go to www.mdng.com

MEDICAL EDUCATIONHenry J. Schultz, MD

Dr. Schultz is a Distinguished Educator, Mayo Clinic and Mayo Foundation; a Clinician Educator, Mayo School of Graduate Medical Education; Chair, Residency Review Committee-Internal Medicine; a member of the Board of Directors, The National Residency Matching Program; Chair, In-Training Examination Steering Committee of the American College of Physicians; and a member of the Education Committee, American College of Physicians

MDNG: How can an electronic system for the evaluation of residents’ rotations and education experiences enable the assessment of resident feedback?

HS: Most resident evaluations are formative; there are observations about resident behavior or attitudes or skills or deficiencies, which are limited in time and scope. The most important thing is for these evaluations to change behavior, to improve residents, and to help make them competent. The electronic evaluation is a very powerful tool that allows educational administrators, such as a program director, to take multiple bits of information and to assimilate them into a comprehensive, ongoing evaluation process (ie, summative evaluation) that gives a broader picture and helps in making decisions not only about the resident’s development, but also about their confidence, their ability to take the boards, and that sort of thing. It’s a tool to allow roll up of a formative evaluation into a summative evaluation.

MDNG: How large of a problem do you feel it is that there are no standards on what constitutes adequate resident supervision in the law, and how do you feel about attending physicians being held liable for the negligence of residents who are under their supervision?

HS: I, and I believe other members of the RRC and the ACGME, feel strongly that supervision guidelines are a matter of accreditation, and they’re not a matter for legal bodies to weigh in on. The current essentials for common program requirements for ACGME have more than adequate standards governing supervision. One of the important responsibilities of the ACGME and the RRC is monitoring the adequacy of supervision. Residents are now polled electronically and confidentially, every three years at least, about the adequacy of a variety of standards in residency training, and one of these is supervision. So, all residents will have the opportunity at least every three years—many more frequently than that—to confidentially report back to the ACGME about whether or not they are being adequately supervised.

MDNG: With the busy schedules that come with residency, is there a need for online learning programs?

HS: There is a need for learning venues other than traditional case-based learning and traditional lectures. The residency review committee for internal medicine is currently actively engaged in a dialogue with some of the program director societies, especially societies that represent small programs—clinical cardiac electrophysiology, interventional cardiology, the new program in transplant hepatology—to see if there are other venues that might be utilized for some core conferencing, such as Web-based conferencing. We’re just now engaged in that dialogue and we hope within the next year to come up with a set of standards whereby programs can utilize other learning venues to fulfill some of the requirements that we currently have for core conferences.

MDNG: What initiatives are the RRC and the National Residency Match Program currently working on?

HS: One is the so-called Educational Initiatives Project, or EIP project; this is a new initiative just approved by the ACGME whereby programs with an accreditation history of success …can enter into a different accreditation process that will allow them to receive up to a ten-year accreditation cycle with some ongoing, yearly monitoring data of resident duty hours, supervision, and compliance with common program requirements. In return for that, we would give them relief on many of the more restrictive and more quantitative program requirements in internal medicine. We would expect these programs to provide the residency review committee with new initiatives in two areas: one iscompetencies—competency-based education and outcomes-based evaluation; the second is quality—training residents in an environment that makes quality patient care one of the highest ideals. The idea is to train residents to be quality physicians or to deliver quality care in an environment that is heavily invested in the institution.

To read the full interview, go to www.mdng.com