Chapter 10: Changes in Academic Medicine over the Past Decades

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Chapter 10: Changes in Academic Medicine over the Past Decades

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After reflecting briefly on the discussion in Interview Session one, Ms. Yadiny sketches how academic medicine has changed in the past decades. She notes the increase of expenses, patient volume, and structural changes to the healthcare system as well as the increasing competition for research money. She gives examples of how these contextual issues play out in the lives of faculty and leader. Ms. Yadiny comments on the challenges of mentoring faculty in this environment. She states that Dr. Ronald DePinho has positively "raised the level of the discussion" about research at MD Anderson, noting that this is threatening to those who aren't of the highest caliber. Ms. Yadiny comments on the challenge of balancing a commitment to compassionate care with a forceful pursuit of hard-driving science. She notes that MD Anderson is a unique institution because it is an academic-corporate hybrid.

Identifier

YadinyJA_02_20160301_C10

Publication Date

3-1-2016

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; On the Nature of Institutions; MD Anderson Culture; Working Environment; Institutional Mission and Values

Transcript

Tacey Ann Rosolowski, PhD:

Well, one of the things I wanted to do today, I mean we had gotten talking, and so I neglected to ask you, before we turned on the recorder, if there was anything that you wanted to follow up with from our conversation last time. I have a couple of follow-up questions, but I wondered if there was anything you had lingering in your mind, that you wanted to touch on, from last time.

Janis Apted Yadiny:

No, I don’t think so. I find it really interesting discussion, because in some way it was very healing for me. I think of Ray, Ray was a friend. Not that I knew him really, really well, but whenever I would go and talk to him, we’d have real talks. I think of many others who’ve come through this institutions, that I’ve been able to sit down with and talk to, and it’s fascinating how many leave feeling ground up. That’s not right. That’s not right, that people put in so much of their heart and soul, into an institution that they have loved and helped build, and they leave disappointed and feeling disrespected. I’ve seen, over the last three years or four years, the light go out of some people’s eyes, who are so committed. They still do fabulous work with their patients. I know this because I’ve shadowed clinicians in clinics, and I see how they connect with their patients and how dedicated they are. But once you get out of that clinic and you start talking about the institution, the light isn’t there any more, it’s like gone. I’m not blaming anybody around this. I think that academic medicine has become what it is across the country. I think we have a national problem, we may have an international problem.

Tacey Ann Rosolowski, PhD:

I wanted to ask you about that, you know how it’s changed over the years, the challenges, the newer challenges that have come up, and they’ve gotten to the point, you know, that people get ground up, get demoralized, at the ends of their careers, good careers, when they should be really proud and resting on lots of laurels and feeling really good.

Janis Apted Yadiny:

Yeah. Well, there are a lot of dimensions to that question. If we look at the national problems, of challenges, of money going out of research science and money going out of—or it getting harder to provide the kind of healthcare that one really wants to provide, because things are so expensive. Why are they so expensive? Because we have new technologies and new drugs and new procedures. All of this ups the ante, ups the cost of running these places. We have pressures for more patients who want to get in, we have patients coming into a place like MD Anderson, with very complex diseases, because they’re living longer. There are a whole lot of dimensions, a lot of dimensions to this, and it’s easy to say, from the government perspective, or out there if you’re not in healthcare, we need to cut the costs. Okay, tell me how. Who’s going to suffer the cost-cutting, right? Where is the impact going to be on the individuals? I think that the whole rough around Obamacare is, you know, is just a first step towards trying to get some costs under control. The fact that a lot more people have healthcare is a good thing, but the fact that they have to figure out how to pay for it and go through all this process of trying to figure out these very different plans, I don’t agree with that, I think that’s nonsense. It just troubles me terribly, that we don’t have a healthcare system, we have a healthcare enterprise, with a lot of players in competition with each other. So when it really comes down to the individual, you’re sort of at the mercy of… I mean, have you ever read an insurance policy from one end to the other? Nobody can understand them. Try to figure out Medicare, holy smoke. So it’s just become incredibly complex, and then trying to bring down the costs within these very complex institutions if phenomenal. It is challenging.

Tacey Ann Rosolowski, PhD:

So how do you see those challenges playing themselves out in the lives of these individual leaders?

Janis Apted Yadiny:

Loudly. Loudly, forcefully, and in ways that make it hard for even them to understand fully, what’s going on. There was a faculty member who came down here, this is four years ago, Susan Block, came from Harvard and gave a lecture here, and we had lunch with her. Susan said, “I’ve just finished an advanced leadership program at Harvard Business School, and it was for people in healthcare,” and she said, “Most of the people in there were from the insurance companies,” you know, along with clinicians and so on. She said, “We spent almost the entire time”—and I think it was a three-week program—“talking about end of life issues. You know, that’s where a lot of the costs go, yeah? And she said, “We all agreed that in ten years, healthcare, as it’s delivered in this country now, will be unrecognizable.” Now, we’ve tried to think about that, it’s four years into what she said, I don’t find it unrecognizable, except where I find it becoming unrecognizable is with the faculty, because they’re pushed to see more people. They have clinical productivity, but they have ways of measuring how many people the faculty see, their productivity, and believe me, not all the faculty are really tremendously productive. So you’ve got a management issue there, which is the management of certain faculty who are not as productive as other faculty. How do you do that? You have faculty who can’t see as many patients, because they are doing very complex procedures.

Tacey Ann Rosolowski, PhD:

Right.

Janis Apted Yadiny:

And so how do you measure what they’re doing? The really good ones, the really productive ones, are told to see more. They feel like they’re making up for the ones on the other end, who aren’t seeing as many. I’m working with a group right now, where they’ve made the mistake, because of such pressure to get clinics fully staffed, they’ve hired some warm bodies. Never a good thing. So they’re dealing with faculty who aren’t as good, aren’t as skilled, aren’t as productive and hey, not as motivated to become productive. So that pressure on the clinical side of the house is real, and so now you have clinicians in their fifties and sixties, this is not the healthcare they signed up for, and they’re having to adapt to this and they’re wondering, what’s this going to mean in the future. On the research side, you have just the tremendous competition for money, and the fact that it’s all driven by getting grants. Some of the research faculty, the really, really good ones, tell me I spend all my time writing grants, I’m never in the lab, rarely. You know, I manage a bunch of post-docs and early career faculty, and try to make sure they’re productive and blah-blah-blah, but I’m in my office writing grants.

Tacey Ann Rosolowski, PhD:

You know, when you say it that way, it’s almost as if, it’s like wow, the problems seem to be simplified, simplified to these things, and I’m trying to think how do you mentor someone through that, you know how do you help them develop leadership, in a situation where their life has become so overly simplified. I spend all my time writing grants, or I have to spend all my time seeing patients or filling out paperwork. How do you get people to see beyond that, to here’s how you develop yourself?

Janis Apted Yadiny:

Well first of all, you have to really understand their environment, so that they get it, that you stand, you can stand in their shoes to a certain extent and you know what’s going on. Then, you have to show them, allow them to see how developing certain skills, like being better communicators, being better at resolving conflict, understanding each of their faculty and what motivates them. Understanding how to mentor or how to give performance feedback, and do it, actually do it, saves them time in the end, makes for a more satisfactory work environment. People want to work with people they feel good about and like. It can lead to greater productivity, may lead to greater, better science. It could. There’s a lot of research going on, on teams now. One of the things I think is phenomenal about what Ron DePinho [oral history interview] has done is he’s brought in some exceptional scientists, and for other scientists here, who were accepting and open to this, what they’ve told me is it’s raised the level of discussion, and they feel so much more engaged and challenge, and like they’re really at the cutting edge. That’s phenomenal, when you get into an environment like that. Now, that kind of thing can be threatening to scientists who aren’t of that caliber, but I know that’s what Ron is aiming for, is that caliber of science coming out of MD Anderson, and frankly, I think he’s right. Why have a research arm to MD Anderson if it’s not going to be the best? Moving people to that level takes bringing in some really exceptional scientists, and then helping some of the exceptional scientists who are here, or have the potential to be exceptional, get to that level, be in that milieu, I get that. I think what’s happening for Ron, I would love to talk to him about how he feels about what he’s seen as a leader, how he’s had to change, maybe his own perspective on things, but leaders at his level are spending a lot of their time raising money. They’re not writing grants, they’re out asking for money, to keep that very expensive enterprise going. Research science is expensive, that’s why pharmaceutical firms gave up on it, the R&D, they’ve cut way back, which is why they’ve lobbed research over to the academic milieu, is because they can’t afford to do it. But on the other hand, the academic milieu can’t run as fast as the pharmaceuticals. So now you’ve got the academic trying to perform in partnership with pharmaceuticals in a way that kind of pushes science forward a little more quickly than it was. That’s, I think why they’re doing the Moon Shots.

Tacey Ann Rosolowski, PhD:

Absolutely.

Janis Apted Yadiny:

Get these geniuses together around these very complex problems and see what we can do.

Tacey Ann Rosolowski, PhD:

And it is creating cultural changes within the institution for sure.

Janis Apted Yadiny:

It definitely would and obviously has to create change, upheaval. I guess the question out there now is what’s MD Anderson going to be in five to ten years, but that’s the same question Dana Farber is facing, and the Hutch, and Mayo and everyone else, they’re all facing that question of who are we. You know, we like to think of ourselves as these care-giving, patient-focused—and we should be—places, yes, yes, yes, but behind the scenes, when you have to drive hard, get money, publish, you have to drive really hard, yes. How do you balance that against—how do you make that… It’s kind of hard and soft at the same time. How do you ensure the care, compassion, connectedness unique to patients, the ability to really slow down and listen, with this hard driving science going on in the background, or maybe even at the bedside. We talk about bench to bedside right? So you come out of the bench like, you know, in your Maserati at 150 miles an hour, and you’re at the bedside, and then you have to be this other person. It’s challenging, it’s very challenging.

Tacey Ann Rosolowski, PhD:

Very challenging, yeah, yeah. Are there leadership issues that you feel are specific to MD Anderson, the unique context here?

Janis Apted Yadiny:

Well, it’s hard to say, because I have limited experience in other healthcare institutions. My healthcare experience was overseas, and when I was at Michigan, I wasn’t in healthcare, I was there ten years. I think what’s unique to MD Anderson is kind of like well, it’s kind of like Mayo, in a sense, and like Cleveland Clinic, although Mayo, there is a medical school associated with Mayo. You don’t think of Mayo as a medical school. In Cleveland Clinic, there’s a medical school associated, but that too, you don’t associate. It’s not a medical school, a medical school with contracts, you know, with other institutions. It’s set up in a different way, so it is truly an academic/corporate hybrid, and that—the medical schools are too, but less so, because they have a real focus on education. MD Anderson’s focus on education, although we say it’s really important, because we do, we train so many residents, thousands. We have a graduate school, we have a school of health professions and so on. That education focus is much less dominant than it is in the medical school, where you’re there to educate. So yeah, it’s unique in that sense, and I know, when I bring people here from out of state, from Washington, for instance, or Boston or New York, who have never been here, they are shocked at the size and complexity. Now, we’re not as big as Mayo, we’re not nearly as big. Mayo is three times bigger than we are. Cleveland Clinic is two or three times bigger than we are, even Hopkins is bigger than we are. So it’s very interesting to me, that we’re always running around saying we’re so big and complex, and we are, and yet those other institutions are big and complex too. I don’t know if we’re more complex or not, you know? I’d have to walk through—I mean, you could spend a lifetime studying them.

Tacey Ann Rosolowski, PhD:

What do you think the visitors are responding to? I mean, is there something about the culture they’re picking up on, that makes an impact?

Janis Apted Yadiny:

Well, you know they tend to think of MD Anderson as a hospital, and so you know, you have a big hospital, but oh no, we have 30 buildings or something. We have South Campus, we have the Zayed Building, we have that 1MC, we have this whole complex of five or six buildings all together, right? The sheer size is phenomenal, and then it’s in the midst of a medical center that most people don’t have a clue about, from out of state. They come and they’re shocked that it’s all here. It’s like the best kept secret in the United States, the Texas medical center. Yeah. So I’ve had people come who really should know something about this and be agog.

Tacey Ann Rosolowski, PhD:

Yeah, it’s kind of incredible.

Chapter 10: Changes in Academic Medicine over the Past Decades

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