Originally recorded at University of Utah on November 17, 2016. (Annotated transcript below)

A Generation Away from Value

[Bob Pendleton:] We are here today to talk to Dr. Brigitte Smith about what it is to be a leader in the space of value. It is so fantastic to have you here today. First, why did you go into medicine?

[Brigitte:] In college, I was thinking about pharmacy. I thought I would be grossed out by blood and hadn’t even considered medicine in my undergrad for that reason. I took an elective course where community physicians presented, integrating the science and the clinical side. I was really inspired. All of sudden, I dove into the MCAT and went to medical school.

[Bob:] I’m so captivated by your career path. You are a vascular surgeon, a technical expert, but then you decided to complement that with a career path in the education and the value education. How did that unfold?

[Brigitte:] Education became my academic career focus while I was a resident. I started in general surgery, not really sure what I wanted to specialize in. Shortly after I made up my mind about being a vascular surgeon, the University of Wisconsin was approved for a brand new type of training program – the integrated Vascular Surgery residency. It sounded like a fascinating way to train because it removes a lot of the fluff of different types of general surgery that I wouldn’t need to be a practicing vascular surgeon. That got me very interested in graduate medical education, how paradigms change, how they are approved and assessed and evaluated. Being involved in a brand new training model is where my education interest started.

The value related education interest was an accident. I’m a product of the residency training where quality improvement work and value wasn’t taught very well. It’s an ACGME core competency—“do these IHI modules and do a project.” No one explains what value is or why it matters.

When I got here, value is just all over the place. It was clearly important institutionally. It turns out that general surgery needed a curriculum to teach this stuff to their residents. I needed a role in education and they needed someone to teach value, so fake it til you make it. I said great, I’ll figure this value stuff out. I’m not a content expert, I can find a content expert, I’ll develop the curricula, and steer the ship. As I got more involved, I got really excited about the content too. Now I’m trying to become an expert in what I’m trying to teach.

[Bob:] Value is really new, none of us were trained in any of this. We’re all trying to learn on the fly. You jumped into something brand new, and are blazing a trail in value education. It’s both exhilarating and frightening. I’m curious about the frightening part. What things have you found particularly daunting and challenging in these last 6 months?

[Brigitte:] The first thing was figuring out who my resources were. I started on this massive tour to meet everybody I could identify that had a value role. I just started cold-emailing whoever I could come up with—the Chief Value Officer for our department, Rob Glasgow, Sandi Gulbransen [Director of System Quality], Pam Proctor [Director of Patient Safety], you [Bob Pendleton, Chief Medical Quality Officer]. I wanted to figure out what value was, and why it mattered at this institution. It was enlightening but also frustrating because I realized how little cross talk and connection there was between clinical operations and graduate medical education. That was frustrating.

"I’m trying to be an inspiration and lead them not with carrot or stick but with teaching some sort of intrinsic reason why they should care."

As I’ve been teaching the general surgery residents, getting them to understand why it matters has been challenging. I really appreciate that because I’m only a year and a half out from my training, it obviously didn’t take me long in my career to realize that value matters out in the clinical world. But imparting that wisdom to general surgery residents who are really focused on clinical patient care and just getting their patients taken care of, that’s hard. I’m trying to be an inspiration and lead them not with carrot or stick but with teaching some sort of intrinsic reason why they should care.

[Bob:] What do you think it’s going to require to create this generational change where the trainees get it, where value is not having to inspire but it becomes what it means to be a doctor. How do you see that playing out?

[Brigitte:] Over and over, I come back to that it really needs to be a genuine core culture shift. All of the leaders in the institution that these residents interact with every day in the true clinical setting, those are the people that are going to show them that it matters. When you’re in the OR, and you ask for an instrument and they don’t have it open on the field yet, and you said, pause, don’t open that. What do I have that I can use instead? Because that is an added expense. That is modeling that behavior for the trainees—cost matters. I should think about that when I make these choices. Or in the clinic, whether you order an MRI versus a CAT scan. All of those moment to moment choices in the whole department aren’t modeling that behavior every day, they are not going to realize its value just because I say it matters. It really has to be a broad sweeping culture change in the whole group.

[Bob:] So this naïve guy who 5 years ago said ‘we’re going to transform healthcare’ and our timeline is 5 to 10 years, and what you’re telling me it’s really a generation.

[Brigitte:] That may be, I guess.

[Bob:] Yeah...I think you’re right as I have seen this play out. It is going to be a generation away.

[Brigitte:] Identifying mentors within the department of surgery has been hard because I’m asking residents to do QI projects, work through the PDSA cycle and learn the steps to problem solve appropriately. I imagined that each group would have a faculty mentor interested in quality work who could lead them. What I’ve discovered is that even though I have 6 fantastic volunteers interested in quality, they too are in the process of expanding their own knowledge and skills in quality/process improvement. As a result, teaching the specific steps in the problem solving process (and lean principles) may not always be their focus right now. They are trying to impart the importance of culture and the mindset. As far as having mentors to teach the rubric, we still don’t have those experts. It’s a generation away.

[Bob:] As far as work in the organization that excites me most, your work really fits that bill. As I want to talk about the group you’re leading with medical student education reform. I’ve been fortunate to be part of that group, and see you masterfully lead that group to share a vision. Tell me a little bit about what you’re trying to accomplish with that group.

[Brigitte:] That was another happy accident. I was on the SOM curriculum committee, and all of these different working groups came up for education transformation, and value-driven healthcare was one of them. I thought that sounds like what I’m already doing. I’d love to be involved. They needed a leader, so here I am. That’s very flattering that you feel we’ve been able to get buy in and support from everyone that is involved.

[Bob:] What would success look like 6 months from now?

[Brigitte:] That’s tricky, because I’m trying to figure out how this fits into a broader, bigger overhaul of the overall SOM curriculum. The value-driven healthcare component is clearly valued by the institution and is primed to be implemented. We’re hoping to implement first year elective courses in the 2017-18 academic year. A course on value, quality, service, cost, safety—the five main domains—and some electives. We can pilot our first year curricula and then roll out over the next four years. Ideally this becomes a certificate program with 15-16 credit curricula, experiential learning and capstone projects. This will take time and effort to receive formal approval. Over time, I hope it’s seen as important and valuable enough to become part of the core curriculum.

[Bob:] When you work with your fellow value colleagues either in surgery or in the education space, what are some of the things that give you confidence and excitement that you are on the right path?

[Brigitte:] One of the first things that comes to mind is our SOM working group, the individuals that come to those meetings and contribute to the effort. I’m in the room with you, and Rob Glasgow, Diane Liu, Susan Pohl, Ryan Murphy, Brad Poss. I’m repeatedly impressed and humbled to be able to lead such an amazing group of people. It’s inspiring to have a core group of faculty very committed to this, and doing an amazing job.

The other thing has been Luca Boi, one of the senior value engineers who has been helping me with the department of surgery curriculum. Luca coaches me through the content, helping me understand the next step of what to teach the residents. That kind of commitment and continuous involvement keeps things moving, holds the residents credible and affirms the importance of this.

[Bob:] That’s fantastic. You talked about Luca and coaching. Success is going to be building coaches in every nook and cranny of the organization. You talked about this culture change that this is new for the residents. When the residents get the coaching, what is the receptivity? Do have any sense of that?

[Brigitte:] I feel like they are getting more and more interested as the process matures. When they were first told to come up with a problem, it was hard for them to scope it and to understand why it would matter. As they are getting deeper and deeper into their projects, I’m seeing them get more engaged and interested. Part of that lesson has been to stick with it for these first 6 months and let it be slow going, let it evolve. Let them start to see why it matters, as they experience it. There is definitely a group that is excited, there is a group that is ambivalent, and there is the group that’s resistant and feels like its extra work.

[Bob:] What advice would you give to a brand new faculty member to consider in their first 90 days?

[Brigitte:] My tour of meet and greet was one of the best things I did. Just knowing who my allies were and who was excited about value, and why. Taking the time to go around and meet people was really valuable for me. Not everyone has been able to contribute directly to what I’m doing, but it helps to know the organization and who the stakeholders are and who your resources are. That was really worthwhile to take that time to just do it. Aside from that, patience and perseverance.

[Bob:] Amen to that. Patience and perseverance are definitely success factors for all of us. Thank for spending some time with us today. Thank you for your work. I’m so excited about the efforts that you’re leading. Its faculty members like you that are truly going to transform healthcare delivery.