[Bob Pendleton:] I am delighted to be here today with Dr. Rob Glasgow who is the department of surgery vice chair of clinical operations and the department of surgery’s chief value officer. Rob–I have a great question at first today. How did you wind up in medicine?

[Rob:] That’s a good question. It’s funny you asked that because we are interviewing resident applicants this morning and someone asked me the same question. My generic answer is that there wasn’t anything else I ever would have been. Ever since I was a little kid playing in the sandbox, I was always the doctor. There was never any other direction since I was a little kid moving forward even through high school and college, this is what I was going to do. If you ask the question why? I think the real issue is for me it is a way of expressing my desire to be outward facing, to do things on behalf of other people. I was at a great restaurant this weekend and I remember saying thank you to the waiter and realizing that he probably has that same feeling I get about being a doctor in terms of providing something that has enabled somebody in our case, giving them health, and in that case a very nice evening of relaxation and enjoyment with my family.

What that means to me now, several years ago I had a group of consultants following me through clinic trying for figure out what is it that we do that provides an exceptional patient experience. At the end of the day, I was being debriefed by the consultant, He said I have a question for you? At the end of your visit when you say goodbye, they say thank you and you never say you’re welcome. I was totally embarrassed. If my Italian mother heard this she would be disappointed, totally disappointed. I gave it some thought, I was out walking with my wife after that. I reflected and the real issue that occurs to me, the reason I have a hard time saying you’re welcome to that gesture (of thanks), is that when someone reaches that point of trying to convey how much they appreciate what you have done for them, that is the gift, that is the reward. Perhaps that’s why I went into medicine. That is what drives me is - that sense of emotion, that bond, that sense that I’ve done something for somebody and they feel that intense moment. That’s why I do what I do.

[Bob:] I remember hearing that story once before and it really captivated me and resonated with me in terms of that deeply personal connection with being a doctor. And one of the things you have had a career transition of the past few years of going from being this highly skilled, deeply compassionate physician to taking on this leadership role(s) in healthcare transformation moving to deliver high value care. I’m curious about why that transition? And what prompted you to pursue that opportunity if you will.

[Rob:] It’s interesting you say that. This was also a discussion I had earlier today with a couple of colleagues. When I decided to go into medicine, the world I thought I was getting into turned out to not be the world I got into. What I mean by that is I did what you are supposed to do, I did it well, I went to the best training program I can think of, I went to the best fellowship program, I got the best job at the best institution and started down a pathway of doing the job that was asked of me – in a paradigm that set us up for not being successful. In other words, of rewarding things that were not aligned with why I went into medicine. A system, a construct, of how we do surgery and how we deliver health that were in conflict with some of the other aspirations and career goals I had. Actually, I reached a critical point about three years ago, where basically I’d had it. I checked off every box to say I’m successful, I was promoted, I was facing another promotion, but I pretty much had had it. I didn’t want to continue on that journey of trying to do more without having what I’m doing be aligned with what my personal goals for my career. To me one of the biggest gifts was the opportunity to start working with Sam Finlayson, our department chair, who shared my vision. He and I had a couple of difficult but very powerful conversations about what we felt was wrong and what he enabled me then the opportunity to take a step back and say what can we do to fix this. It turned out to be the great opportunity given the current paradigm of health care reform because it is exactly what is needed. For me a career in medicine is fantastic. I would hope everybody else could be so satisfied with their careers, but I don’t think that the system we had before and the rewards and the construct we had before are conducive with us having a lot of value in our profession. The reason I jumped on this opportunity, and was given the opportunity, and trying to really invest everything I can into enhancing what we consider a high-value healthcare system. It’s not only high-value healthcare for our patients and providing outstanding care and tremendous value by the various parameters that go into that equation, but also to do this for our colleagues, for us in healthcare. For me the real challenge is that I’m struck by the fact that a lot of us in medicine have lost sight of why we did this and I see this day in and day out. Not as much here at the University of Utah, because I think most of us have gotten on that movement, but especially so in our broader community of providers, especially in my area, surgery. People are very disillusioned, very disengaged, upset, feeling lost. And it doesn’t have to be that way.

On a more personal note, I have a son and daughter, my son in particular is a sophomore in college, my daughter graduation from high school. Both looking for a career in healthcare, both for the right reason. I would not want them to have to go into a health care system or a method of delivering healthcare, practicing medicine that was what we had, or what we currently have in a lot of other environments and communities. My hope is that we can get it right, so when they go into medicine, they feel fulfilled.

They wake up every day and say this is the coolest job that can be. Yes the rewards will be there, they might be different, and they might be less they might be more. That’s not the goal. The goal is to wake up in the morning and say I get to do something really cool. That would be a real gift. In terms of my legacy for my department, for my profession, that would be a cool gift to give somebody. I have 15 years of my career left. That’s what I would like to do.

[Bob:] I have no doubt you will continue to be successful in leading that. Hearing you talk I’m reminded of a historical figure in medicine. I don’t usually give a nod to orthopedic surgeons, but a hundred years ago, a guy named Ernest Codman had this really cool idea called the end result, which kind of gets what you are talking about. If we are in the patient care business, ought we not care enough about the outcomes of the care we deliver so that we learn from that and improve. There is deep fulfillment that comes from that process. But, 125 years ago, Codman was kicked out of Mass General and ostracized by his colleagues. What is allowing us now to still build on that same simple vision and actually move forward in improving how we deliver care to our patients? How our colleagues find fulfillment in that? What is different now?

[Rob:] I guess there are things being cast upon to look at things differently, external forces. I think most people view this as a challenge. As I’ve looked into this, and I’ve learned a lot from you and your leadership in this. Within those challenges are opportunities.

If you really look, for example, at our value equation of quality and service—what's wrong with saying we want to do what is right? In the realm of service we want to do it right and on the cost side we have to be careful of how it is we do this.

When I was in training at a great institution, UCSF, we could barely measure any of that. We had no idea what was good, what was bad, we had no idea about what was appropriate, and even then didn’t even know how to measure were we doing it well. All of us are motivated by knowing that we are doing well. Everybody who has risen to or has gone through the education we’ve gone through has lived report card to report card, knowing yes, I’m doing this great. I really think that if we look critically at this concept of doing what’s right, doing it for the right reason and doing it right – that gets us back to who we are. And Codman, that vision was very true, but the problem but we didn’t know how to do it. We couldn’t measure it, we didn’t know what it meant, and we didn’t know what it looks like. It isn’t until very recently that we started to figure this out. I think our institution has done a magical job at identifying worthy opportunities and what should we focus on. We have a lot of work to do but I think we are off to a good start.

[Bob:] I think you comment of starting to figure this out totally resonates with me because that’s how I feel. We are just at the beginning of actually making this really, really meaningful. But it is also hard, messy, challenging. In your role you’ve been a leader in thinking about measuring longitudinal outcomes with NSQUIP registry and really starting to integrate that into how providers get that feedback about outcomes of their patients and drive improvement. What are some of the biggest barriers and challenges you see to go from where we are now to futuristic ideal state of the perfect end result described by Codman?

[Rob:] I have a great slide when I talk about the challenges we have had, for example with our operating cost tool rollout and how to operationalize VDO, of this cartoon of this cowboy trying to lead a horse to water, and the horse saying “Nope” it is a great, great cartoon. Our biggest challenge is getting everybody on board. When I talk to people who say this is too hard, it isn’t important – what I have in my back pocket are a series of examples from colleagues who have gotten together as cohesive groups of providers in trauma for example, transplant service. Where they have gotten together with strong leadership, gotten everyone on the same page, gotten all of the incentives aligned, they have sat down and how best can we do this? What is the Utah Way of providing trauma care? And show the results that they have and not only selling but also excelling exceptionally well by any nationally collected data or outcome measure. To see the pride they have in that. It is possible, it’s just a matter of getting a critical mass of people involved and getting started. But the other side of that is that it can’t all just be on the provider to do that. This is the time where we in healthcare need partnership with our administration mores than ever. It can’t be on us, it can’t be on them, they can’t judge us we can’t complain about them. We have to work together. In each example I mentioned is where that alignment has brought forth great, great measures of performance and the other thing is that you look at the cohesion of those groups and how they do things, it is admirable. I wish upon everybody that kind of success. I’d like to step back and smile and say “look at what you did.”

[Bob:] I love the two examples you gave. Truly transplant and trauma lead nationally prominent groups in delivering high-value care to patients in a really powerful way. The thing that strikes me when I think about that, you commented that the providers have to lead this effort but leading is not dictating, it’s really having the skills to engage the whole team, partnering with administration, working effectively with other care providers – be it nursing, therapy services, lab, whoever. We don’t get trained to do any of that as doctors. We get trained to be independent soldiers how do we move forward in giving colleagues that gift of actually those leadership skills to leads these care teams effectively?

[Rob:] Those who get involved in leadership have to want to be there. They have to believe in the mission. How do we encourage people to do that? We define what our goals, institutional, department, service line, and say here is an opportunity to lead that. And the resources have to be there to support them. When I took this position, under the direction of Dr. Finlayson, he provided me with a couple of opportunities to take a step back to reflect on who I was. I did a course through the business school, which was the perfect course at the right time to process my strengths, weaknesses when it comes to rally the troops to be a transformative leaders. That was a concrete example to enable people with knowledge and skills to do this.

I think it really comes down to providing the right people the right opportunity and removing barriers from their way. Letting them work toward a goal that we all agree is the goal, but pulling off the barriers and impediments to getting there, defining the rules of engagement and rewarding them when they get there. That I think is imperative.

Not everyone can go get an MBA and it probably isn’t necessary, but there are opportunities at strategic points for people to pick up extra skills. For me it was this executive leadership course could not have come at a better time. What it means to be a transformative leaders as opposed to being a coach or something like that? These various leadership styles and theories behind that speak to people.

[Bob:] It’s interesting because I’ve thought similarly. What a better captive audience to learn new things and new skills, I mean doctors - that’s what we are trained to do. All professions that are trained to embrace lifelong learning and continue to build skills in different ways, but that is physicians at the core. Your comments about giving people this opportunities, broadening their horizons, and identifying more skills and more tools to learn.

[Rob:] For the overwhelming majority of us on faculty at the University of Utah, like other academic health centers are in academics because we want something more. I’m saying more in the qualitative sense, not quantitative sense, of being a care provider. That is not to undermine the importance of providing care. For me I’ve done four basic operations – I’ve done one over 2000 times, for me it is a lot like my high school job at the tomato processing plant. Grabbing the bad tomatoes before they go to the next guy. For me it is this need to do something more. This concept of value transformation is clearly that pathway for me to have something more. I think that is important as we acknowledge there are people for whom it is a great opportunity to express that added aspect of their career something that is beyond the day in and day out. The day in and day out can get very difficult, can get boring, can be very exciting, and can be very stressful. I think all of us are here because we want something extra beyond taking care of patients. That aspect clearly defines me and most of my colleagues.

This concept of value transformation is clearly that pathway for me to have something more.

[Bob:] People who are drawn to an academic medical center environment. This is a preselected pool of people who embrace that challenge of diversity in what they do. In trying to lead discovery in whatever avenue, this is just one more avenue.

The last question is you mentioned this recalibrating your career and you mentioned this legacy of the 15 year time horizon that you have. Fifteen years from now, how will you know that we’ve made marked improvement in value transformation? In particular in the department of surgery.

[Rob:] How will we know we are successful? Boy that’s a tough one. That’s a tough one. I don’t know if we will have an ultimate goal, a point to say that we’ve arrived. Some would say we have arrived already. I mean by every measure we have done very, very well. We are doing very well in my department and that’s mainly on the work of other people. I’m glad to celebrate our successes across our department and across our institution. I guess I have to go back to my last comment. Maybe this speaks to advice I got from two people, two very important people to me. One was my father and one was probably my biggest mentor in my career, Sean Mulvihill. Both of them gave me advice when I completed training. On the first day of my job here, Sean and my dad, one summer vacation sitting on our patio overlooking the mountains, both comments were you know your kids don’t care what your CV looks like. So what is going to be your measure of success on your career? I get validation by what I do for the reasons we spoke of in terms of doing things on behalf of other people that are wonderful and personally fulfilling. But when the days are all done, what I’d like to be able to look back on is to say that I’ve helped establish or create something that my kids would look at and say, you know what this has been rewarding. This is what my dad did. I guess I maybe with that I speak to the fact that my older kids are both are interested in medicine and healthcare. What I really want for them is a brighter future than where we were going before we got on this value train. I’m not sure that answers your question directly. I don’t need external measures of performance, what I do need is look back and say that we made a difference, that people, not just difference on behalf of patients but that we have made a difference, made a more viable future for my own kids if they choose healthcare, and for my colleagues. That this continues to be the best profession that it can be.

[Bob:] I couldn’t say it better. I think it coming up with success of being a quantitative end point, misses the whole point of all of this work. Engaging in better, and fulfilment is the admirable end game. I want to thank you so much for talking with us today and sharing your insights. I continue to learn a lot from you and continue to just be impressed and stunned with the effectiveness of your leadership. Fifiteen years from now, you will have achieved all the successes you’re striving for.