Quick clip: 3 minutes

[Bob:] How did you get into medicine?

[Diane:] How in the world did I end up in medicine? It really starts with human suffering. The human suffering of one person—my grandma. Have you ever been to Philadelphia's China Town?

[Bob:] I have not, although I am going to Philadelphia in June. Is it a must go?

[Diane:] It's a must go. Philly's Chinatown has the best food of all the Chinatowns.

My grandmother lived in Chinatown, and when I was in high school, I went to visit her in the middle of winter. I knew that she was diagnosed with Alzheimer's, but I didn't understand what that meant. I went there to help bridge some care for her between my relatives. When I got there—to her apartment—one of the first things I noticed was that the gas and electricity were pretty much turned off. And my mother explained to me that they were worried about her safety; that she would leave things on. I didn't understand, yet, what that meant. But I knew I was going be responsible for making sure that she got a warm meal and that the home was taken care of.

There was one moment when I was there; it was the middle of the night and I woke up because my grandmother had turned on all the lights. And I remember waking up and thinking, "It's really cold in here," and I saw her; she had no clothes on, and she was totally confused. She didn't know who I was. And that was, I think, the moment where I understood vulnerability. So that, for me, was a defining moment. Why or how could I live a life without giving something? Here was a woman who, up until that point, was actually the most responsive adult in my life growing up.

My parents are immigrants and when they first immigrated here they went from the west coast to South Philly in the 70's, which is not a pretty picture. For me, thinking about my parents and my childhood, it was my grandmother who was there as a responsive adult; that strong person [now] contrasted with the vulnerable human being in front of me. It really solidified in my mind, even though I wasn't mature enough to understand it then, that [was] the moment, I would say, that I became interested in medicine. Because our profession allows us—affords us—this privilege of addressing human suffering.

[Bob:] That's a powerful story. I wonder if it explains your early career experience in New York. You finished medical school here [University of Utah], and then did a pediatric residency at Mount Sinai. You also helped develop a care delivery model for special needs children. Tell me a little bit more about your early career.

[Diane:] Right out of residency, I joined this really dynamic multidisciplinary family health center in Queens, specifically Astoria, which is one of the most diverse zip codes in the United States. I was sort of out there on my own. I think that concept of professional autonomy was actually really alarming to me. I was on my own, practicing medicine, trying to deliver quality care, and yet the demands placed on me and the priorities placed on me—which aren't unique—were all related to volume.

The bottom line was, you need to see x, y and z number of patients. Also, as a pediatrician, I was delivering vaccines. So, while I'm trying to balance what I know (medical knowledge), with what I need to do (deliver care), and meet the demands of what practice actually is (business operations), I also had to fill in the gaps of care delivery that might not traditionally be met by clinicians.

When I completed my contract with that health center, I knew it wasn’t the right place for me. I felt like I needed to explore how to be the advocate I wanted to be; why I chose pediatrics. I was contacted by a Pediatric Neurologist I had been fortunate to work with during my time as a resident, David Kaufman. He was probably one of the most, if not the most, empathetic clinicians that I had met. He said, "We're looking for a pediatrician." He was the medical director at the time of a non-profit organization, and his expressed reason for seeking a pediatrician was because the families had asked for it. I thought that was so fantastic, that he was responsive to the families who said, "You know, we really want a pediatrician; we have family practitioners who are great but what we're looking for is a pediatrician."

And the reason why I ended up joining that practice, or that organization, mostly settled on the fact that I admired so greatly the compassionate care that he delivered in a really intense place. The academic environment in New York is really intense. And he was caring for some of the most marginalized populations—when we think about children who are solely on Medicaid in a city where they have special and unique needs; we're talking genetic conditions with families who are stretched thin. I felt like this was, in a way, turning over a new leaf—a new chance for me to embrace some of the things that I loved about pediatrics, which includes advocacy.

[Bob:] Over the years I’ve watched you merge that deep patient-centeredness and advocacy with the recognition that in order to do right by patients, we have to do things a little bit differently as doctors. Which gets to the whole quality and process improvement space of how we look at and design better systems for our patients. Tell me a little bit about when you started making the connection between patient centeredness and quality/process improvement.

[Diane:] That's a great and loaded question. I think first I should confess that my authentic self wasn't actually always there. I wasn't always that patient-centered. I think that's the beauty of self-discovery. Through the process of residency and residency training in an incredibly intense environment, I feel that I lost some of those core values that drive patient centeredness. And because of that, going down a pathway that I didn't feel was consistent with the human being I wanted to be, I think that sets the foundation for understanding that improvement (in general) is a core human opportunity. I wasn't always in a place where I was at the pinnacle of my best self. And that's a painful reflection—to recognize that medicine and the practice of medicine doesn't always lead us down paths where we are supremely proud of ourselves.

And so, with that being kind of a foundation, going into practice helped me return to center. It is my patients who bring me hope. You get to work with these incredible families. Pediatrics is just the most wonderful part of medicine, to be around children who discover; children who've been traumatized and then heal; caregivers who have hope despite significant adversity in their lives, and trying to raise a child in that. For me, I think the first answer or the first step, is that I wasn't always patient-centered.

I think you go through training and you mature through that training. And in that process of self-discovery you gain some insight into what type of human being you are, and how you can address human suffering. We're given the opportunity to become our best selves in health-care delivery. With improvement, we translate what is the best care into daily practice. When we fail, we say it's okay because we're learning from that. It's a journey and a process of understanding how to close that gap between what we're actually doing or who we actually are—where we are as a profession—and what the standard is that we're trying to achieve.

[Bob:] The idea of losing our way in health care is really profound. If you haven't read the book "American Sickness," it just came out about a month or two ago, it paints the stark reality and complexity of our current health care system. For me, I think the path forward is getting back to why we went into health care in the first place. As you look at the next generation of doctors, do you think they need to be trained the same way that you and I were trained? Or do you think that there needs to be an evolution to empower them to do better?

[Diane:] Definitely the latter and I only say that because I believe that we're entering a phase in health care delivery that we haven't necessarily seen before. I have heard some perspectives that wonder, ‘is the ACO, HMO version two?’ What is it that makes this time period different than before? I can think of a number of things; the fact that social media has greatly transformed our dynamic as human beings influences it. The information age; the fact that physicians need to be information stewards and it's such a barrier to try and figure out how to do that, requires a new mindset—a growth mindset. It requires students to be willing to celebrate the challenges that come with failure. Students need to know that there are some things that are just out of their control, but their learning is not. When you talk about the training that we need to have, in my mind, it’s about our ability [the teachers] to let go and allow them to embrace new methods and methodologies.

Human lives are at stake and the training environment is really intense. It's hard to be accountable, and at the same time learn from that accountability, when you are so worried that you are going to harm someone. But I think students in this training time period can be empowered, like you are saying, to help us think outside the box of health care delivery.

[Bob:] As you're talking, I'm reminded that we have a long way to go in building a learning health system. Moving from our historical culture of “shame and blame” to viewing care delivery as a series of controlled experiments where we are continually learning and evolving. That's new for our trainees. What gives you hope for the future as you think about your grandmother and what drew you into medicine?

[Diane:] There are a few things that give me hope. One is the fact that we are thinking about team science. I don't necessarily think we never thought about it, and I don't believe that we didn't practice it before, but we are deliberately emphasizing it in ways that we didn’t in the past. When I think about those students who are applying to medical school and what they communicate about their experience—why they're pursuing medicine, when I'm talking to applicants or reading about their application, I listen for and look for team science experience. We are only going to rescue one another by doing it together. I think that's part of it.

Second is, I get hope every day, because I get to see the face of three-to-five-day-old newborns; the face of the caregivers who now have this precious little package that they are trying to move forward with. I think to myself every day we get a chance to say, "Okay, how are we going to be better?" Because there's something very tangible in front of my face that forces me to think about how can I make sure that this little package has the full potential, the full opportunity as an adult.

There are so many things that I think are exciting and hopeful in medicine, those are just three. The fact that we can actually think about teams in health care, and quality improvement offers a platform for that, every day in pediatrics, I have the privilege of seeing hope in a face of a newborn, and visionary leadership. That brings me hope.

About: Dr. Diane Liu serves as a member of the Graduate Medical Education (GME) Value Council and Associate Chief Value Officer for the Department of Pediatrics at U of U Health.