Who Will Lead?

In a time of unprecedented challenge and change in health care …

By Rick Krupinski

When William Barsan, M.D., led the establishment of the U-M Department of Emergency Medicine in 1999, he also, by virtue of raising the discipline to department status, sharpened the view members of that department have into other disciplines and services. Emergency medicine is at the crossroads of all other specialties, a critical care entry point, and its wide window into how other services operate is one typically not shared by other specialties.

It was this unique perspective that gave rise to the idea that learning more about how the hospital — and entire health system — works would be valuable education for residents in training. “Doctors need to understand all that goes on around them,” Barsan says. “Understanding administration and operations makes them better citizens of the health care community and it’s critical for anyone, especially residents who have expressed interest in becoming involved in administration in their careers.”

And so, at Barsan’s request, the idea began to take shape, first as a popular seminar series emergency medicine residents could elect to attend, organized by Jeff Desmond, M.D., and Marie Lozon, M.D., both associate professors of emergency medicine. The series covered topics such as health laws, regulatory issues like privacy and compliance, advocacy and physician compensation, and “grew organically,” according to Desmond. Along with colleague Susan Stern, M.D., Lozon and Desmond were awarded a two-year U-M Graduate Medical Education Innovations Grant in 2008, and the emergency department seminar series idea that inspired it all became a structured 20-month program. Along with a separate medical education track, the effort that became known as the Healthcare Administration Track formed the GME Scholars Program, available to all resident trainees within the Health System.

With a goal of better preparing graduates to assume and succeed in leadership positions in health care administration, the training participants receive takes on even greater relevance when one considers the future challenges of fixing a broken health care system, implementing reform under the Affordable Care Act, reining in out-of-control costs, restructuring unbalanced payment systems, and dealing with facilities, equipment and technology that quickly become outdated. Meanwhile, as baby boomers age, the swelling patient population and its escalating needs will demand attention even as change and solutions are being sought. Leaders, it’s safe to say, are sorely needed.

In the Healthcare Administration Track, participating residents — 15-20 new ones per year — complete pre-requisite readings; attend small group seminars, expert panel discussions and workshops; and complete projects, including a core project designed by the residents themselves, often around a problem or need they’ve encountered in their area of study. “The projects,” says Desmond, “help them to apply learning. It’s a chance to experiment, double-check interests, to succeed or fail.”

“They become project champions,” Lozon adds, “advocating for changes and better ways of doing things.” Completed projects are expected to be of quality that will lead to publication in an appropriate journal, and are presented at a final program seminar and submitted to a relevant regional or national meeting.

As central as the core project is to the Healthcare Administration Track, enormous value also comes from the expert speakers who meet with the resident participants. Drawing upon expertise from within the U-M and outside, the speakers and other program components cover 10 broad domains: health care economics, operations management, advocacy and outreach, information technology, hospital administration, professional and leadership development, health care law and regulations, human resource management, quality management, and nursing. Doug Strong, CEO of the U-M Hospitals and Health Centers, has presented to each cohort. Faculty members from the U-M’s Ross School of Business, School of Public Health and the School of Nursing, among others, have also presented.

“It gives residents a line of sight to operations leadership,” Desmond says. “Graduates of the program enter the workforce higher and move up faster. There’s also been significant interest from junior faculty. This is leadership training that’s physician-focused.”

The value of the track was recognized by other residency programs, which began approving participation for their interested residents — representing a significant commitment of time on the part of departments and residents alike. The resulting mix of specialties brought new insights and perspectives to the program, providing, as Barsan notes, “a great non-silo experience.” A tireless steering committee is central to guiding the program, with members representing emergency medicine as well as other residency specialties such as pediatrics, otolaryngology, and physical medicine and rehabilitation.

John Rhyner, M.D., currently a cardiology fellow at Northwestern’s Feinberg School of Medicine, completed his U-M internal medicine residency and the Healthcare Administration Track in 2011. Rhyner wants to remain a clinically-focused physician practicing electrophysiological cardiology — but he also wants to spend part of his time in administrative capacities “in order to help make the hospital where I work more efficient.”

His interest in process innovation and quality improvement led him not only to analyze and recommend alternatives to the internal medicine resident jeopardy call system (the on-call system used to cover residents who can’t make their service), but also to investigate, with fellow resident Eric Dueweke (M.D. 2008, Residency 2011), the prevalence and incidence of catheter-associated urinary tract infection and sacral decubitus ulcers at the U-M Health System. Rhyner’s recommendations for changes to the process of resident coverage are being considered for implementation within the internal medicine residency program.

Rhyner participated in the administration track to gain a better and more specific understanding of a large academic medical center — the context in which he sees his career — and to become familiar with the many forces at work within the system. He also wanted to gain skills in assessing a practical situation critically — a cause-analysis approach — and to further develop his skills working with people in all capacities of the organization.

“Technology is wonderful,” he says, “but our biggest challenge is to harness and use the tools we have.” Working across residency silos became a productive tool for Rhyner during the program.

Tim Peterson, M.D., an assistant professor of emergency medicine who also holds a master’s of business administration and co-directs the program with Lozon and Desmond, adds that working across disciplines “shows residents how valuable collaborations are — within the Health System, across the U-M and outside. We have a number of top schools at the U-M, providing a lot of expert resources and opportunities for some truly innovative collaborations.”

At the end of the GME Innovation Grant, the program was no longer an “innovation,” so no further grant support was forthcoming. The Department of Emergency Medicine, which had contributed resources since the earliest days of the program, couldn’t bear the costs associated with the larger, more encompassing enterprise the Healthcare Administration Track had become. Since other residency programs had come to benefit so much from the track, those departments were approached and asked to contribute $1,000 per year per participant.

The departments agreed. In days of lean thinking and cost containment, the financial commitment from the departments resounded as proof positive of the track’s educational value and success.

Its participants and graduates enthusiastically reinforce that value. After earning her medical degree from Albert Einstein College of Medicine in New York, Rachel Bartash, M.D., came to the U-M for residency training in internal medicine. She’ll complete her residency — and her participation in the Healthcare Administration Track — this year, and begin a position at the VA Ann Arbor Healthcare System. She and physician-husband Jeff Vainshtein have enjoyed their time in Michigan and, while making no commitment, admit they may well be here for the long term. The Healthcare Administration Track exceeded her expectations, she says, and provided her with “a good foundation of knowledge about health care administration and policy.”

Bartash undertook a project with Carol Chenoweth (M.D. 1984, Fellowship 1991), professor of internal medicine in the Medical School and clinical professor of epidemiology in the School of Public Health, to come up with an education-based quality improvement tool to help lower blood culture contamination rates in the medical ICU. While analysis of the data they collected will be the final phase of her project, Bartash is hopeful they’ve been successful in reducing contamination rates. She wants to remain in academic medicine, combining a clinical focus with administrative work, as well as research in quality improvement.

“In medical school,” she says, “we learn all about the clinical aspects of medicine, but there’s the whole other aspect of health care administration that we’re not exposed to. “The admin training is a great learning opportunity for those of us considering careers that will include health care administration,” Bartash continues, “but even for those interested in just clinical or research careers, what we learned is crucial to everyday practice.”

It’s a point Jeff Pothof, M.D., echoes. “We know how to create excellent physicians, but they get no experience with how the whole system works, how to play nicely with others in the sandbox.” After earning a medical degree from the University of Wisconsin School of Medicine and Public Health, Pothof completed his emergency medicine residency at the U-M, including a year as chief resident. He says the chief resident role was a great way to learn the administrative underpinnings of residency training: “How do you evaluate residents? How do you provide educational opportunities for those who need them? For those doing well, how do you challenge them more?” He admits that he signed up for the Healthcare Administration Track thinking it “sounded cool,” wanting an administrative niche but not sure exactly what that niche might be. He knew he liked to effect change, and operations became his administrative focus: finding the best way to do things.

For his project, Pothof collaborated with colleagues to study patients with gastrointestinal bleeding who needed endoscopy, searching for ways to improve the process. The project offered the opportunity to evaluate patient assessment practices, analyze procedures and data, and interact with hospital administration.

Today, Pothof — not long out of his training — is chief of emergency medicine at the William S. Middleton Memorial Veterans Hospital, which is affiliated with the University of Wisconsin Hospital and Clinics in Madison. “The administration track’s good mix of topics,” he says, “teaches residents to be successful, allowing them to go on to more training or direct experience in the administrative area of their choice.”

He also says the best testament to the track’s value is that Brian Sharp, M.D., who is about to complete a U-M emergency medicine residency — and the Healthcare Administration Track — is their number one recruit; he’ll soon join Pothof at the University of Wisconsin as assistant medical director in UW’s emergency department.

Ora Hirsch Pescovitz, M.D., holds one of the biggest jobs in the University. As the U-M executive vice president for medical affairs and CEO of the Health System, Pescovitz holds top responsibility for three hospitals, 40 outpatient sites, more than 120 clinic and office locations throughout Michigan and northern Ohio, a top-10 medical school and its family group practice, the clinical activities of the School of Nursing, more than 26,000 faculty and staff, nearly $500 million in federally funded research projects — all while continuing a 15-year positive operating margin.

Pescovitz, a pediatric endocrinologist, is the perfect example of a physician who took on a bit of administrative work along the way. She’s presented to residents for the last two years. “Health care administration practices, policies and processes are an integral part of a health care ecosystem,” she says. “A physician who understands both the administrative and clinical sides of the complex and changing world of health care will have a deeper understanding of the work that they do as it relates to the overall health system. I wish I had that type of exposure as a resident, or even as junior faculty!

“This year I decided to forego a formal presentation and let the residents ask me about the issues most important to them,” Pescovitz says. “I am glad I did — it led to a very engaging discussion. I really wanted them to know that all parts of a health system are important for achieving maximum effectiveness.”

Those engaging discussions were a highlight for Jessica Leschied, M.D., a second-year resident in radiology who also completed an intern year in Grand Rapids, Michigan. “I find it exciting that the meetings with speakers take on controversial and timely topics,” she says, “like health care reform and medical-legal issues.” The discussion presents different backgrounds and perspectives, which Leschied finds important to future clinicians.

No stranger to multiple perspectives, Leschied, a Canadian, did her undergraduate work in Canada, earned her M.D. at the Royal College of Surgeons in Ireland, lived for a year in Hungary, and is completing her residency in the U.S. “I’ve experienced a lot of health systems,” she says. “I went into the Healthcare Administration Track mostly to learn more about the system in which I’m training now. It’s motivated me to be more involved.”

Different backgrounds and perspectives are what’s behind the synergy Lozon identifies as critical to the program’s goals and success. “Across departments, tracks, academic interests — that synergy is what takes participants from issue to solution,” she says. Lozon tells of one resident who worked with Health System leaders to create a guideline for ethical allocation of scarce resources should the region experience a mass infectious or medical emergency. Part of her project has been incorporated into the guidelines for the state of Michigan. “She got to sit at the table with influential people in our health system,” Lozon reflects. “There’s not another opportunity like that.”

Late last year, Lozon, Desmond and Peterson took a group of residents to Lansing to meet with Michigan lawmakers and officials, to become more familiar with how decisions are made and public policy is formed. It left Leschied “charged,” particularly the opportunity to meet with Olga Dazzo, director of the Michigan Department of Community Health. “That’s public health at the grass roots level,” says Leschied, whose interests tend toward health education and public health policy in areas such as radiation safety and disease screening. Leschied, in her first year of the program, is considering as her core project a study of radiation exposure in fluoroscopy, looking at pre- and post-radiation levels relating to intervention and perhaps developing an educational tool or pre-imaging checklist.

John Rhyner feels strongly about the value of the Healthcare Administration Track. “There’s a growing need for leadership qualities and skill sets,” he says, “and the program is relevant for anyone who wants to understand what meaningful change is all about.” With the Affordable Care Act, which became law in 2010, he says, “Medical centers will become islands of reform, and health care metrics will be transferred to health care systems. We need to think of different ways of providing care.”

According to Pescovitz, “As health care becomes more integrated, and as quality of care takes on a more central role in practice and administration, physicians with this robust knowledge and training will be extremely valuable to their organization.”

“One of the goals is to get to us early on,” Leschied adds. “If we don’t think about these things, there will be no changes.”