The Department of Medicine held its fifth annual strategic-planning retreat at the UCSF Mission Bay Conference Center on October 10, 2014. Over 100 members of the department and distinguished guests were treated to six personal and engaging "TED-like" talks by the following department faculty:
- Susan Lynch: "The Human Microbiome"
- Carmen Peralta: "Structuring Serendipity: The Value of Unusual Mentorship"
- Margot Kushel: "Studying Homelessness: Using Research to Impact Social Determinants of Health"
- Rebecca Shunk: "Was That a Double-Double Animal Style?"
- Alex Smith: "ePrognosis"
- Ryan Greysen: "High Touch' Technology to Engage Patients and Families Across the Continuum of Care at UCSF"
Talmadge King opened the program by reviewing the goals of past strategic planning retreats. He emphasized that people are our most important asset and that the department is making progress in many areas including increasing faculty and staff diversity. We have increased the number of endowed chairs and we are extremely proud of the percentage of faculty who are members of scientific societies. The department continues to be #1 in NIH funding and residency directors have ranked our internal medicine residency program among one of the best in the country. Please click here for a view of Talmadge's entire presentation (only available to UCSF faculty and staff)
Beth Harleman, Associate Chair for Strategic Planning and Implementation, noted that it has been five years since the initial strategic planning retreat in 2009. She asked, "Where do we need to change course?" "What makes UCSF great? "What do we need to protect, nurture and support?" And finally, she said the program would let us appreciate what is being done at UCSF today.
Below is brief description of some of the DOM Voices talks. A video of each talk will be available for viewing by early 2015.
"The Human Microbiome"
by Susan Lynch
Humans are an ecosystem primarily comprised of microbes. We house trillions of microbes in and on our bodies, 10 times as many microbial cells as human, which we refer to as the human microbiome. While it is becoming increasingly evident that the majority of human skin and mucosal surfaces are colonized by microbes, the bulk of these microbes reside in the gastrointestinal tract. These microbial communities contribute essential functions, including digestion of complex carbohydrates and production of essential vitamins. The food we eat represents one of the strongest selective pressures that shapes the gut microbiome. And in western nations, the last few decades have represented a profound change in the types of foods we consume. In parallel with this we have seen rising prevalence of "Western diseases" including obesity, asthma, auto-immune and chronic inflammatory diseases. If we begin to view the gut microbiome as a large metabolic organ which transforms dietary components into bioactive products which enter the circulation and bathe the entire human host, we now begin to appreciate its utterly critical importance to human health. It also invites us to reconsider our view of diseases that we traditionally consider to be located at, and isolated to, specific body sites may well be driven, at least in part by disturbances to the gut microbiome. Manipulation of the human microbiome can lead to incredible efficacy for some indications. But it is incumbent upon us as a community to understand the basis of success and failure of microbiome manipulation, as well as the long-term outcomes associated with these approaches.
I envisage a future where the functional capacity of microbes is harnessed to prevent, treat and cure disease. We must break down the walls of the silos we currently work in, and engage in truly multi-disciplinary integrative studies of human systems that include the microbiome as a critical organ. We must also encourage creative thinking in research, questioning dogma and welcoming new paradigms. This, I believe is the path towards our ultimate goal of truly personalized medicine.
"Structuring Serendipity: The Value of Unusual Mentorship"
by Carmen Peralta
I have often wondered how a successful researcher develops. As we begin to travel the road to becoming a researcher, pressure mounts on having to come up with the "best idea" on our own, and to make it happen. After all, the measure of our success is supposed to be independence. So I decided to gather evidence on the development of successful senior researchers right here at UCSF.
Yet, as I reflect on the forces that have been the most influential in my path, those transition points represented by the arrows- hardly any of these arrows were linear. Hardly any arrows were made possible solely by the box to its left. In fact, serendipity has been my friend. The biggest leaps in my career have come from investments by people in me.
So, how does a researcher evolve? How does a researcher move the field forward? I believe a researcher does not make him/herself, but rather people make a researcher. And I believe that my career thus far is evidence that serendipity is a key ingredient! Informal meetings with people, relationships formed out of common ground, intersections of arrows in careers that appear linear are the propellers. In my case, these random encounters and relationships have moved my career forward. These people allowed me to dream, to remain idealistic.
How do we structure serendipity? I propose three phases: CREATE, SUPPORT, INVEST in the culture and systems that make this possible. Large system initiatives are important, but just as important are initiatives that touch our daily lives, and that come from small programs.
I believe that building an academic culture where the community and the institution invest in ensuring there is room for serendipity mentorship, where people invest in other people is possible.
As I move forward, the personal challenge for each one of us as members of this community is to have the humility to understand that, perhaps, for some of us, some of our greatest contribution to science will come from the discoveries of those we train.
"Studying Homelessness: Using Research to Impact Social Determinants of Health"
by Margot Kushel
As I was starting my research fellowship, I was given the advice to consider studying the thing that drove me the most crazy. The thing that seemed most profoundly broken was the way we cared for homeless patients. An estimated 10% of Americans living in poverty experience homelessness every year. At SFGH we took care of many homeless people: and what we were doing wasn’t working. This decision led to an immensely satisfying career trying to understand how homelessness affects health and health care outcomes—and designing interventions to decrease homelessness and improve health related outcomes.
To do policy relevant work it is important to be knowledgeable about policy discussions that are taking place in the public sphere. If we are going to contribute thoughtfully to the public dialogue, we need understand that dialogue and engage with it. I believe this is true in every academic setting—but it is more true here. Because we are a public institution, we have an extra responsibility to the public—to use our expertise to try to inform the public dialogue around key issues that affect health. There is a conversation in the blogosphere about whether readmission penalties should be decided by data that has been adjusted for SES. I agree—I agree that hospitals should not be penalized for taking care of the poorest and most vulnerable around us. But—I also believe that we can’t stop with adjusting. Because adjusting for SES will never be enough. We need to actually do something about it—to talk about the conditions that breed poverty and to try to find solutions: solutions that support health.
We have a responsibility to understand and help design solutions for those things that fall just outside of medicine, but influence health so directly. I have been so lucky to work at UCSF—to work at a place where so many people are trying to solve the puzzle of improving health. And I have been so lucky to have been allowed to follow my own passions, to work on what interests me.
"Was That a Double-Double Animal Style?"
by Rebecca Shunk
As we all know from the 1999 IOM report, To Err is Human, and our failures are not the result of lack of competence or recklessness but stem from the fact that we are all human and all make mistakes. It is now clearly acknowledged that failures in communication and teamwork are responsible for more than 75% of medical errors and injuries. I am here today to say that we need to embrace not flee from the fact that we make mistakes. If we all do this we can then commit to learning some basic communication skills that we can reproduce routinely. By doing this, all of us, nurse, physician, pharmacist, and patient alike can help reduce some of these avoidable errors.
For me my adventure into teamwork and communication formally began in 2010 when the VA implemented the patient centered medical home nationwide. At the core of this model is communication and collaboration with teams. It turns out the medical home model is much more than just knowing how to be a good team player. It is a mutual understanding of the work and who might be best to do it.
It is critical that we teach our interprofessional learners communication tools and strategies to improve patient care and safety. We want to make sure the trainees keep that love of patients and medicine that started them on this difficult journey to become a doctor in the first place. I want to end by saying that in my mind this teamwork and communication teaching is key to keeping that passion alive. To have a resident find joy in seeing his patients and coming to clinic is really what we all imagined this career in medicine to be and why we all wanted to go to medical school in the first place.
by Alex Smith
I want to talk with you today about prognosis. By prognosis I mean the expected outcomes of treatment. When most people hear the words prognosis they think about life expectancy, or how long someone has to live, and that’s what we’ll focus on today. In residency I realized just how hard this was to have these conversations, and that I had a lot of work to do. I went on to train in palliative care, so I could gain the advanced skills in talking to patients about prognosis, and general medicine research, so I could figure out how to study the science of prognosis and prognosis communication.
Since 2009 there has been a movement to challenge physicians and the public in a real conversation about the important role of prognosis in medicine. When most clinicians think about prognosis in medicine they think about end of life care. They think about people like my Dad with incurable cancer. They think about hospice. And that makes sense – no where is it more clear that prognosis is vitally important than when time is really short.
One of the important steps we and others in the Division of Geriatrics have taken is to move clinician’s understanding of when prognosis is important further upstream, to older adults with years left to live, not weeks to months.
The problem is that physicians often do not have access to high quality information about prognosis for older adults. Prognostic tools exist, but they are buried in the literature. To address these gaps, we conducted a systematic review of prognostic indices for older adults. We reviewed thousands of abstracts and located 16 validated non-disease specific prognostic indexes for older adults.
We created ePrognosis – or estimating prognosis for the elderly. It is a Cancer Screening App in iTunes. We make it easy for clinicians to access the indexes in our systematic review. And we do it for free. We want to revolutionize the way clinicians think and talk with patients about prognosis in clinical settings. We want to challenge clinicians to think about not just incorporating prognosis into clinical decisions, but offering to discuss prognosis with their older patients. Not all of them will want to, but many of them will. We need to couple these discussions with acknowledgment of the uncertainty inherent in prognosis.
Together, we can move this nation toward a more mature conversation about the important role of prognosis in clinical decision making – one patient at a time.
"High Touch' Technology to Engage Patients and Families Across the Continuum of Care at UCSF"
by Ryan Greysen
The challenge: Technologies such as mobile phones and computers have made us more connected than ever – we now expect communication to be instantaneous, information to be accessible, and options for goods and services to be customizable. Not surprisingly, patients and their families increasingly expect timely, reliable access to information and options to personalize their care. Growing evidence also suggests greater engagement in goal-setting, decision-making, and self-management leads to better outcomes and may lower costs. Major payers for clinical care and research increasingly seek more patient-centered approaches as well. While mobile technology for health (mHealth) has potential to facilitate these goals, the field currently lacks a unified vision and strategy, is distanced from providers, patients and families (especially the most vulnerable), and has scant evidence of efficacy and value.
The opportunity: UCSF is poised to lead the emerging field of mHealth with a vision centered on engaging patients and families in their care. More specifically, DOM is uniquely positioned to create a “high-touch” mHealth strategy that will engage patients and providers across a wide range of clinical, educational, and research settings to generate evidence and demonstrate value.
The strategy: DOM can leverage traditional strengths of excellence in clinical care, education, and research while innovating with interdisciplinary collaboration and paradigm-shifting design. “Ward of the Future” to be constructed on the 15th floor of Moffitt-Long with the migration of the Mt. Zion inpatient service to Parnassus in 2015. This project will use adaptive, patient/family-centered devices connected to the EMR to increase engagement from admission and through the continuum of care including post-acute settings (rehab, SNF), primary care, and home health.
Department's Economic Model
Talmadge King gave an update on the department’s economic model including UC Health and the market forces which are pushing health care providers to be provide better coordinated and less expensive care. FY14 was a very strong year financially for the department and a particularly strong year for philanthropic giving. The department will continue to do well despite all of the challenges ahead in FY15 and we will continue to adapt and succeed in the changing environment. Please click here for a view of Talmadge's entire presentation (only available to UCSF faculty and staff)
The retreat participants moved into breakout sessions later in the afternoon which included the following:
- Recruitment and Retention: What can we do to create the best possible environment in which to work and build careers? Led by Beth Harleman and Jeff Critchfield
- Research: How successful have we been in creating a community of researchers? Led by Bill Seaman
- Education: How do we ensure faculty development is in place and of high quality for all of faculty participating in our educational programs? Led by Pat Cornett
- Clinical Activities: Diverse settings and systems: How do we learn and share with each other? Led by Niraj Sehgal
A special thanks to the retreat facilitators: Bonnie Johnson, Elissa Keszler, Maria Dall'Era, Pat Cornett, Christine Razler, Maye Chrisman, Paul Volberding, Mike Peterson, Neil Powe and Niraj Sehgal.