Learning the Language of Systems Change
Resident Stories: Nathaniel Gleason, MD
UCSF Medicine Residency Track:
Born in San Juan, Puerto Rico; grew up in California
Brown University: AB, American Studies
UCSF Primary Care/General Internal Medicine Residency
Health and Society: Health Systems & Leadership Track
What made you interested in medicine?
I’m legally blind, and didn’t even think I could go into medicine until I was at least 25. I’m a musician – I had a couple bands, played guitar for hire, and did a lot of recording engineering.
On three separate summers I had gone to Ecuador and Mexico to work on public health projects. Each time, I befriended young community doctors who did everything from delivering babies to suturing wounds. Those are things I will never be able to do, and that’s partly why it took me a long time to come to medicine. However, I did have the idea that this field would be forever intellectually interesting, and would provide intensely meaningful interactions.
When I was 25, I went to El Salvador and had some time on the pediatric wards. I thought, “There’s clearly a non-surgical role here.” I got taken with the idea of primary care.
You came to UCSF for medical school. What made you decide to stay at UCSF for residency?
"At some institutions, the residency director conducts report. Chief residents are somewhat secondary – maybe scribing at the board. Residents are rather passive – they are being taught about something, or it’s not especially lively. At UCSF, morning report is entirely run by residents. Faculty are there and they make contributions, but almost like a consultant."
The main thing was the high standard of clinical reasoning among residents. A lot of active learning happens during morning report, when residents who were there overnight as well as those who came in that morning discuss cases. This is the most focused, dedicated hour for education, and it’s an amazing barometer of a residency program.
At some institutions, the residency director conducts report. Chief residents are somewhat secondary – maybe scribing at the board. Residents are rather passive – they are being taught about something, or it’s not especially lively. At UCSF, morning report is entirely run by residents. Faculty are there and they make contributions, but almost like a consultant. The level of discourse is so incredibly high, and that expectation is just part of the culture.
Also, I was a primary care resident. When you are in the hospital, you get all the same training and opportunity that the categorical residents do. When you are doing primary care, you get this second home within a primary care division. It’s a special, extra layer of relationship and mentorship. That was a huge attraction.
What were some key learnings from residency?
Increasingly, a lot of residency applicants are interested in improving the health care delivery system. Even if you know how to make improvements, implementing those changes and getting them into the delivery system turns out to be really hard. UCSF is way out in front on this question, by educating residents through project-based learning on the state of quality improvement and implementation and dissemination sciences. We have lots of national leaders in those fields here, and they’re doing projects with residents.
I went through what is now the Health Systems and Leadership track of the Health and Society Pathway to Discovery. It was a really formative experience. We worked on two yearlong projects, and had the chance to work with the UCSF Medical Center leadership on issues they cared about. One of these was reducing “door-to-floor” time, aimed at reducing delays in the Emergency Department. We went off and gathered data, tested interventions, measured results, and shared our findings with the Medical Center leadership.
You are now a faculty member of the Division of General Internal Medicine at UCSF. How did residency prepare you for your current position?
Part of my job includes addressing access to specialty care, and the way that primary care physicians and specialists communicate and coordinate care. We know that we have a terrible access problem – it can take months for patients to get in to see some specialists.
I jumped into this role immediately out of residency. There’s no way I could have done that without the Health Systems and Leadership Pathway program. I already had a sense of what the main stakeholders in a problem like this were focused on. The complexities of health care financing, the push-pull of fee-for-service and increasing accountability for the cost of care – that is a whole language that is hard to learn from just reading about it, but that you grow to understand through project-based learning. Before I started this job, I knew how health systems leaders talked about these issues, what drivers are they trying to balance, and what measurements they found useful.
That experience was priceless. I wouldn’t have had the confidence to start in this job without it. It would have seemed preposterous as a first-year faculty member to go talk to the specialty service chiefs about what we were doing right and wrong in the way we referred and co-managed patients.
Do you have time for outside interests?
My wife, Anne Fischer, and I have two sons – Max, 9, and Ben, 6. I still play music and I’m teaching myself carpentry and furniture making.