As our class takes a step forward toward graduation, I thought we should take a step back and explore some of our motivations of going back to school in spite of the opportunity costs. And more importantly, how these ideas have changed since that decision. I also want to start digging into next steps. Here goes…
He describes himself as someone “incapable of stress” and yet, by others as “provocative”, two things that rarely coexist. But do so in the venerable Dave Ramos, classmate and cardiologist. Clearly, he’s a man with a vision. Since our class’s earliest days, Dave has been one to turn heads, quiet a room, and create sparks from our professors. He wants to “start things over” in healthcare. I’ve jokingly accused him of nihilism, to which he simply laughs back, a sign I take as acceptance. I’ve always appreciated the edge. I get the sense that he wants to build it right, from the foundation up. I spent a lunch with him trying to access the spaces behind the ideas.
“Why an MPH?” I wondered. Dave shares that he came to the program thinking that the biggest concern in healthcare reform is that there wasn’t “physician participation in the conversation”. He believed that MDs were the “center point.” I remember well when Dave mentioned this in an early Masters Class, our professor responded by saying that physicians were also a “big part of the problem.” And here’s the thing. This was a comment that Dave welcomed. He came to the program to acquire tools and was happy to give up old ones. So that was his first epiphany. “The U.S. healthcare delivery system is magnitudes bigger than just physicians,” he told me.
Dave described a culture of doctors from his generation. These were the “old schoolers” who believed that medicine was also about entrepreneurialism, where the culture was intertwined with autonomy and self-preservation. He wonders if a lack of unwillingness to be self-critical has led to stagnancy in the system. “On the surface, no logical person could believe that fee for service is a good thing.” In this world, physicians were professionals who charged for services – no different from lawyers, accountants, and the like. At a time when physicians felt underappreciated and undercompensated, fee for service was the antidote. There may be no rationale for doing an EKG every six months based on outcomes, but the lack of data allowed for a blank check under the auspices of “patient care.”
“But what was your first Aha moment?” I asked him. He shared a story… Three years into his private practice (circa 2003), Dave met with his business accountant to go over productivity stats (I already sensed this didn’t end well). The accountant told Dave that his partner was out-producing him, not in terms of number of patients seen, but rather in number of tests ordered. Dave, coming to terms with his new self, told him “this isn’t justified.” And that this was an assault on his profession. Dave knew what he brought to the table – representation of his patients’ best interests. While others considered another lucrative scan to be “neutral to the patient,” he didn’t want to increase radiation exposure, force patients to endure the road of “false positives,” etc.
This planted the seed that there was something “very wrong” with healthcare in this country. The story doesn’t end there. In 2007, Dave left that practice and joined another. The pendulum had swung. The new practice was riddled with gross inefficiency, fragmentation of care, and provider-focus over patient-focus. Although the practice was run by well-trained physicians who were incentivized by their academic credo, they paid little attention to the business. Over time, Dave became manager of the practice, which five years later, merged with Columbia University. Integration became the change that spawned Dave to think more broadly about the delivery system. He wants a specialty practice balanced on high quality and efficiency while being comprehensive and well integrated.
“Isn’t this the vision of healthcare reform?” I asked him. Dave maintains the calmest of expressions, but I register a hint of disagreement. He responds that government is simply changing the carrot. They aren’t asking the right questions. He explains that we are changing the game but not impacting the right endpoints. That there is a danger inherent is that the new system can be easily gamed with no improvement in quality. For example, a recent value-based scoring of hospitals showed that the highest rankers had no overall improvement in morbidity and mortality. And markers aren’t real outcomes. Like giving discharge instructions for patients with heart failure instead of actual improvement.
Where’s the middle ground? That’s when Dave thought of the MPH. And since starting, he has learned about all the players – from pharmaceutical companies and administrators, to scientists and health economists. Everyone is contributing to providing quality of care. This is a partnership. “Even the lawyers, “ he said jokingly (a playful dig on two of our classmates). He says that many of his business instincts have been confirmed, such as “looking forward and folding back” a concept we learned in Strategic Management. It’s not just school for school’s sake – this is go time for people like Dave.
He describes himself as humble, and its clear to us that know him that he truly is. But he says that people assume that humility is weakness. I think that this humility allows him to be open to growth. Where does he want to go post-MPH? Dave says he would like to be the CEO of his faculty practice organization, which is made up of six multispecialty centers. He wants to bring bench and medicine together. To bridge the gap between university and community. And to make sure that academic findings trickle down into the community. Because ultimately, it is about the health of the community. After all, his heart now belongs to public health. Or does it? For that we have to stay tuned to the next chapter in the post-epiphany era of our own, Dave Ramos.