Reflections from the HBS Healthcare Conference

Shawn Li MD MBA

Internal Medicine Resident at MGH

PGY-1

March 27, 2019

I had the opportunity to attend the 2019 HBS Healthcare conference this past February. The day was jam-packed with insightful speakers and thought-provoking discussions. A few takeaways from the day:

Keynote speaker and CEO of the Boston Medical Center Kate Walsh talked about the challenges she faces leading the largest safety-net hospital in New England. While the national conversation is centered around reducing healthcare utilization, often the most at-risk patients need more healthcare services rather than less. Balancing how to deliver high-value care to vulnerable patients with the financial health of the institution proved to be a difficult problem. In particular, Kate highlights the conundrum of care delivery innovation in a fixed-costs heavy organization. Because of disproportionally high fixed costs, most services seemed to have a positive contribution margin. Thus it became difficult to parse out which services were genuinely adding value.

Population health was also a topic that came out across many different sessions. While we saw familiar use cases such as implementations of data analytics from the payer side, it was heartening to see population health blossoming on the provider side as well. Co-founder and COO of Landmark Health, Carol Devol, showed how in-home medical services are transforming the care for patients with multiple chronic conditions. By working with primary care practices, in-home care fills an unmet need for many. As a medicine resident, I realized just how high the opportunity cost of coming to a doctor’s appointment is for many patients. I whole-heartedly welcome new ways that we can reach our sickest patients in their own environment.

At the end of the day, the mission is to provide health to the patients we serve. It’s important to hear different perspectives from the various stakeholders on how they are tackling the toughest problems in healthcare. My experience at the HBS healthcare conference has given me new insights on how we can redesign and reshape the healthcare delivery system.

Physician Meets Real-world Healthcare: My Perspectives from the 2019 Harvard Business School Healthcare Conference

Sarah J. Moum, M.D.

Fellow in Neuroradiology at MGH

PGY-6

March 26, 2019

As physicians, what is our vision for the future of healthcare? Our consensus likely includes more efficient, effective, and equitable healthcare for all. Is this different from the vision of non-physician administrators, health insurance leaders, and other businesspersons? At its core, no; but in its implementation, definitely.

The future of healthcare was the central topic of conversation at the 2019 Harvard Business School Healthcare Conference, which I attended in February at the Harvard Business School in Boston, Massachusetts. The conference was an excellent opportunity for me and other attendees to witness leaders from United Healthcare and other giants within the business of medicine lay out their plans for increasing the accessibility, efficiency, and personalization of healthcare.

What I found particularly interesting, and somewhat disconcerting, was that many of these plans did not include physicians in a central or decision-making role. Undoubtedly, delivering healthcare efficiently in the setting of limited resources requires adopting new approaches from other areas of industry; the future practice of medicine will differ significantly from how it is currently practiced and how it was practiced in preceding generations. However, allowing advancing technologies to reduce or remove the doctor’s role in the interest of efficiency may have negative consequences for both patients and the system as a whole. Training and tradition have afforded physicians with a special fund of knowledge and a unique perspective of both the science and the humanistic side of disease and treatment. Physicians can add value to evolving healthcare business models.

Attending this conference reminded me that while the practice of medicine is an art and a science, it is also a business. As a physician, I must work to help integrate the unique physician perspective into the evolving business model of healthcare. In turn, physicians, like myself, must embrace new technologies in daily clinical practice. Moreover, it is critical for our profession that both seasoned and young physicians alike are involved in conferences, such as this one, where the ideas about the future of healthcare business are discussed and developed. Reflecting on my experiences at the 2019 Harvard Business School Healthcare Conference, I am reminded of the words of an active innovator in value-based radiology, Samir Patel, MD: “If you’re not at the table, you’re on the menu.”

16th Annual Healthcare Conference at Harvard Business School: Back to the Future of Healthcare

Nandish Shah, MD

Resident in Radiology at Brigham and Women’s Hospital

PGY 4

March 26, 2019

As doctors, we often focus on what’s right in front of us--the patient, the patient’s chart, the labs, the imaging. We pride ourselves in figuring out the case and moving on to the next one. Long days blur and we ease into the humdrum. This conference was the metaphorical ‘deep breath,’ a time to take a step back and think about the big picture. No call, no pager, no ANCRs. When again am I going to hear a keynote speech by the CEO of United Healthcare? What made this conference great was its focus on the future of healthcare and the role technology will play in it. There was a panel session on redesigning payment models and one on digit health solutions in underserved populations around the world. Others included digital health improvements in the patient health experience as well as in meeting mental health needs. In a multi-trillion-dollar sector, clearly there are key players besides doctors. It was nice to hear and meet people from various backgrounds working to improve healthcare.

My favorite talk during the conference was one given by Kate Walsh, the CEO of Boston Medical Center (BMC). She talked about social determinants of health, how BMC has worked to increase access to affordable housing, and the opioid epidemic in Massachusetts among other things. But the slide that stood out to me was an illustration differentiating “equality” from “equity” from “true equity.” Basically, “equality” gives everyone the same start no matter the barriers they face. “Equity” involves addressing the gaps in care so that those with little can reach those with more. But “true equity,” something that she envisions for BMC and healthcare overall, involves addressing the structural barriers that led to the inequality in the first place. By the way, this is not a new graphic and a quick search will yield a picture that will explain it much better than my attempt. Regardless, the message is clear: improving health outcomes will depend on our ability to change the underlying socioeconomic inequalities that pertain to healthcare.

While I do have to go back to the dim lights of the radiology reading room, I am excited to carry the lessons from this conference forward. As doctors, we have an incredibly important role in the direction of healthcare, one that is unique for each specialty. For radiologists, improving health outcomes may involve better access to breast and lung cancer screening among other things. Or AI algorithms to determine public health outcomes on imaging, such as osteoporosis and fracture risk based on the density of the spine on a CT of the abdomen and pelvis.

For future trainees: Meet people! Network. Many people besides attendings can open doors in your professional career. We are not the only ones on the dance floor. Maybe tango with the MBA, MPH, or the software engineer. 

Stories of the ACGME: Not Just Duty Hours

Jonathan Zebrowski, 

Resident in Psychiatry at MGH/McLean 

PGY 4

March 20, 2019 

As residents, we often experience the Accreditation Council for Graduate Medical Education (ACGME) as a term associated with myriad regulations and recurrent duty hours surveys. Indeed, coming into the 2019 ACGME Annual Educational Conference as a first-time attendee, I expected several days of interesting but nevertheless dry and technical discussions about the regulatory environment that shapes resident experience. The meeting — this year’s theme was “Rediscovering Meaning in Medicine” — was instead almost entirely composed of groups of dedicated educators and trainees sharing deeply compelling stories that have fueled a desire to continue improving the residency environment.

The conference kicked off with a round-table discussion between ACGME CEO Thomas Nasca, National Academy of Medicine president Victor Dzau, and Association of American Medical Colleges president Darrell Kirch. Each spoke at length about the personal experiences, often involving painful losses of physicians close to them, that have led them to think more urgently about the pressures of medical training They then discussed the collaborative between medical training organizations spearheaded by the National Academy of Medicine, as a means of unifying efforts to support physicians from the very beginning of their education through a lifetime of practice.

Afterward, two days’ worth of breakout sessions focused on issues ranging from implicit bias training for program leadership to novel mechanisms of engaging residents in quality improvement initiatives (as opposed to just teaching them about what QI initiatives are.) Most were designed to be highly interactive, this led to me making a large number of connections with a wide variety of educators all interested in reshaping the residency training environment. Most attendees seemed eager to almost immediately start implementing ideas in their own programs.

A particular highlight of the meeting was a session on mentoring and advising LGBT learners, which drew a wide audience including program directors, coordinators and trainees from across the gender identity and sexual orientation spectrum. I was also thrilled to reconnect with one of the panelists, Dr. Sheryl Heron, who was a mentor of mine at the Emory University School of Medicine as I began my own journey into residency. I particularly appreciated Dr. Heron’s constant focus on the idea of inclusion as a broader ideal encompassing the aims of diversity and representation in residency training.

Reconnecting with Dr. Sheryl Heron, an Emergency Medicine Physician and Assistant Dean for Medical Education and Student Affairs at Emory University. 

 

I attended this year’s conference as I am particularly interested in physician wellness, medical education, and quality improvement, and the content and depth of the discussions I participated in far exceeded my expectations. I have returned to Boston with new ideas that I hope to put into practice in my own future role as an educator. And the next time I take a duty hours survey, I’ll have a far deeper appreciation of the ACGME and the work it supports.

The 16th Annual Healthcare Conference at Harvard Business School: Back to the Future of Healthcare

Ariadne K. DeSimone, MD, MPH

Resident in Radiology at BWH

PGY-3

March 20, 2019

While I spend my work day at Brigham and Women’s Hospital learning and practicing radiology, which is in and of itself extremely fulfilling, my interests extend beyond the practice of clinical radiology and include health policy and management, value-based healthcare delivery, and public health. I explored these interests in medical school, including by pursuing a joint MD/MPH in Health Policy and Management, and have been fortunate to be able to continue to learn about and apply these topics while in residency by attending various Centers of Expertise dinner sessions, participating in the Value-Based Health Care Delivery course, and, most recently, spending a full Saturday in early February at Harvard Business School at the 16^th Annual Healthcare Conference.

The theme of the conference was “Back to the Future of Healthcare” and it featured a series of keynote speakers and panel discussions. We heard from Steve Nelson, CEO of UnitedHealthcare, about how the state of health care today is a “wicked problem,” yet how he has a vision for how technology can enable Americans to make gains in terms of health and wellness. I attended a panel discussion about “Reforming Healthcare Delivery.” Some of the points raised related to how health care and healthcare delivery is local and how it is important to deliver health care from diverse sites, including in the home.  Next was a panel discussion about “Consumer Health and Wellness – Using Data and Technology to Drive New Solutions.” Consumers are frustrated with the healthcare system because of price, convenience, and access. We listened to Kate Walsh, President and CEO of Boston Medical Center, articulate her steadfast belief that achieving health equity is fundamental to addressing health care costs and that healthcare organizations should tackle gaps and structural barriers. A panel discussion on “Digital Health: Bubble or Worthwhile Investment” concluded that digital health is a worthwhile investment (not a “bubble”), especially healthcare IT solutions and platforms. “Adopting Disruptive Technologies in Healthcare: The Next Horizon” panel discussion touched on how important it is to include physicians from the beginning on teams focused on innovation and digital health solutions. The conference concluded with closing remarks by Martin Madaus, Chairman and CEO of Ortho Clinical Diagnostics. He outlined what he sees as potential changes to come in health management: from a physician-controlled paternalistic approach to self-monitoring and self-directed with assistance from expert coaching; from reactive disease management to proactive health management; from lab information only available to experts to consumers fully empowered with their lab data; from standard lab testing to AI-enabled digital physiology; and from one-size-fits-all to individualized precision medicine with deepening understanding of an individual’s risks to health.

At the end of the daylong conference, I was inspired by how many people want to work together to improve the value of health care in this country.  Attending the conference further confirmed my hopes of serving in a leadership position within an academic healthcare system in the future or in a consultant role to various healthcare organizations and systems. I would recommend this conference to anyone interested in learning from experts in the business of health care.

Institute for Healthcare Improvement National Forum

Dania Daye, MD, PhD

Resident in Radiology at MGH

PGY-5

January 3, 2019

I was fortunate for the opportunity attend the IHI National Forum in Orlando, FL from December 10^th-12^th.The conference brings together national and international healthcare leaders to discuss quality improvement in healthcare and means to move from volume to value for better and safer patient care. This year, the conference had 10 tracks: equity, improvement science, joy in work, leadership, maternal and child health, mental health and well-being, moving from volume to value, person-center care, population health, and safety.

On the first day of the conference, I had the opportunity to learn about improving healthcare through better quality measures by attending an 8-hour course taught by Dr. Robert Lloyd, a world-renowned authority in this field. One of the quotes from that session that stuck with me was a quote by Dr. Deming who said: “Without data, you are just another person with an opinion,” highlighting the importance of collecting actionable data to improve healthcare.

One of the unique aspects of the forum was the opportunity to interact with and learn from healthcare leaders from across the world. In the opening session of the conference, I learned about a powerful patient-centered platform that has been implemented in Scotland, Care Opinion, where patients provide input about their care. It is the equivalent of TripAdvisor for Healthcare and has led to tremendous patient engagement in Scotland. In another session that day, I learned about the visionary healthcare strategy in Singapore, a country that has one of the best healthcare systems in the world. Their healthcare strategy centers around 3 pillars: moving beyond hospital to community, beyond quality to value and beyond healthcare to health.

One of the most impactful concepts that I learned at the forum was the importance of focusing on PERSON-CENTERED care, rather than patient-centered care, as it is most often referred to in the literature. Patient-centered care is visit-based while person-centered care is based on accumulated knowledge of people over time allowing for better understanding of their health problems, preferences and needs.  Moving forward, I will be striving to incorporate many of the concepts I learned to improve the care of patients in interventional radiology and beyond.

To close, I will end with one of the most powerful quotes from the forum: “You treat a disease; you win you lose. You treat a person; you win no matter the outcome.”

National Health Policy Conference

Shana Neelu Coshal, MD

Resident in Public & Community Psychiatry at MGH

PGY 5

March 1, 2019

“It’s about life, not about health.  Health is simply a tool to live your life.”

-Dr. Charlotte Yeh (ER physician) during Value Based Reform workshop

I had the privilege of attending the National Health Policy Conference in Washington, D.C. in February 2019, during a pivotal time in health care reform.  Sadly, what was most apparent was the lack of mental health parties at the table along with the persistent theme that our current mental health system will remain abysmal without reform.   There is no health without mental health.  Therefore, if the social determinants of health i.e. the conditions in which we work, live, and age, are responsible for 90% of all health (as opposed to our actual health care system which only attributes 10% to overall health), then all policies are health policies, and if all policies are health policies, then all policies are mental health policies. 

Value based reform was the hot topic of the conference.  This type of program rewards health care providers for quality of care delivered to the patient.  Psychiatry, largely, has nervous to this type of model as behavior determines outcome, something that we do not usually see within our control.  The greatest lesson I took away was that the solution to this problem is that what is missing on the consumer side is trust.  And trust can be developed through co-creation of healthcare with the consumer, and collaboration with the community.  Combined strategies for providers and consumers working in concert have shown to have the best effects.  Consumer engagement provides real-time feedback and shapes the program over time for the better.  Mental health would benefit from a creative design makeover to improve its overall structure by focusing on making the provider’s life and the consumer’s life better.  A new concept, “consumer work flow of life” highlights an approach to model delivery of care that is simple, relevant, and easy to use.  I am very familiar with “provider work flow of life”, being the provider, but I had never stopped to think about our patients’ workflow of life and what would practically make it easier and more enjoyable to consume care.  The average doctors visit is 2 hours, someone with a chronic illness like severe mental illness could spend up to 10 hours a week at doctors appointments.

Most people in healthcare are familiar with the aforementioned social determinants of health, but this was the first time I was introduced to the personal determinants of health, which include resiliency and adaptation, purpose, optimism, and social connection.  These all ultimately contribute to how consumers cope and build assets.  Fostering these characteristics and targeting them in healthcare and societal interventions is essential.  Interestingly enough, studies found loneliness to be the greatest similarity between all frequent flyers in the emergency room.  Loneliness is the strongest predictor of dissatisfaction with our health care system.

Currently we are in the digital health revolution and the culture of innovation has spawned digiceuticals, defined as technology that has clinical outcome.  These technologies can be used to close health disparities as opposed to expanding them.  Artificial Intelligence should not be programmed with human biases that would maintain these health disparities.  The cell phone is showing to be an amazing platform for behavior change.  Applications have been clinically proven by the FDA to treat substance use, attention-deficit disorder, and emotional dysregulation.  These mobile interventions have no side effects. 

Finding Meaning in My Own Work: Attending My First ACGME Conference Part 2

Douglas Cassidy, MD

Resident in General Surgery at MGH

PGY4

March 9, 2019 3:00 PM
The second day of the conference featured 2 sessions on interprofessional collaboration, including an interactive session featured below. The principles discussed can apply beyond just institutional change, including but not limited to carry over into interprofessional team training and simulation as well.

The session focused on Kotter’s 8 step change model in order to make changes to an organization. There is an interprofessional dimension to every facet of patient care, and it is important to have representatives and leadership from all professions and a designated champion to help empower change and encourage buy-in. The 8 steps are featured below, but the most meaningful to me were forming a powerful coalition to generate a climate for change as well as empowering others and implementing and sustaining change.

First, with regards to forming a coalition, it is critical for leadership to remain in charge. Leaders can designate a representative from their profession; however, if leadership doesn’t maintain a direct line of communication and commitment then attempting change is futile. I have found this true in developing my own research and projects in an interprofessional setting, particularly with team training. All professionals must feel as though their opinions and thoughts are validated as they play an integral role in the team. Without the input and a champion or representative from each professional that is aligned with their respective leadership, the project will suffer, and change will not be achieved.

Second, those on the front lines of change must feel empowered with their work in order to create a sustainable environment. This reflects back on the theme of the conference and an often-forgotten component of well-being: “finding meaning in your work.” Many conversations around wellness focus on outside services such as fitness, transportation, and childcare and family assistance.  However, it is critical that our trainees find happiness and meaning at work, especially during the stressors of residency. By finding meaning, we can tackle both institutional change and wellness simultaneously.

Kotter's 8 Step Change Model adapted for Institutional change

March 10, 2019 9:00 PM

Just some final thoughts after returning from Orlando. The conference was a great experience, stress-free, and highly educational. Being able to attend sessions both specific to general surgery and related to my research was highly informative and has helped me translate what it takes to implement interprofessional change into developing an interprofessional team training simulation. For each phase of the design process, I need to make sure that all parties have input, and we can work to build a sustainable simulation for the future. This conference is large and diverse enough to offer sessions for educators across specialties and with varying interests. I’m thrilled that I had this opportunity to meet other health professionals with my interests and learn from their experiences as I advance my career toward a role in medical education.

Finding Meaning in My Own Work: Attending My First ACGME Conference Part 1

Douglas Cassidy, MD

Resident in General Surgery at MGH

PGY 4

March 8, 2019 10:15 AM

Opening of the ACGME Conference 

The 2019 ACGME Conference in Orlando, Florida kicked off with a wonderful panel discussion led by Dr. Timothy Brigham featuring Dr. Victor Dzau of the National Academy of Medicine (NAM), Dr. Darrell Kirch of the Association of American Medical Colleges (AAMC), and ACGME’s Dr. Thomas Nasca about their own personal experiences with burnout and finding meaning in medicine. Dr. Kirch’s narrations of his struggles with burnout and depression as a medical student were especially inspiring as far too often physicians seem incapable of admitting to their own struggles, trying to portray an image of strength. As physicians, we are taught about the importance of empathy with regards to our patients; however, we often neglect to share this same empathy with our own colleagues in medicine. One of the most telling statistics of the discussion was that a higher proportion of physicians commit suicide compared to the number of opioid deaths in the general population. Not to dismiss the opioid crisis, but we must not ignore the struggle and issues we face within our own profession. Looking forward to a great conference with schedule sessions in general surgery as well as fostering and developing interprofessional relationships.

Discussion Panel featuring Drs. Brigham, Dzau, Kirch and Nasca

March 8, 2019 5:30 PM

I spent the first day of the conference attending surgery-specific sessions including a discussion of a national pilot program assessing the feasibility of entrustable professional activities (EPAs) in a general surgery residency. EPAs are made up of a group of milestones and are a framework for assessing competency in real world settings. For instance, in general surgery, and EPA might consist of management of benign biliary disease (see image). This EPA is made up of several milestones that demonstrate but are not limited to competency in knowledge, care of the patient, and intraoperative performance. The EPA bundles these milestones and subsequent competencies. Research has shown that there are growing concerns about the training gaps in residency for general surgeons and that an increasing number of graduates are not ready for independent practice at graduation. Although trainees are granted progressive responsibility, this is countered with diminished autonomy, especially with the influence of societal values and expectations.

This ongoing study touches on some of the struggles that face general surgery residencies, and likely all residency programs, with ongoing assessment. EPAs are meant to be frequent, directly observable, and based solely on the encounter or interaction being observed. The goal is to create a floor, rather than a ceiling, that allows for discrete credentialing in residency to allow graduated independent practice. In order to make frequent, observable assessments, there must be attending buy-in with regards to participation. There needs to be an easy and convenient way to provide assessment that is universal across residencies. With appropriate buy-in, EPAs would provide more meaningful assessments than the current graduation requirements of 6 clinical and operative evaluations. 

An example of an EPA in General Surgery for benign biliary disease