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    Looking back on a distinguished career in academic medicine

    The AAMC’s chief health care officer, Janis M. Orlowski, MD, reflects on three decades of change in academic medicine — and the challenges ahead.

    Janis M. Orlowski, MD

    Janis M. Orlowski, MD, had just completed her fellowship in 1988 when she was hired to join the nephrology practice at Rush University Medical Center in Chicago. As the first woman physician in the group, she was a bit of a novelty to the practice’s patients — and not always a welcome one.

    “Come to find out that people would call to get an appointment and when they heard they were going to be assigned to Dr. Janis Orlowski, there were a number of people who asked not to see a woman physician,” Orlowski recalled. “My boss at the time brought the group together and said, ‘We’re not going to support this. If they don’t have a nephrologist and they are being assigned by our group, they can see Dr. Orlowski, or they can go somewhere else.’”

    Ten years later, 50% of the patients who called for an appointment asked to see Dr. Orlowski, so the group had to have another discussion — this one about how they would fairly distribute the new patient workload.

    “It’s hard to remember that I started in medicine at a time when people did not want to see women physicians,” Orlowski says. Today, women make up more than 50% of new medical school applicants and matriculants, and studies have shown that patients cared for by women physicians have better outcomes than those cared for by men.

    Medicine has, indeed, changed greatly since Orlowski graduated from the Medical College of Wisconsin. A practicing nephrologist throughout her career, she spent her early career at Rush, where she rose to become associate vice president and executive dean of Rush University Medical Center and Rush Medical College. In 2004, she was hired as chief medical officer (CMO) of MedStar Washington Hospital Center in Washington, D.C., and shortly thereafter added clinical operational responsibilities to her title, eventually becoming both CMO and Chief Operating Officer. In those roles, she oversaw the center’s medical staff, as well as clinical care, patient safety, medical risk, perioperative services, ambulatory care, and medical education programs.

    In 2013, toward the end of her tenure at MedStar, she made national headlines during a news conference updating the public about the condition of victims of a shooting at D.C.’s Navy Yard, when she made a heartfelt plea to end gun violence in America.

    Orlowski brought that same candor to the AAMC, where she has served as the organization’s chief health care officer. In that role, she leads several AAMC groups, including the Council of Teaching Hospitals and Health Systems, which represents the interests of approximately 400 major teaching hospitals and health systems, including 64 Department of Veterans Affairs medical centers.

    During the pandemic, she served as a key liaison between the CEOs and CMOs of the nation’s leading academic medical centers (AMCs) and the federal government, as well as coordinating efforts to understand the clinical implications of COVID-19, alleviate supply shortages of personal protective equipment, and ensure that hospitals were receiving appropriate funding to care for hundreds of thousands of critically ill patients. Orlowski is retiring on July 1.

    She recently sat down with AAMCNews to reflect on her career, as well as the challenges facing AMCs in the years ahead.

    What do you think are the top five challenges facing AMCs in the next few years?

    The first challenge is the shortage of health care personnel. Not having enough physicians, not having enough nurses, not having enough respiratory technicians. The second issue is definitely the well-being of the staff: We certainly can’t work at the pace that we’ve worked for the last two years, but what do we do? How do we catch up? These issues will require strong leadership at our institutions.

    The third is addressing health equity. Everyone is horrified at what they saw during the pandemic and how health equity issues significantly and disproportionately affected individuals of color. So even though health care treatment is only a small portion of overall health, how do we do our part to improve that?

    The fourth issue is climate change. Climate change is also a health equity issue and an access issue. And as we look at it further, U.S. health care represents about 10% of the carbon footprint in the United States. The U.S. Department of Health and Human Services has asked our institutions to reduce our carbon footprint by 50% by 2030, to virtually zero by 2050, to have an institutional plan for climate change, and to name an executive to be responsible for that.

    The fifth is sort of a perennial issue, but I think it’s going to be a bigger issue in the future and that is health care financing. There are three parts to this. The first is that there are increased costs for both the workforce and for supplies, and there has not been a concomitant increase in the payments that the health care system receives. Second, the Medicare trust fund doesn’t have sufficient money. There are concerns in the next decade that it will be bankrupt. So there will be a lot of pressure to reduce costs. And the third is funds flow: How do academic health centers continue to provide funds for education and research and for the community?

    We’ve been talking about the physician shortage for a long time, but during the pandemic, the shortage of nurses has gotten critical. What do you think are some of the solutions?

    Early in the pandemic there was a lot of pride in being a physician or a nurse, but as COVID has worn on for two years, there are some negative perceptions in nursing — not about the care that they provide but about the overall job. How do we make these jobs more tenable? How do we make it so that people don’t feel stressed, they feel adequately compensated, and they feel fulfilled in what they do?

    In many of our institutions for the last couple of decades, we have worked with an all-RN [registered nurse] nursing staff. We have not had LPNs [licensed practical nurses] or three-year nurses or anything other than degreed nurses. That had to do with quality of care and what they saw as the professionalism of nursing.

    But what we’re seeing is maybe going to a structure where the RN does the work that specifically requires a nursing degree and license, such as passing medication or assessing a patient, and then LPNs and nursing assistants and others do the bathing, the feeding, the other services that need to be provided. And I think the same thing will happen in other professions, with pharmacists and respiratory therapists. I think what we’re going to see is pyramiding within different job classes in order to get the job done.

    We saw a lot of travel nurses during the pandemic who were making more money by switching jobs, often within the same city. Is that going to settle out, and do you think that nurses are compensated fairly?

    The traveling nursing situation spiraled out of control and should have been stopped at some point. Certainly there was a need for travel nurses and being able to bring nurses to areas where there was a high intensity of patients with COVID. And what we did see is that the pandemic first started on the West Coast and more nurses were needed there. And then they went to New Jersey and New York, and the East Coast. So that kind of travel which sort of equaled out geographic needs, I think was fine. But at some point, people were able to get two times, three times their salary by leaving their institution and going across town.

    We were in the middle of COVID. There was a crisis going on. And people were leaving. What we do know is that care suffered because of that. Care is best in teams that work together for a long time and understand the collective principles of quality and team cooperation. So we did see a number of hospital-acquired infections and other in-hospital events go up, part of it as a result of COVID but also part of it because of staffing. I do believe that one of the things that we need to look at after the pandemic is, how you prevent the situations where the system is taken advantage of in regards to staffing.

    Do nurses need to be paid fairly? Absolutely. I mean, everyone needs to be paid fairly, there’s no doubt about it. But I think that nurses’ salaries in the United States are very healthy.

    What we know of teams and workers is compensation is important up to a certain point. And what people really are looking for is an institution or a place to work where they feel that they are valued, where they have team members who they trust and who they can count on, where they feel that there’s a good esprit de corps, where their outcomes are excellent, and where their benefits are good. Bottom line is that they want to be valued.

    We need to look at all those elements and say, how do we build a workforce that is in it for the long haul, and in it for good quality? Having the right culture is what gets nurses, gets respiratory therapists, gets people to come and stay with your institution. So there needs to be a lot of work about rebuilding our culture.

    Do you think that the pandemic will accelerate any needed reforms in academic medicine? Telemedicine is one example – it increased dramatically during COVID-19, thanks to changes in how providers were able to provide care and be compensated for it.

    Telemedicine was one. Another was the acknowledgment of health equity. And certainly, the well-being of the work staff was another.

    One of the things that we learned that we’ll never do again, is that we didn’t have a clear understanding of our supply chain — and we continue to suffer from that. We have to look at our supply chain and then look at where our dependencies are so that we do not find ourselves with such critical supply shortages.

    We also have a responsibility to go back and engage in a conversation with the public about science, and about what we learned about the pandemic, what we did right, what we could do differently. How do we rebuild trust between the health care community and the public? And how do we support public health because in the U.S., we have an underfunded public health system, and that was noticeable during the pandemic, and it probably led to more deaths.

    There are some people who say, you know, we had one pandemic in 1918 and 1919. And we have another 100 years later. What I would say is, based on travel, based on infections, it’s not going to be another 100 years before we see another pandemic and we need to prepare now.

    Talk to me about women in medicine. You’ve been a trailblazer for many years. Do you think it’s easier or harder for women physicians today?

    It’s interesting when I think back over 40 years of being a doctor. I was in medicine when women were a minority and not welcomed by everyone. I had more than one professor tell me that I had no right to be in medicine. It’s very strange to think back on those times, but that wasn’t unheard of. They didn’t get in trouble for saying that to me. But I think that medicine has benefited from having women, both in the care and the compassion that we give our patients.

    There are still challenges. There are gaps in pay, which is pretty shocking. We still see significant harassment and sexual harassment and so we have to work on our culture. And we still see that women leave academic medicine after a couple of years as an assistant professor because many times they have not been mentored or given the support they need. As women leave medical school, it’s a very difficult time, because not only are they starting a new career but they’re in their peak childbearing years. I had my son when I was a fellow and it wasn’t easy. In the end, I would tell everyone that being a physician despite these issues is a wonderfully fulfilling career, and I would encourage anyone to choose this career path.

    What are you most proud of?

    First of all, it’s been an incredible privilege to take care of patients. As I look back over the years and I think about the different patients I saw: What an honor, what a blessing, what a privilege. It has been a privilege to have colleagues who have worked with me and supported me. It’s been fun being the woman in medicine who was told it’s not going to work out, that she’s taking someone else’s place. And then to see the success.

    Other moments I’m proud of: When I was at Rush, we did these contracts with Cook County Hospital to integrate health care and our residency programs. This was a big event at that time. There was a time when I was the chair of the Illinois State Medical Society and we were involved in issues of tort reform, where there were not sufficient doctors in certain parts of the state. I was the 150th president of the Chicago Medical Society.

    When I came to MedStar, I had the privilege of being part of a very large system and integrating that system. And I feel that I was instrumental in helping MedStar Washington really dramatically improve quality.

    Before I came to the AAMC, I was one of the founding steering committee members of the Chief Medical Officers group, so it’s been fun to see how that has grown. I can remember, 15 years ago, talking about and needing to have a leadership academy and now that is in place.

    Working at the AAMC has been a victory lap of sorts. I’ve had the unbelievable privilege of talking to so many of the academic medical centers that are providing fabulous education and research and care, to be the liaison to the Centers for Medicare and Medicaid Services and to other federal agencies. And I just feel that because of people who have come before me as well as my colleagues, I’ve been in this incredible seat where we’ve learned from as well as helped so many people. It’s been a privilege to be part of academic medicine.