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    Scaling the mountaintops of academic medicine

    The AAMC’s president and CEO looks back on how far academic medicine has come — and ahead to its future heights.

    This column is based on Darrell G. Kirch’s final address, delivered at Learn Serve Lead 2018: The AAMC Annual Meeting in Austin earlier this month.

    It is truly humbling — and an incredible honor — to have served as only the fourth AAMC president and CEO since that role was created in 1969. Drs. John A.D. Cooper, Robert Petersdorf, and Jordan Cohen are the giants on whose shoulders I stand. It was their vision and leadership that brought us to the modern version of the AAMC as the “big tent” where all parts of academic medicine come together.

    After reading their powerful valedictories, I was struck by how steadfastly the AAMC has worked for progress in our core missions of medical education, clinical care, and research over the last half-century, and the imperative to achieve diversity, inclusion, and equity in health care. But I also saw how much has changed. A metaphor from my beloved Rocky Mountain home state helps illustrate the point.

    Colorado has 53 mountain peaks over 14,000 feet tall. Each step up one of these “fourteeners” brings a higher and more expansive view of the landscape. Academic medicine advances the same way. Over time, the landscape of our missions remains constant. But as we ascend, we gain clarity when we look back. And with each step higher, we see more clearly what lies ahead.

    From the higher vantage point we’ve reached today, we can see how far we’ve come. In clinical care, my predecessors defined the challenges of having so many Americans without health insurance and decried how our nation’s health outcomes lagged, despite constantly rising spending. Nearly 10 years ago, our community took decisive action with early support for passage of the Affordable Care Act, and today, we are unwavering in defending the ways expanded health insurance coverages improves — and saves — lives.

    Many academic health systems also are working to replace what Jordan Cohen called in 2005 our “obsolete” fee-for-service payment system that rewards volume more than quality of care. We can now see the progress our health systems are making to improve quality of clinical care as well as health outcomes. A recent study in Health Affairs showed that patients treated in teaching hospitals have up to 20% higher odds of survival than similarly ill patients treated at nonacademic facilities. We are reaching a level where true, “value-based” care is coming into sight.

    Medical schools and teaching hospitals also are leaving their “ivory towers” to engage the communities beyond their walls. More are becoming anchor institutions — proactively listening to and partnering with their communities to improve health. Your work to revitalize neighborhoods is helping the homeless leave the streets and bringing grocery stores to food deserts. You are hiring and training new employees and supporting 6.3 million jobs nationwide.

    When I visit academic medical centers, I am proud to see a level of diversity that I don’t see in other parts of our society ... But the toughest part of our climb may lie ahead. We must be relentless in surmounting health disparities, unconscious bias, overt sexual harassment, and gender and race-based gaps in salary equity.

    Medical education is undergoing a profound transformation as well — making a paradigm shift from a time-based learning progression toward learning and assessment based on competencies, entrustable activities, and milestones of advancement. We also have “flipped” the classroom, with lecture halls giving way to flexible spaces with more interactive forms of learning. And after decades of discussion, we are finally taking action on interprofessional education of the health care team.

    Technology is playing a greater role in education. While some are concerned it may overwhelm the human side of medicine, technology also offers powerful tools to enhance learning, from simulation labs to virtual reality. As artificial intelligence progresses, the use of an interactive, voice-activated “digital assistant” at the side of every physician is within sight. Done right, this technology could free doctors from routine tasks and allow a full focus on the patient, enabling us to recapture the human connection at the core of medicine.

    On the research front, Dr. Cohen’s farewell address in 2005 celebrated the completion of the human genome project. That new world of science has since yielded CRISPR gene editing, immunotherapy, and data networks that combine and analyze staggering amounts of clinical and research information.

    Fundamental discoveries by your scientists have translated into declining cancer death rates, thanks to breakthroughs in research, early detection, and targeted treatments developed in academic medical centers. And advocacy by the AAMC and its partners over the last three years has put research funding back on a trajectory of meaningful, sustainable growth. A recent analysis showed that every new drug approved in the United States between 2010 and 2016 can be traced back to NIH-funded studies, many conducted in academic medical centers. In this post-truth, fact-free world, we are seeing the enormous power of truth in science.

    We have made gains in diversity, inclusion, and equity, too. Our student applicant and matriculant pools are being diversified through holistic reviews in admissions. In 2017, women surpassed men as medical school matriculants for the first time, an achievement that was sustained in 2018. In particular, black women have boosted their numbers significantly as medical school graduates.

    When I visit academic medical centers, I am proud to see a level of diversity that I don’t see in other parts of our society. There, our learners, faculty, staff, and patients reflect the full range of Americans — veterans, Medicaid recipients, people with disabilities, immigrants, the rich, the poor, and people of all races and sexual orientations. They all come together to accomplish great things.

    But the toughest part of our climb may lie ahead in reaching other goals. We must be relentless in surmounting health disparities, unconscious bias, overt sexual harassment, and gender and race-based gaps in salary equity. We must redouble our efforts to bring more black males and American Indians and Alaska Natives into medicine. We must strongly advocate, in the courtroom and the court of public opinion, for the ability of medical schools to select and prepare future physicians to care for an increasingly diverse patient population. And we must remain a clear voice about the important contributions of immigrants to medicine and science, and fight for the Dreamers and their aspirations to become physicians.

    Nothing has the power to shape culture more than a leader who not only seeks excellence in our core missions but remains true to our core ethical principles and creates a culture of respect and inclusion.

    However, one looming threat could stop us in our tracks — the threat to our own personal well-being. Today, more than half of the physicians in this country are experiencing symptoms of burnout. Tragically, as many as 400 physicians, including some of our learners, die from suicide each year.

    We need to acknowledge that burnout, depression, and suicide are not the failures of individuals. We need to change the systems that are wearing them down. With the establishment of the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience, strongly supported by the AAMC, we are finally making progress in finding solutions that can make the environment of care and learning more supportive of our well-being.

    Like too many students, in my first year of medical school, during a brutal winter quarter of gross anatomy and never seeing the sun, I became burned out. My anxiety and depression were on the verge of derailing my career aspirations. My fear of being judged negatively and the dark shadow of stigma nearly kept me from seeking help. But an extraordinarily empathic student affairs dean steered me to the treatment I needed.

    Many of you have a story like mine. We need to tell our stories and beat back the stigma that causes so many of our learners and colleagues to suffer in silence. The final part of our journey I want to highlight concerns the importance of culture and leadership. On every campus I visit, I see the many ways you are changing culture to be more collaborative, to value humanistic qualities as much as academic achievement in our learners, and to create a culture of innovation that will lead to true value in health care.

    As a nation, we are struggling to define the culture we seek. Is it one of hierarchy, exclusion, privilege, and power? Or is it one of compassion, inclusion, community, and accountability? Academic medical centers can be shining examples of those latter qualities, and we need leaders at all levels striving to strengthen that culture. Nothing has the power to shape culture more than a leader who not only seeks excellence in our core missions but remains true to our core ethical principles and creates a culture of respect and inclusion.

    Dr. Cooper closed his final speech at the AAMC annual meeting in 1985 with a wish that in 30 years, a young medical scholar or educator would stand on the same podium and say, “We have lived through one of the golden ages of medicine.” When I look out from the new heights we have reached in our missions, I can say that today. My wish is that when my successor stands here years from now, she or he will be able to say the same thing.

    Thank you for the privilege to work for and represent you for 13 years. I deeply appreciate your unwavering support and abiding commitment to improving the health of all. I am certain we will all keep climbing mountains, no matter how high they prove to be.