By Jennifer J. Salopek
S. Claiborne “Clay” Johnston, MD, was named inaugural dean of the Dell Medical School at the University of Texas at Austin in January 2014. A practicing neurologist, he was formerly associate vice chancellor of research at the University of California, San Francisco. He spoke with Wing of Zock Editor Jennifer Salopek by telephone on May 13, 2015.
Salopek: What opportunities for innovation does being the dean of a new medical school bring?
Johnston: It’s a huge opportunity. If you’re ready to take on the challenge, you can take a look at all aspects of academic medicine—the way we train medical students, the way we train residents, the way we provide clinical care, the way we interact with the community. We really have an opportunity to rethink the whole academic enterprise.
Salopek: You’ve published an article called “10 Backward Things About Our Health Care System.” Which of those problems can a new kind of medical school address? For example, many that you cite are payment issues.
Johnston: I think, fundamentally, payment issues are a lot to blame for the current state of health care. The way most medical schools are paid is that they rely on very large clinical operations and on margins from those operations to execute on their educational and research missions. As large clinical operations, they’re invested in the current system of care. But by accepting fee-for-service as the only model for health care, they’re driven to do more stuff: more MRI scans, more surgeries, more complex care—and driving up consumption. That has taken us out of alignment with society, where a lot of the opportunities now depend on getting more funding for health promotion, and call for the health care delivery end of it to have some accountability for cost. They have to be pushing for innovations that drive more efficient care and reduce waste in addition to improving outcomes.
By re-envisioning our role, we can avoid blindly accepting our current payment system and instead try to stay more closely aligned with society. That means going to the payers, who really should be representing our interests, and designing optimal health programs for them and with them; and then working with practitioners—whether they’re our faculty or not—to deliver those better optimized strategies for health promotion.
Salopek: When you think about those problems and the way health care could be, does the doctor of tomorrow start to look different once those promises are realized?
Johnston: We will always need doctors who are really focused on the one-on-one encounter with the patient and doing that extremely well. But what we’re missing today is physicians who are focused on the system and thinking about solutions more broadly. We need to be more interprofessional than we have been before, we need to understand technologies more and how can they impact health, we need to be more on the health promotion side so we’re thinking more about population health, and we need to be training leaders.
Who is going to get out there? How do you manage change? How do you get people to do things that put them at risk? How do you understand the economics of health care and how that impacts decision making? Those are all things that traditionally aren’t a part of medical school—they certainly weren’t for me—but definitely will be part of ours.
Salopek: What else will be different and innovative about the curriculum at Dell Medical School?
Johnston: We carve out nine months for an Innovation and Leadership block, during which students can choose one of three tracks—population health, health care redesign, or research. Each track has a practical project that is integrated with priorities identified by the system—they’re not fake projects—and which will be scaled if they’re successful. Training will reinforce the necessary skill sets to be successful in each area; for example, the founders of our new Design Institute will teach design thinking and creative problem solving. The focus is on creating projects that will have real impact.
Salopek: Why is this important?
Johnston: There’s a lack of entrepreneurial leadership in health care—not necessarily people going out and starting companies, but people who are very creative and providing solutions to system problems on a large scale. Those are the people who we think we need to train. Our graduates may spend 80 percent of their time in the direct care of patients, but we hope that they will spend the other 20 percent working directly to improve health at scale.
“The community brought us here; they voted to increase their property taxes in the middle of a recession, and we are here to give back in spades what they have invested.”
Salopek: How will research look different at Dell?
Johnston: We are looking for opportunities to translate out traditional laboratory-based research by improving our systems and providing better support. Innovative research really hasn’t happened at the far end of the clinical spectrum, in direct patient care, in terms of answering questions about the makeup of the care team, how often we should round on patients, how do we train practitioners? There’s almost no research and no funding in that area. There’s also great potential for research in population health; often, when grant funding ends, the project goes away. I think it’s one of our fundamental functions to test innovations in health care delivery at that operational and clinical end, ready to embrace and scale them if they’re successful.
In our current scheme, we expect that somebody will do this under a grant, that work will be published, and that will compel the health care system to embrace that [innovation]—but that doesn’t happen. We must have the health care system and its current payers at the table, recognizing what sorts of innovations are of benefit to the people they represent. There’s a tremendous amount we can do on population health and clinical care to shift research to innovation more broadly.
Salopek: How does the curriculum design embrace current thinking about communication, interprofessional training, empathy, and patient centeredness?
Johnston: We think of it as person-centered education and care. “Patient” assumes that someone is sick. We want to be taking care of people, both as well beings and not just in health care delivery settings. Those are all things that medical education has tended to neglect for a number of years, and it’s important that we bring them back. We are feeling pretty liberated by the notion that access to data is much better, and that it’s impossible to force in all of the facts that are relevant to the future physician, as we take a hard look at what we really want our students to learn.
Salopek: How might the students you accept for your first entering class be different from those who might be accepted by more established medical schools?
Johnston: We are embracing our newness in every possible way. We want to train leaders and risk takers and creative thinkers, so we will attract and be interested in students who are a little less traditional. Perhaps they won’t come directly from undergraduate experiences, having demonstrated leadership elsewhere. Our group of students will look quirkier. Austin loves to embrace its quirkiness, and we do as well.
Salopek: What has been the most surprising thing you have discovered in your first year on the job?
Johnston: How visible this position is, how excited the community is about the new medical school, and how much attention they’re paying to its development. The community brought us here; they voted to increase their property taxes in the middle of a recession, and we are here to give back in spades what they have invested.