DOM in 2018: A Look Back and a Look Ahead

This was a year of tremendous accomplishment by the faculty, trainees, and staff of the UCSF Department of Medicine (DOM).

This was a year of tremendous accomplishment by the faculty, trainees, and staff of the UCSF Department of Medicine (DOM). In its "America’s best graduate programs" issue, US News & World Report ranked our department as the best internal medicine department in the U.S. For the 5th consecutive year, the DOM led the nation in NIH grants, becoming the first department ever to pass $200 million in such grants in a single year. UCSF Medical Center was ranked 5th in the nation by U.S. News, making it the top hospital west of the Mayo Clinic, with several of our divisions (nephrology, pulmonary, endocrinology, oncology, and geriatrics) in the top 10 in their specialty.

But the numbers don’t capture the spirit and soul of this magnificent department. In this end of year message, I’ll offer a little color commentary to accompany the statistics, and highlight some of the ongoing challenges that we’re working to address.

Clinical Care

Several years ago, I was speaking to a group of UCSF medical students. I thought they should appreciate how much the world of medicine had changed from "back in the day." "All of you are entering a profession utterly different from the one I entered 30 years ago," I said gravely. "You’ll be under relentless pressure to figure out how to deliver the highest quality, safest, most satisfying care… at the lowest possible cost."

One student raised his hand. "What exactly were you trying to do?" he said.

I often think about that student’s question. There is no doubt that the transition from volume to value is replete with challenges, such as measurement burden, checkbox medicine, and the emerging evidence that today’s quality scores disadvantage academic health centers and institutions that treat low income populations. Nevertheless, it’s hard to argue against a shift to a payment system promotes high value (vs. high volume) care.

Our department has not only accepted this challenge, we are determined to lead. We’ve embraced Lean methodology and the Learning Health System concept as organizing principles to guide continuous improvement. We’ve developed and nurtured clinical partnerships with a variety of community providers and hospitals, including UCSF Health’s links to Dignity Health, John Muir, One Medical Group, Marin General, and our colleagues at UCSF Fresno; stronger ties to community clinics at Zuckerberg San Francisco General (ZSFG) through the San Francisco Health Network; and a more robust outreach strategy to our veterans by our faculty and trainees at the San Francisco VA Medical Center. We’ve implemented – and often pioneered – innovative ways of organizing care, ranging from new apps to manage hypertension to team-based care to telemedicine to eConsults and remote glucose management. We’ve even launched the nation’s first geriatric HIV clinic!

I want our department to remain at the forefront of building and testing innovative new models of care delivery, and we’re doing just that. Toward that end, this year we launched the Center for Clinical Informatics and Improvement Research (CLIIR), led by Julia Adler-Milstein, recruited from Ann Arbor) to build on our tradition of digital innovation and to study and scale the things that work.

What are the challenges in clinical care? I see the main ones as trying to figure out how to provide access to all the patients who want to see our physicians (both generalists and specialists); how to take advantage of our growing number of academic-community partnerships; how to improve care value (particularly lowering the costs of care) in an environment in which our survival depends on this; how to succeed in our educational and research missions in the face of relentless clinical productivity pressure; and how best to leverage digital tools and strategies to achieve all of our aims.

What are we doing to address these challenges? For one thing, we are taking a central role in driving health system strategy. I am co-chair of a newly formed UCSF Health Strategy Committee. Other DOM faculty serve in a variety of top leadership roles, including CEO at ZSFG and CMO of the San Francisco Health Network; acting Chief of Staff at the VA; and, for UCSF Health, Executive VP for Physician Services, CMO for Adult Services, Chief Quality Officer, Chief Physician Experience Officer, Chief Innovation Officer, and Chief Health Information Officer. We are also helping to lead efforts in quality improvement, Lean, and digital innovation across all sites. I’m grateful to our many service and clinic chiefs across our system, and as well as to Michelle Mourad, Vice Chair for Clinical Affairs and Value, and Andy Gross, Associate Chair for Ambulatory Care and Population Health (both at UCSF Health), for their tremendous work and commitment.

Research

In a department whose faculty and trainees last year published more than 3,000 articles and were awarded more than 600 peer-reviewed grants, it’s impossible to capture the depth and breadth of our research contributions in a few paragraphs. Suffice it to say that there are few departments anywhere that can match our contributions to new knowledge, in areas that range from health equity to precision medicine to manipulating the immune system or editing genes to cure illnesses.

3000+

publications

 

 

600+

peer-reviewed grants

 

 

This growth depends on people, resources, and facilities. Our campus at Mission Bay has grown in leaps and bounds (UCSF’s research enterprise at MB is now approximately the same size as the one at Parnassus), but is also surrounded by a number of pharmaceutical, device, and technology companies that seek partnerships with our world-class researchers. New research facilities are slated to come on line in the next few years at Parnassus, the VA, and ZSFG.

The challenges in research are familiar. Despite our growth, we still don’t have enough space on any of our campuses, and research space at Parnassus is in desperate need of a major upgrade. Our multiple campuses pose a challenge in terms of communicating with colleagues and nurturing communities. (San Francisco’s streets seem to be filled with two types of vehicles: ride-sharing cars and UCSF shuttles.) NIH funding lines have gotten tighter – so while our researchers have had amazing success in garnering external funding, they find that they have to run a bit faster each year to do this. Our campus infrastructure, particularly for clinical research (IRB, contracting) is far from perfect. Increasing demands on both the clinical and research side have made the “triple threat” faculty model more elusive.

David Erle and Diane Havlir, our Associate Chairs for Basic and Clinical Research, respectively, have been hard at work (along with many other faculty and staff) to address these problems. We have been a leading voice in plans for the “New Parnassus,” working to ensure that DOM faculty and programs are well represented as this vision unfolds. We’re also pushing for a coherent vision for the Mt. Zion campus as an important ambulatory hub and research site. We have launched new programs to recruit and retain top research faculty. The success of the In Residence Associate Professor Support (iRAPS) program, now in its third year, has been impressive, and we are looking at other ways to better support our research faculty, ranging from funding opportunities to building stronger research communities. We have also taken a lead role in pushing the campus to improve the IRB and contracting processes.

Education

Our training programs, under the overall leadership of Associate Chair for Education Pat Cornett, have long been known as being among the nation’s best. We remain exceptionally proud of our trainees – many of whom become leaders at UCSF and around the world. In the past few years, we have launched efforts to increase our residents’ exposure to subspecialty medicine and fundamental science, including a new molecular medicine consultation service supported by a major gift from the Chan-Zuckerberg BioHub. Many of our faculty serve as coaches for groups of UCSF medical students participating in our innovative Bridges curriculum, which embeds students in clinical practices to not only learn clinical medicine but also teamwork and quality improvement. Our teaching evaluations remain near the top of all departments, and our faculty serve as leaders throughout UCSF’s educational enterprise.

In 2018, after 23 years of exemplary service in the role, Harry Hollander will step down as residency program director. The search for a new program director, being chaired by Lisa Winston and Goop Dhaliwal, has energized our educational community, and we have seen some outstanding candidates. I hope to be able to announce a new program director early this year, someone who can build on our many strengths and take the program to even greater heights.

Philanthropy

UCSF continues to be a powerhouse in philanthropy, and our department is a key player in these efforts. Last year, UCSF ranked 5th in the nation among institutions of higher learning in philanthropic dollars received. This might not seem all that remarkable until one realizes that our school is a health sciences-only institution, with no business, law, or undergraduate school… and no sports teams!

Some of this success is due, no doubt, to the unmatched economic engine of Silicon Valley, and the generosity of those who have been fortunate in their business pursuits. But much of our success can be traced to the remarkable work being done by our people – work that prompts donors to trust that their gifts will lead to breathtaking discoveries and models of care. Our department is well represented in the plans for the UCSF Campaign, which aims to raise $5 billion over the next few years (the Campaign is already 3/5ths of the way to its ambitious goal).

Our People

It is now well appreciated that rates of burnout among U.S. physicians are rising, driven by increasing economic pressures and the burdens associated with our bumpy path to digital medicine. With NIH funding relatively flat, our researchers – like those everywhere – are also struggling to achieve a stable funding path.

I am pleased that UCSF and our department are aggressively addressing faculty and staff burnout with programs that range from advanced teleconferencing (the DOM is investing $500,000 in teleconferencing equipment across our campuses) to new faculty orientations to robust leadership training. I am also pleased that we’ve seen impressive improvements in satisfaction, for both faculty and staff, although there is much more to do. A special thanks to Beth Harleman, Associate Chair for Faculty Experience, and her team for their work in this area.

In addition to improving the work climate for all of our people, we are making special efforts to diversify our workforce and build a more inclusive culture. The appointments of Sarah Schaeffer and Meshell Johnson as directors of diversity for our trainees and faculty for the DOM, respectively, coupled with a variety of programs within the campus and School of Medicine, have made an important difference. I am particularly proud of our residency program, which last year doubled its fraction of interns from groups underrepresented in medicine. Our fellowships also saw a significant uptick in diversity in this year’s match. As we work to diversify our faculty, it will also be key to create a more diverse pipeline of trainees, many of whom will become our faculty and leaders of the future.

Of course, it’s impossible to talk about people and UCSF and ignore housing costs. While there are many joys associated with living in the Bay Area, this is probably our greatest challenge, particularly when it comes to recruiting and retaining. Although there is little the department, or UCSF for that matter, can do about these costs (except for building or buying new campus housing, which UCSF is doing), we are acutely aware of the issue and doing what we can to help.

Leadership

I am privileged to be surrounded by an exceptional group of leaders, all of whom share my commitment to making our department the most innovative, exciting DOM in the country, as well as the best place to work. The Chair’s Council, comprised of the Associate and Vice Chairs of the department, assist me in leading this department of 750 paid faculty, 3,000 employees, and a yearly budget of half a billion dollars. In addition, our 36 division chiefs, national leaders in their own right, manage their divisions with tremendous skill and passion, with the able assistance of our division managers. I’m particularly grateful to Neil Powe, Ken McQuaid, and Michael Peterson for leading our services at ZSFG, the VA, and Fresno, respectively, and to Maria Novelero and Michael Chen, Associate Chairs for Administration and for Finance, who perform one miracle after another to make the whole thing work.

All in all, while this is a time of considerable challenges in healthcare generally and academic medicine in particular, we continue to enjoy remarkable successes. It’s an honor to be leading this department for many reasons, but one of my favorites is that it gives me a bird’s-eye view of the amazing work that our faculty, trainees, and staff do, every single day.

Robert Wachter, MD
Chair, UCSF Department of Medicine
Holly Smith Distinguished Professor of Science and Medicine
Lynne and Marc Benioff Endowed Chair in Hospital Medicine