The UCSF Department of Medicine in 2020: The Importance of Collaboration and Teamwork

UCSF, and our Department of Medicine, are storied organizations, and both have much to be proud of. Our role in the founding of the biotech industry, or in addressing the HIV/AIDS epidemic, and in areas ranging from medical education to patient safety to health disparities… I could go on and on. We are in an enviable position, unquestioned world leaders in the field of academic medicine.

But, truth be told, this is a scary time to be a leading “legacy” organization. The stories of organizations that were the top in their class but ultimately fell as new companies entered the market just keep on coming. Whether your favorite example is Blockbuster or Sears or Kodak, it is not hard to find cases of world leading organizations whose primacy was threatened by new technologies, new ways of doing work, or the drag of their own inertia.

One of the most important insights about transformation is that no one individual, division, or department has all the skills and vision they need to transform. To stay ahead, organizations need to create the conditions in which people with various skills and backgrounds can come together to look at problems through new lenses, to apply insights from one field to another.  

As we look back on the past few years and think about the coming decade, I’m struck by the importance of taking advantage of new collaborations to transform our work and grow our impact in a rapidly changing world of health and healthcare. Below, I highlight a few of the key areas in which teamwork and collaborations are essential to success – focusing on both successes and also some of the challenges that need to be addressed.  

Clinical Care

As I look at our clinical sites, an overarching theme is the creation of larger and more geographically distributed delivery system networks. This, in turn, highlights the absolute requirement of having first class informatics tools – ranging from electronic health records to telemedicine – to improve care and weave these networks together.

At UCSF Health, we’ve doubled our size and revenues over the past 7 years, partly through new affiliations with community-based delivery systems, including John Muir in the East Bay, Marin Health to the north, Washington Hospital in the south, and the Dignity/CommonSpirit and One Medical systems in several locations. These partnerships aim to allow our patients to receive UCSF-level care closer to where they live and work, and free up limited space in our academic medical centers in San Francisco for more patients who require the tertiary and quaternary facilities and specialists whose practices are based there.

At Zuckerberg San Francisco General, the installation of the Epic electronic health record last year linked the hospital and the many clinics in the Department of Public Health, providing more opportunities for collaboration. At the San Francisco Veteran’s Hospital, federal policies that allow patients to seek care closer to home have driven the migration of our clinics and physicians to new locations, particularly to the north, allowing veterans to see UCSF faculty closer to where they live.

And at all of our sites, we have embraced new technological approaches to care, including patient-centered portals, apps, and telemedicine, to create more convenient ways for our patients to receive care. Finally, leveraging our pioneering work in electronic consultation (“eConsults”) a decade ago, we are building on Rob Rushakoff’s inpatient diabetes e-consultation model to consider other disease states that might benefit from this kind of consultation. (We call this strategy “Targeted Automated Electronic Consultations,” or TACOs). All of these innovations share a goal of using new approaches and technologies to bring teams closer together, or to provide our patients access to new sites of care.

Research

Our Department of Medicine faculty, staff, and trainees remain uniquely successful in research. In 2019, our people authored approximately 2,623 publications and secured 373 NIH grants totalling $209 million, again placing the department as the number one Department of Medicine in the U.S. in NIH funding. We have launched a number of programs to support our research faculty, including one we call “NIH-Plus,” which provides flexible dollars to our faculty with each federal grant they receive.

Even with all our successes, we recognize that building new collaborations is essential. Under the leadership of Associate Chairs for Research David Erle (biomedical) and Diane Havlir (clinical), there were several new programs established in the past year, including PREPARE (PRE-Proposal Application REview), which offers our junior investigators feedback on their upcoming grant submissions from seasoned investigators, a new mentorship program for physician-scientists, and a team science grant that offers pilot funds to bring new teams together to tackle complex research problems.

Teamwork can also be facilitated by well-designed space. We are pleased that major new research buildings are under construction on our Parnassus campus (along with the many new buildings at Mission Bay) and at ZSFG – they will provide faculty and trainees modern space that promotes bringing together diverse teams to attack important questions. In the short term, we are slated to pick up a significant amount of new research space at Parnassus when the Ophthalmology department moves many of its faculty to Mission Bay in 2020. Far more research space will come on line in about five years, with the completion of the new Research and Academic Building in the current U Building space on Parnassus. While the allocation of this space is not yet determined, it will undoubtedly provide new opportunities for several large multidisciplinary research groups, including ImmunoX (which includes investigators, many from the Department of Medicine, addressing programs of fundamental and translational immunology), the Digital Collaborative (bringing together a variety of investigators taking advantage of digital tools and technologies), and the new Benioff Center for Microbiome Medicine. Similar efforts will accompany the opening of the new research building at ZSFG, slated for occupancy in 2022.

While our research productivity is the envy of academic health systems everywhere, we continue to be hampered by an underperforming clinical research infrastructure, particularly in the areas of contracting and the IRB. We have been working closely with the campus leaders in these areas to advocate for improvements – luckily, many of these leaders, including Lindsey Criswell (vice chancellor of research), Hal Collard (associate vice chancellor of clinical research), and Payam Nahid (associate director of clinical trials operations), are members of our DOM faculty and are acutely aware of the importance of having a research infrastructure that matches the quality of our faculty and our science. 2019 saw progress in these areas, but more needs to be done. A particular thanks to our director of research administration & revenue management Jon Rueter, who has provided the DOM perspective on these issues and led a pilot program to re-imagine the clinical trials review process for our division of hematology-oncology.

Education

Our department has had an outsized role in the creation and implementation of our new medical school curriculum, named Bridges – which gives students early clinical exposure and an opportunity to work in a clinical microsystem to learn improvement techniques. The successful execution of programs like this always depends on strong teamwork. Our residency curriculum, under the leadership of residency director Rebecca Berman, is evolving to ensure that our trainees have strong exposure to all of the medical specialties, in both the inpatient and outpatient settings. We are particularly proud of a new program to connect junior faculty who aspire to careers in medical education with more senior faculty mentors – another example of working systematically to create and nurture strong teams, including mentor-mentee relationships. This program was developed by Anna Chang and Brian Schwartz, in their roles as Academy of Medical Educators endowed chairs.

There is one threat that emerged this year: like many programs across the nation and in other departments at UCSF, the Accreditation Council for Graduate Medical Education (ACGME) cited several of our residency and fellowship programs for work hour violations. All of our inpatient services have gotten busier, patient complexity has grown, and the care coordination needs of our patients have exploded, but our staffing and care models have not quite kept up. We are working with the leaders of our health systems to address these issues. Solutions will undoubtedly require a combination of larger non-trainee services, more support services on teaching teams, and, possibly, more trainees – the latter only when the educational environment can truly support larger programs.

Diversity and Leadership

We continue to work on diversifying our department and creating an environment in which everyone can perform at their full potential. After all, how can teams be effective if they are not diverse across a whole range of attributes, and if some individuals face structural or cultural barriers to full participation? Added to that, we need to be sure our people have the skills they need to be strong leaders, including promoting inclusiveness and bringing out the best in all of their faculty, staff, and trainees.

We have instituted many programs to improve diversity and leadership, led by Beth Harleman, Associate Chair for Faculty Experience, and Meshell Johnson, Director of Faculty Diversity. In 2019, a leadership training program brought together about 20 of our new division chiefs and other departmental leaders. Virtually all of our leaders have completed training in diversity, equity, and inclusion, and many of the School of Medicine’s diversity champions hail from the DOM. Our residency program has gone from 15% underrepresented in medicine five years ago to over 25% today, and there are new programs (including the School of Medicine’s Watson Scholars and our department’s Diversity in Basic Science program) that are providing crucial support for promising young faculty and trainees from underrepresented groups. At this writing, of 14 division chiefs recruited over the past three years, more than half were women and/or members of groups traditionally underrepresented in medicine. In 2019, two more DOM faculty were elected to the prestigious National Academy of Medicine, both women (Julia Adler-Milstein and Diane Havlir). Yet even with these advances, our recent DOM culture change survey demonstrated that the experience of our female faculty continues to lag behind that of our male faculty in several crucial areas. Eliminating this disparity remains a major focus of our department, with several initiatives underway at the department, school, and campus levels.

Conclusion

One of my favorite quotes came from the late Israeli prime minister Golda Meir: “Don’t be humble; you’re not that great.” It's a perfect reminder that arrogance is both unattractive and often a preamble to decay.

Our department is pretty wonderful, but the rules of the game are changing and we have to change with them if we’re going to continue to lead. One of the greatest changes is the need for new partnerships, collaborations, and teams – and to work even harder to value everyone’s contributions and create an environment in which all our people can do their very best work. With great humility but also not inconsiderable pride, we should all feel good about the progress we’ve made toward these crucial goals.

Sincerely,

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