Asa part of my interview series with leaders in healthcare, I had the pleasure to interview Dr. Paul J. Chung.
As Kaiser Permanente Bernard J. Tyson School of Medicine’s Chair of Health Systems Science, Dr. Paul J. Chung leads the development and implementation of a four-year curriculum in topics ranging from patient safety and quality to community and population health. Dr. Chung also leads the creation and growth of a health services research enterprise that includes health equity and social justice for underserved populations. In addition to his new roles at the school of medicine, he is currently an Adjunct Professor of Pediatrics and Health Policy and Management at UCLA; Adjunct Senior Scientist at RAND; Associate Editor of Academic Pediatrics; and Immediate Past President of the Academic Pediatric Association. His personal research interests include primary care redesign for medically and socially complex children; and childhood determinants of adult health.
Thank you so much for doing this with us Dr. Chung! Can you tell us a story about what brought you to this specific career path?
Iwent to medical school in the early 1990s, and I have to admit — I hated pretty much every minute of it. I realized early on that I didn’t much like doctors, at least not the ones that seemed to populate my circumscribed world as a student. It was a different time back then — the doctors I met seemed more certain of their value to society than doctors are today, and with that certainty came, perhaps, a sense of entitlement.
I wanted to be a different type of doctor, and when I joined the Robert Wood Johnson Clinical Scholars Program in 2000, I belatedly realized that I was just one in a large and growing group of doctors who had been fighting since the 1960s, trying to make the healthcare system more effective, more efficient, more ethical, and more equitable.
These doctors gave me a home, and since then I’ve tried to create a similar space for others who are committed to changing healthcare in this country. If you talk to students today, they get it. They see what medicine was yesterday, what it is today, and what it could be tomorrow. That gives me hope and makes me excited to be a part of their education.
Can you share the most interesting story that happened to you since joining your organization?
I don’t even know where to begin. I’ve never been a part of anything like this before, and after 18 months, I still feel challenged every day. I mean, how do you build a medical school from scratch? Like, really? Even though every day is a dizzying experience, it’s the little things that catch my attention. Like the fact that people at the Kaiser Permanente Bernard J. Tyson School of Medicine (KPSOM), and Kaiser Permanente in general, seem to eat really healthy.
This is, without a doubt, the most awesomely committed group of colleagues I’ve ever had the pleasure of working with. I’m learning from them all the time, but I can’t say I’ve fully adopted their philosophy. My idea of fine dining tends toward places like McDonalds and Panda Express, and that qualifies as…an unusual choice with these people.
What makes your company stand out? Can you share a story?
Along with other schools across the country, we in health systems science are trying to pull together emerging threads of the new medical education experience into a cohesive statement. My department exists because medical education has to change. Tomorrow’s doctors will need knowledge and skills far outside the patient-doctor relationship to encompass the various systems that patients and doctors must themselves rely upon in order to create health — families, care teams, neighborhoods, hospitals, communities, healthcare systems, social systems. If the last 100 years have taught us anything, it’s that you can’t be an effective healer unless the systems around you make success possible.
And that’s just my department. There’s so much more about KSPOM that stands out — the relationship with one of the highest-quality integrated healthcare systems in the world, Kaiser Permanente; the curricular innovations focusing on active learning, learning technology, and flipped classrooms, where faculty are in a more facilitative rather than central role; the early clinical and service-oriented experiences; the total commitment to equity, inclusion, and diversity at all levels.
The thing that stands out most to me, even beyond my own department, is the emphasis on student wellness and the REACH program (Reflection, Education, Assessment, Coaching, and Health and well-being). Four times a year, for a week, students will focus on these areas and spend time with dedicated physician-coaches. KPSOM is making student support an integral part of our curriculum in a way that I’ve never really seen before, and that’s downright amazing.
Can you share with our readers about the innovations that you are bringing to and/or see in the healthcare industry? How do you envision that this might disrupt the status quo? Which “pain point” is this trying to address?
I’ll set some background. The U.S. healthcare system eats up 17% of the GDP, about as much as we spend on national defense, social security, and public education combined. We provide great healthcare to some, not-so-great to others; too much to some, not enough to others. We spend so much money on healthcare that many of us believe one of the biggest threats that healthcare poses to the country’s health might be opportunity cost. Spending an additional dollar on healthcare may mean not spending a dollar on something else that could have improved our country’s overall health more, like infrastructure, housing, schools, economic development, higher wages, or climate change mitigation.
We need to reduce the amount we spend on healthcare while simultaneously spending every healthcare dollar better, making care more effective, efficient, ethical, and equitable. We need to then take those savings and invest them back in the country to help generate health at its true source — our families and our communities. That’s how we disrupt the status quo. Every single graduate of our school is going to know this, deep in their bones. And they will feel obligated, as graduates of our school, to become the change that they want to see in the world.
What are your “5 Things I Wish Someone Told Me Before I Started” and why. (Please share a story or example for each.)
- The smartest person in the room is the one who best recognizes other people’s better ideas. I can acknowledge now that I’ve never had an original thought in my life. Occasionally, I’ve been lucky enough to see the connections between other people’s brilliant original thoughts.
- Failure feels bad. To get anything useful done, you have to be okay with feeling bad pretty much all the time. Since my first child was born 17 years ago, I have felt bad in one way or another every single day. Parenting is great, and it completely sucks.
- The world is complex. Complexity science, one of the foundational sciences for systems, emphasizes the importance of random walks and implies that excessive goal orientation stifles the creativity needed for evolutionary survival.
- Health is a political, not scientific, construct. How we define health and the metrics that we choose to measure it are decided upon, formally and informally, by the stakeholders who get to sit at the table.
- Everything pales in comparison to the yin and yang of culture and incentives, and the fundamental question of power.
Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
I respect the Commonwealth Fund a lot, but in general, I’m not a huge fan of rankings. The outcomes that we rank ourselves by are a motley assortment of things determined by whatever outcomes particular stakeholders feel are important and whatever data happen to be available. That being said, why does the U.S. rank so poorly?
- Culturally, we place too much emphasis on healthcare, given that healthcare is a limited tool in society’s health toolbox. Healthcare is great at solving simple-to-complicated, mild-to-moderate health problems. It has never been great at solving complex, severe health problems. Might we become great with continued enormous investments in R&D and care resources? Maybe. Or maybe we can do what other nations do — minimize the emergence of many complex, severe health problems by supporting the social infrastructure and making high-quality healthcare for simple-to-complicated, mild-to-moderate health problems more equally accessible for all.
- The basic problem of healthcare is not that we provide mediocre service. If we provided mediocre service but had the world’s best infrastructure, schools, social welfare system, etc., then we’d be in pretty great shape as a nation. The problem is that we pay such extraordinary prices for this service, and we deliver it so inequitably. And yes, our service IS mediocre — or rather, it’s great for some, bad for others, and mediocre on average. However, there are systems doing a great job that illustrate some of the ways we can improve. I’m going to sound conflicted, but high-quality integrated systems, like Kaiser Permanente, are managing to fix some problems of price, inequity, and mediocrity. Some academic teaching hospitals have shown great quality, especially with complex, severe health problems. Some community health centers provide genuinely great comprehensive primary care to highly vulnerable populations. Everywhere you look, you can see models of the kinds of high-value care that would impress any nation. But we’re not yet set up to reward or incentivize these types of care, so their implementation is pretty limited, and pretty random.
You are a “healthcare insider”. Can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
- Start with healthier patients. It sounds facetious, but I’m serious. Invest in society at a level that allows every person to grow, learn, work, and live with a sense of safety, equity, civic duty to others, and orientation to the future. Once you allow the healthcare system to function within the zone for which it was intended — simple-to-complicated, mild-to-moderate health problems — you will see a more modestly scaled but more effective healthcare system.
- Engage in serious local and national discussions about what we mean when we say “health.” I have my own definition, which I won’t share because it would take too long to explain, but the thing is that my definition is just my definition. Everybody has their own, if they have one at all, and we need to be really transparent about what we’re trying to achieve. Are we trying to keep you alive? Are we trying to improve your quality of life? What does quality of life even mean to you? Are we trying to allocate our resources to create the best quality of life for the greatest number of people, even if that doesn’t necessarily mean the best quality of life for you? What do we owe to you? And what do you owe to everyone else? We have to have these conversations. Patient-centered care and shared decision making are important components of this, but it goes beyond the patient-doctor relationship and really speaks to how systems of care are structured.
- Make necessary care for simple-to-complicated, mild-to-moderate health problems equally available to all.
- When I say equally available to all, I mean truly equal. This will require addressing deeply rooted, institutional inequities, like social factors that influence where providers decide to practice, leaving many communities, especially rural communities and communities of color, underserved. It also means using carrots and sticks to incentivize providers to provide necessary basic services to patients regardless of ability to pay.
- If you can address the first four, you may not need a fifth. None of these are simple problems to solve, but that doesn’t make them any less our responsibility.
Thank you! It’s great to suggest changes, but what specific steps would need to be taken to implement your ideas? What can individuals, corporations, communities and leaders do to help?
In many ways, changes that are occurring right now in pursuit of the Triple Aim — which is to improve quality, enhance patient experience and reduce costs of care — are steps in the right direction. But we need to keep building on these changes until we touch every corner of the healthcare industry, gradually transitioning large sums of capital and labor from healthcare to other health-relevant social sectors over a period of decades. Simultaneously, we need to intensify the kinds of quality-focused and equity-focused changes we’ve been starting to see within our healthcare systems so patients who need care the most are always protected. And healthcare leaders need to be out front on social reforms, listening to the communities they serve, committing organizational resources to them, and pushing public and private sector partners to do more to improve social conditions and equity in our neighborhoods and our nation.
At KPSOM, we want our students to be a part of this effort to integrate with communities and understand the social and structural factors that influence their health outcomes. We’re doing this by partnering with community health clinics; making equity, inclusion, and diversity a focus of our curriculum; and teaching basic skills for facilitating change. We hope that these experiences will help shape students’ perspectives on what health care means and show them how they might someday move the system in a better direction.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
Probably the most influential book I’ve read that has made me a better person (I don’t know about leader) was Lipstick Traces, by Greil Marcus. It starts with the Sex Pistols and ends up being the first great meditation on complexity I had ever read at the time (I had just started college). No one can understand the health care system without first understanding complexity, those vast hidden webs that connect us all and make unintended consequences always far more important than intended ones. Great fiction, like Age of Innocence, Gilead, Sense of an Ending — books that filled me with a compassion I didn’t know I was capable of — might have made me a better leader.
How can our readers follow you on social media?
I don’t do the Facebook and the Twitter and other newfangled doodads 😊 I follow my kids on Instagram but only as a silent and somewhat unwelcome fan. Sorry.