Moving Academic Medicine Forward

By:  Kathleen Sebelius
Date: June 11, 2012
Location: Baltimore, MD

Johns Hopkins is a terrific place to be talking about the future of medicine.

More than 100 years ago, when Abraham Flexner had to decide which institution to use as his model of medical education, there was little question which it would be. The influence of Johns Hopkins, he wrote, can hardly be overstated. And a century later his words seem truer than ever.

Hopkins has been a leader time and time again: the first major medical school to admit women; the first to use rubber gloves during surgery; the first to develop renal dialysis and CPR. Hopkins helped develop new specialties from neurosurgery and urology to endocrinology and pediatrics.

More recently Hopkins scientists have made discoveries at the foundation of genetic engineering, neurotransmitter pathways, and that most cutting-edge medical technology of all, the checklist.

The last 15 years have been shaped by Dean Miller who came to Johns Hopkins with one of the hardest jobs possible. He was asked to take one of the most renowned medical schools and hospital systems in the world, and make it even better. But that's exactly what he did.

So Dean Miller, let me add my congratulations to those you've received today.

But even here at Johns Hopkins, we must also acknowledge how far we still have to go.

Over the last couple decades there has been a growing consensus about where we need to move our health care system: toward a focus on prevention and maintaining health, a greater emphasis on primary care, more coordination between providers, greater value for dollars spent, and better use of evidence, leading to continuous improvement.

We're moving in that direction. But I think it's clear that we're not moving fast enough. Though we've been talking about these reforms for decades in some cases, our health care system is still marked by uneven quality, unequal access, and runaway costs that put care out of reach for far too many families.

And yet, as I speak to you today, I'm very optimistic.

Over the last few years, we've seen a number of powerful trends converge: The rapid adoption of electronic health records, a growing public awareness about the importance of prevention, a new eagerness and willingness among providers to embrace change, and the Affordable Care Act -- the most important health legislation in over 40 years.

The combination of these trends has created a unique opportunity for progress in health care. And no one is better positioned to take advantage of that opportunity than Johns Hopkins and America's teaching hospitals.

Today I want to talk about a few key areas where I believe we have the greatest potential for progress.

The first area is making prevention a priority. There is a growing body of evidence that people's behaviors outside the health care system -- what we eat, how much we exercise, whether we smoke or not -- affect our health even more than the treatments and medicines we get when we visit a doctor.

For doctors, this meant experiences like designing the perfect regimen for your patient with diabetes, only to see them go home to a neighborhood where the lack of healthy food options meant their chances of sticking to that diet were almost zero.

So over the last three years, this Administration launched what is probably the most ambitious effort in our country's history to help people make healthy choices: funding innovative local programs for reducing chronic disease; new laws to make sure kids get healthy school lunches; and historic legislation to make it harder for tobacco companies to market their products to kids -- since we know that every day, 3,800 young people smoke their first cigarette.

We're also making it easier for doctors to promote good health in their practices.

A key benefit of the health care law is that recommended preventive services like cancer screenings and wellness visits are now available for Medicare beneficiaries and many other Americans at no additional cost. So doctors no longer have to worry about those patients skipping their mammograms and checkups because they can't afford the co-pay or deductible.

But prevention only works if leading institutions like Johns Hopkins make it a priority.

That starts in your clinical work where you can give your patients the tools to live healthy lives. Getting a teenager the support he needs to quit smoking may be more important than any test or exam you might provide. And helping a young parent identify asthma triggers in her home may determine whether or not her child truly thrives.

You have a unique role in your patients' lives, and a powerful opportunity to affect their health well after they leave your offices.

But we also need better research about which community-based prevention programs work and which don't -- especially in areas where we've only just gotten started, like childhood obesity. We've seen the positive impact of programs like building safe routes to school and smoke-free public housing. But now we need to measure and study their results -- because we know that by honing and improving these interventions, we can reach more people in more communities more effectively.

Another area we're focusing on is primary care which is fundamental to helping people stay healthy. Yet we face a dire shortage of providers across the country today. As chronic diseases continue to rise and our population continues to age, the need for primary care providers will only grow.

In the Obama Administration, we're doing our part by increasing reimbursement rates for primary care. And we've added thousands of slots to the National Health Service Corps. If you go and practice primary care in an underserved community, we'll help you repay your loans -- a win/win.

But we also need academic medicine to further explore the importance of primary care in your research and underscore it in your training. Far too often, especially at our leading teaching hospitals, primary care has been treated like it was less challenging, less important, and a less worthy use of a physician's skills. We need to change these attitudes, and that starts with our medical schools.

But ultimately, the choice belongs to the next generation of doctors. So, to the medical students here today, I ask you, directly, to consider becoming a primary care physician. If you want to help lead the biggest transformation of medicine in decades, there's no better place to be.

That brings me to a third area where academic medicine can continue to lead. That is in moving our system toward care coordination.

Thanks to the medical breakthroughs of the last 50 years, millions of Americans today are living with chronic conditions that would have killed them 50 years ago. It's good news that we're living longer. But it also means we have a new group of patients who often suffer from multiple, chronic conditions.

You may see a patient with congestive heart failure. But she also has chronic asthma, uncontrolled diabetes, and is a smoker. As she sees more and more individual doctors, the chances that something may fall through the cracks increase. And then, so do the costs of her care.

But we know that doing something right often costs less than doing it wrong. And under the health care law we're changing the way we pay for care -- to get high value for the dollars we spend.

We're supporting models like Accountable Care Organizations that will get paid for keeping their patients healthy and not just how many tests and procedures they do. Many of them are led by teaching hospitals, and we need you there going forward on the frontlines of our work to deliver higher value care.

But if we are going to make coordinated care the rule and not the exception, we also need to make sure it's at the heart of our medical school curricula. There was a time when it was good enough just to train the best specialist in every field. But today, no one person alone can keep their patient healthy. It requires primary care doctors and specialists, but also nurses, community health workers, and substance abuse counselors.

And this multidisciplinary, team-based care, must be part and parcel of training the next generation of physicians. It's why the surgeon and author Atul Gawande likes to say: today, we need pit crews, not cowboys.

These are three areas where Johns Hopkins can lead the way. But I also want you to think beyond your own patients, your own students, and your own research grants.

One of the most important breakthroughs in medicine over the last 10 years was the surgical checklist developed right here at Hopkins. When ICU doctors and nurses implemented the checklist, you saw a real difference.

But what really made the checklist so powerful was when other leaders and other institutions took it up. Michigan hospitals gave it a try and ended up saving 1,500 lives and reduced health care costs by $200 million in just 18 months. Now, hospitals everywhere have embraced it.

So this is the final place I'd like to ask you to step forward. Beyond the three pillars of research, education, and patient care at the heart of academic medicine, we need you to take on another mission. We need you to serve as a model for the future of health care.

Change is hard. People often see the initial advantage of trying something new. But then there are costs and risks involved, and after a few bumps in the road, the temptation is to stick with what you know -- even if it's not working well.

But change becomes easier, if someone creates a path for you to follow. Institutions like Johns Hopkins have always been models for the rest of the nation. But that has been about more than just new facilities or the latest ranking in a particular publication.

It's also means pushing this country forward, even from the front of the pack, to build a better health care system for all Americans.

I look ahead with great hope for the future of medicine. There will be more obstacles to overcome. But in the face of great challenges, the pioneers of American medicine have never been discouraged. We're going forward together -- because today, a stronger, healthier America is on the horizon.