Leaning into Change to Fulfill Our Promise: Address of J. Larry Jameson, MD, PhD, Delivered at Learn Serve Lead 2021 -- the 132nd Annual Meeting of the Association of American Medical Colleges
November 9, 2021
Friends and colleagues --
Today, as Chair of the Board of the AAMC, I want to use this Learn, Serve, Lead forum to encourage us to “lean in” and enact change where we know it is needed. Academic Medicine is a complex ecosystem. Like other ecosystems, we must evolve to remain competitive and viable. This audience is uniquely positioned to catalyze this evolution -- with your passion for academic medicine, your commitment to improve health for all, and your ability to use evidence-based knowledge.
Our shared experience with COVID-19 provides a poignant case study in adapting to a rapidly changing landscape. Science has never moved more quickly. Our front-line physicians, nurses, and staff demonstrated remarkable adaptability and resilience -- and they are indeed heroes. Our students and faculty pivoted their approach to learning. And, while too many have died, we have also saved countless lives through innovations in care and the rapid development of mRNA vaccines.
While I highlight these successes, there are areas in which we could have done better. In my view, our country did not fully harness the power of academic medicine – for test development and widespread, frequent testing; for expedited, non-duplicative clinical trials; and for large-scale pooling of clinical data. Despite determined efforts by many, we failed to communicate effectively to large fractions of the population.
We should be proud of what we accomplished during COVID, but we should also learn from this experience – preserve the elements that worked well, like telehealth and the strategic use of Zoom interviews, but also acknowledge the challenges and do better in the future. I cite this well-known example of our shared experience with COVID as a preamble – as a call to action – for us as leaders in academic medicine – to adapt continuously – to innovate – to implement – to lean in – to make academic medicine more relevant and effective. As most of you know, with your input, the AAMC has developed and launched an ambitious strategic plan that outlines a path to a healthier future through learning, health care, discovery, and community collaborations. Now, it is up to all of us to ensure its implementation.
I want to start our journey together by grounding us in our missions. We have the privilege of serving as physicians – preventing disease when we can, treating patients when disease inevitably occurs, and supporting them when our options are exhausted. As scientists, we are challenged to unlock the closely held secrets of nature, and when possible, to translate these newly discovered clues into knowledge and treatments. We are learning to collaborate with our patients and communities to focus on prevention, improve outcomes, and close gaps in health disparities. We have the privilege of transferring knowledge and experience to eager, stunningly brilliant students, who inherit a future we cannot reliably foresee.
I highlight these classic missions of academic medicine because they reflect the complexity and importance of our professional roles. Because of that complexity – and the importance of what we do -- there is an understandable reluctance in academia to be nimble and embrace needed changes. We are, indeed, burdened by complexity and steeped in tradition.
I want to challenge you – challenge us – to accelerate needed changes in health care and science. We know the potential of the US Healthcare system. We are the innovators of most new medical advances; we have generous funding from the NIH that fuels our breakthrough basic and translational research discoveries; American biotech and pharma industries pioneer most new therapies. We have some of the finest healthcare facilities in the world. Nevertheless, it is a long-standing tragedy that our health outcomes lag most of the developed world. Our business community, government, and fellow Americans are losing patience with the cost of healthcare delivery and challenges with access.
In this audience, the sources and potential solutions to this paradox are well-known – social determinants of health, persistent health disparities, misallocation of resources, particularly relative to prevention, and a payment system that is overly bureaucratic and not well aligned with incentives to optimize outcomes at lower cost – to name just a few issues that are well known to you.
As physicians and leaders in academic medicine, we cannot wait for others to address these challenges. Change will happen either with us, or to us.
While these challenges can seem intractable, I am convinced that we can solve these problems -- big and small. Remember, you have power to act locally in your own institution and in your communities. Each step that we take to improve access, reduce disparities, or advance prevention adds up. We can all implement these changes locally -- in our classrooms, clinics, laboratories, and operating rooms.
We own the culture of academic medicine. We should remember that our profession is largely self-regulated. We created most of our policies – formal and informal. We establish the curriculum – explicit and hidden. Therefore, in principle, we can change these policies and practices. For example, we can decide whether to embrace more holistic criteria for promotion. We can decide whether we value team science as much as – or more than – individual accomplishments. At my institution, Penn, we recently added community-engaged research to our formal categories for scholarship; we set explicit expectations for professionalism and review these for appointment and promotion; we expanded our education categories to embrace teaching and mentoring in practical settings like clinics, ICU’s, and laboratories, as well as in the classroom. We overtly state that we are united as an anti-racist organization, setting an expectation for our culture. I know you have similar examples in your own institutions but I cite these to remind us of the ability to act locally.
As an academic community, using holistic review criteria for medical school applicants, we can select for characteristics and skills that are likely to predict future clinicians that you would turn to for a consult or to care for a loved one. Perhaps these characteristics will not be so heavily weighted towards traditional quantitative measures like GPA and MCAT, which granted, provide one indicator of success. But what about overcoming adversity, demonstrating empathy and resilience? What about curiosity and willingness to learn broadly and take chances on courses that might not earn an “A.” Within LCME guidelines, we can redesign our curriculum and residency training experiences focused on the future, rather than based on tradition. These are examples of “hard problems” involving policies and culture, but they can and should be taken on by the people in this room.
After all, we are innovators and healers. In Walter Isaacson’s historical accounts of innovators like Leonardo da Vinci, Benjamin Franklin, Albert Einstein, Steve Jobs, and one of our speakers, Jennifer Doudna, he observes a recurring theme of creative people feeling alienated early in life, but then overcoming adversity, taking chances, and applying discoveries to real-world problems. There are lessons in these themes. Yes, there are risks to broadening our selection criteria, but there are also risks to NOT embracing a more diverse group of future physicians.
Innovation and diversity are symbiotic partners. Diversity in medicine is a long-standing priority for the AAMC and, I am confident, in each of your institutions. I hope – and believe -- that we have reached an inflection point in the effort to root out racism and bias in medicine. Last year’s widespread outrage over racial injustice has catalyzed an ongoing movement to effect enduring change. Each of our institutions saw a major uptick in applications during the pandemic. After years of slow progress, this increase was fortunately accompanied by the enrollment of more diverse students into medical school and PhD programs. We need to build on this momentum, and ensure that our climate is conducive to learning and positive experiences, so that the word can spread that medicine and science are receptive to diversity, and that exciting professional opportunities await students from a wide range of backgrounds and experiences. The literature is replete with evidence that diversity strengthens the performance of high functioning teams. Embracing diversity and inclusion will help us evolve more quickly and successfully. More diverse caregivers are essential to build trust in our profession, and this trust can accelerate closing health disparities.
Medical education must also adapt to the accelerating, and sometimes overwhelming, amount of information that physicians must learn and digest on an ongoing basis. We will increasingly need highly specialized experts who can digest the information needed to deliver precision medicine. But we also need to support the most complex and challenging specialty in medicine – primary care – a field requiring extraordinary breadth, depth, and expertise to filter the rare from the common. As leaders, we need to guide students towards fields where they can excel and make a difference. An important goal is to minimize financial and lifestyle incentives that do not currently align with a student’s skills or interests, nor with the clinical needs of our patient population.
Innovation in research has been, and remains, a critical part of our relevance and our future. I am trained as a physician-scientist. At each stage of my career, I thought we were approaching the pinnacle of biomedical advances. But we are far from the apex. Around every corner is a stunning unforeseen breakthrough – the emergence of epigenetics for regulating gene expression, the engineering of CAR-T cells to treat cancer, the use of fetal surgery to treat developmental defects like spina bifida, the development of CRISPR-Cas9 for gene editing, and the use of TAVR as a less invasive way to repair heart valves. The tools and opportunities for major research advances have never been greater. The remarkable efficacy and safety of the mRNA vaccines against the SARS-CoV-2 virus shows how much we can accomplish. These types of advances can rarely be supported by academia alone. The platform for mRNA vaccines was developed by two scientists at my institution based upon decades of basic research. But it required collaboration with government and industry to bring this technology to patients. We can seize this moment in history to build support for translational science and quicken its pace by expanding our partnerships with industry, while being transparent and attentive to conflicts of interest, as we collaborate to find and evaluate new treatments. In addition to the practical benefits of new therapies, these breakthroughs give our patients hope and reinforce the value of biomedical science to society.
This call to action – to shape the future of academic medicine -- cannot happen without your leadership and commitment. You are our current and next generation leaders. I encourage each of you to reflect on the way you lead, in education, in your clinics, in your laboratories, in your communities, or at a system level. There are literally thousands of books on leadership. While I encourage you to read some of these and participate in leadership courses, there is no substitute for graduated experience, self-reflection, and mentoring. Academic medicine has myriad leadership niches. Different institutions and different roles require varied leadership styles and experience. You can find your niche within this spectrum of opportunities. Some of these will likely require stepping out of your comfort zone and taking risks. We need leaders willing to innovate boldly, but in a manner that preserves our high standards for evidence, safety, and professionalism.
Before I finish, I want to return to where I started – the privilege of serving our mission areas. I have spoken of challenges, innovation, and change management. I also want to speak of gratitude, because it will remind us of the excitement and importance of what we do. And, it can provide resilience when we navigate the choppy waters that often accompany change.
I have found gratitude and joy in each of my roles in academic medicine. I never expected to be a doctor or a scientist, much less a department chair or dean. Each of our roles is different. I find that satisfaction comes not from titles but from “doing a job well” and “loving what I do.” I will give some examples from my own experience, mainly to encourage you to think similarly about your own professional lives.
I vividly recall a clinical experience as a newly minted intern during one of my first patient encounters. I admitted an elderly man with metastatic prostate cancer. He had lost weight, was listless, and bedridden. He came up from the ER with the common diagnosis of “Failure to Thrive.” My initial assumption was that he was in the final stages of his disease. However, his K+ was elevated. Somewhere from the memory banks of medical school lectures, adrenal insufficiency surfaced in the differential diagnosis. An ACTH stimulation test confirmed the diagnosis, and cortisol replacement dramatically restored his vitality. This diagnosis may not have changed his long-term outcome, but it did improve his quality of life, and reinforced for me the power of knowledge to help people. I know you have similar stories, and I urge you to reflect on your own memories of making a difference in people’s lives. This is the joy of medicine.
For most of my career as a physician scientist, my work has felt more like a hobby than a job. Why else would one awake at 2AM with a novel idea, get out of bed, and head into the lab to get started on the next experiment? It is thrilling when new data turns over a missing piece of an unsolved mechanistic puzzle, ultimately revealing a full picture that is beautiful to behold. Some of these experiences feel like epiphanies and are shared with graduate students or postdocs in the relative isolation of the laboratory. Others occur during a plenary talk when a large group shares the experience of a new insight as they see the final slide with the “big reveal.” Research can be arduous with many failures, so we must recognize, celebrate, and remember these dopamine-rich moments of euphoria. This, too, is the joy of medicine.
Our devotion to teaching and mentoring is arguably the greatest wellspring of joy. I am often surprised when one of my former trainees mentions something I said to them, of which I have no clear recollection, but seemingly provided a memorable pearl or changed their career plans. As you teach students, residents, or colleagues, they will, in turn, use this knowledge to manage untold numbers of patients. For me, this is like a PCR reaction. Teaching is amplification leading to impact.
The spirit of joy touches every aspect of our work – patient care, research, teaching, and engaging with our communities. It can also be found in leadership roles and in implementing the changes in the culture, traditions, and practices of academic medicine that are essential to our future and to improving the health of our nation. Our field needs your leadership at this time, and you can find joy and satisfaction in leadership, as well as in our traditional missions.
I am deeply grateful for our community’s collegiality and sense of purpose. We can meet the challenges of these extraordinary times. We can lean into change -- to improve patient access and outcomes, to create a stimulating educational environment for a broader group of learners, and to translate new scientific insights into novel therapies and cures for our patients.
I call on each of you to join in this journey to a healthier, more equitable future – to enact the change that we know is needed to fulfill the promise of academic medicine.