Administration Dean's Office

The Dean's Newsletter:
December 1, 2008

Table of Contents

v On Professionalism and Patient-Centricity
v Medical Students and Leadership
v Transitions in Graduate Medical Education
v Environmental Venture Project Funding Opportunity
v Awards and Honors
v Appointments and Promotions

On Professionalism and Patient-Centricity

We are all too aware of the multiplicity of factors and forces that have eroded the public trust in medicine as a profession: the fact that many patients lack a personal connection with their primary healthcare provider; the lack of time that most physicians have to spend with their patients; the imbalance between primary care physicians and specialists; the mismatch between the location of physicians and many who need their care; the highly technological environment that, while it defines modern healthcare, is not often accompanied by the personal touch and connection of doctors and their patients; the market forces that have both driven medicine to become more of a business than a profession and contributed to the rising costs of healthcare; and the huge, and growing, number of citizens who lack insurance as well as the fact that the USA is not seen as a world leader in health outcomes – at least on a population basis. These and other changes are not new, but they have converged in a fashion, and at a time, that lead many to the conclusion that medicine has lost its anchor of professionalism. And, sadly, there is truth to this assertion.

While it is true that many individuals profess confidence in their own doctor, most are dissatisfied with the healthcare system as we know it today in the USA. And surveys continue to demonstrate that most physicians who practice medicine are increasingly dissatisfied with their own careers in medicine. A problem, however, is that while the vast majority of Americans believe that significant change in healthcare is needed, there is no unifying consensus about what those changes should be. And while a focus on healthcare reform was a clarion call during the past two years of the presidential primaries, it has given way to the dramatically deteriorating global economic meltdown that has so dominated our lives during the past months. While some say that the financial crisis will make healthcare reform a lesser immediate priority, there are others who believe that the importance of healthcare reform is critical to our ultimate economic recovery and thus should be a priority. I hope the latter is true.

Regardless of the pace of healthcare reform, we can exercise leadership in regaining the public trust in our daily work at Stanford. For our clinical care systems this means establishing a much more focused patient-centric environment. We do not really have that now. Many patients enter our hospitals not really knowing who is providing or coordinating their care. Our highly specialized services do not communicate as proactively as they should in the coordination of a patient's evaluation and treatment. And patient-friendly services, at nearly every level, could benefit from attention and improvement. It is all too easy to assume that these challenges are someone else's responsibility. The reality is that they are the responsibility of each of us – and it is only when we each own our own responsibility that we can make progress.

Put simply, a major goal for our clinical programs and leaders is to make Stanford Medicine as excellent as possible in the delivery of patient-centric care. This does not mean abandoning our great strengths in innovation and discovery – but it does mean implementing them, along with excellent clinical care, in a setting that focuses much more on the experience of patients as individuals – and of their families. To use a cliché, it means delivering care in the manner in which we would like a member of our own family to receive it. Accomplishing this will require some fundamental restructuring in the way we carry out our daily activities. But I would argue that this is not an option if Stanford Medicine is to remain successful.

The rapid consolidation of health care systems currently underway in the Bay Area prompts us to think critically about what differentiates Stanford Medicine and makes it a value-added health care provider in our community. There is no question that our contributions to creating knowledge and our ability to translate discoveries into new diagnostic or treatment regimens are key components of what defines Stanford Medicine. But these cannot be our only defining features. When patients (as consumers) or potential referring physicians have a choice, they will consider not only whether the care we offer is unique but also whether it is delivered with compassion, sensitivity and professionalism.

With that in mind, I was gratified that the leaders of the Stanford Medical Student Association (SMSA) made a presentation to the November 19th Medical School Faculty Senate on "Professionalism in the MD Curriculum: The Student Perspective." Of particular importance was the willingness of SMSA to take ownership and responsibility for fostering professionalism among their fellow students and to seek guidance and support about how professionalism can be fostered at all levels of training and in all interactions. SMSA, led by its President, Tiffany Castillo (SMSIII), had a range of recommendations from issues like attire, timeliness and communications to fostering mechanisms by which feedback about student professionalism would be made available in real time discussions with faculty and supervisors. The SMSA volunteered to take responsibility for overseeing student violations of professionalism, but they also proposed an open dialogue about how we can strengthen a culture of "professionalism" at Stanford. This student-led initiative is enormously welcome, albeit a bit ironic. Indeed, while we should have as a primary focus teaching our students about professionalism, it is also clear that we have much to learn from them as well.

I would add that promoting a culture that fosters professionalism and a patient-centric focus requires the active participation of all of us – faculty, residents, fellows, students, nurses, administrators and all health providers and professionals. This is not an option. I do want to acknowledge the students who have joined with Tiffany Castillo in this effort – including: Sarah Pickard, SMSII, Jon Kleinman, SMSII, James Torchia, SMSIII, Aabed Meer, SMSIII, Mariko Howe, SMSIII, Christine Chang, SMSII, and Malavika Prahbu, SMSII.

I end by noting that the School of Medicine has a Statement on Professionalism in its MD Handbook that is adapted from similar statements promulgated by the American Boards of Internal Medicine and of Pediatrics. Students are expected to meet the standards set forth in this Statement in order to qualify for the conferral of the MD degree from the Stanford University School of Medicine. In reviewing the Statement (which I copy below) it would seem that meeting these standards should be an expectation for all of us at Stanford.

School of Medicine Statement on Professionalism

Professionalism comprises those attributes and behaviors that serve to maintain patient interests above physician self-interest. Professionalism extends beyond interactions with patients and their families, however. Professionalism also involves relationships and interactions between all those involved in medical education and the delivery of patient care including physicians, students, administrators, and allied health professionals. It has implications for research activities and interactions with for-profit companies, governmental agencies, and other outside entities. Professionalism should pervade all of our activities in medicine and should include:

  • A commitment to the highest standards of excellence in the practice of medicine and in the generation and dissemination of knowledge.
  • A commitment to sustain the interests and welfare of patients.
  • A commitment to be responsive to the health needs of society.

The elements of professionalism include altruism, accountability, responsibility, excellence, duty, honesty, integrity, and respect for others. Physicians, students of medicine, and all staff participating in medical student education and patient care at Stanford University School of Medicine are expected to aspire to these ideals, further defined as:

  • Altruism is the unselfish regard for and devotion to the welfare of others and is a key element of professionalism. Self-interest or the interests of other parties should not interfere with the care of one's patients and their families.
  • Accountability and responsibility are required at many levels – individual patients, society and the profession. First, there must be accountability to one's patients and to their families. There must also be accountability to society for addressing the health needs of the public and to ensure that the public's needs are addressed. One must also be accountable to the profession to ensure that the ethical precepts of practice are upheld. Inherent in responsibility is reliability in completing assigned duties or fulfilling commitments. There must also be a willingness to accept responsibility for errors.
  • Excellence entails a conscientious effort to exceed ordinary expectations and to make a commitment to life-long learning. Commitment to excellence is an acknowledged goal for all physicians and students of medicine. A key to excellence is the pursuit of and commitment to providing the highest quality of health care through lifelong learning, education, and reflection. One must seek to learn from errors and aspire to excellence through self-evaluation and acceptance of the critiques of others.
  • Duty is the free acceptance of a commitment to service. This commitment entails being available and responsive when "on call," accepting inconvenience to meet the needs of one's patients, enduring unavoidable risks to oneself when a patient's welfare is at stake, advocating the best possible care regardless of ability to pay, seeking active roles in professional organizations, and volunteering one's skills and expertise for the welfare of the community.
  • Honesty and integrity are the consistent regard for the highest standards of behavior and the refusal to violate one's personal and professional codes. Honesty and integrity imply being fair, being truthful, keeping one's word, meeting commitments, and being forthright in interactions with patients, peers, and in all professional work, whether through documentation, personal communication, presentations, research, or other aspects of interaction. They require awareness of situations that may result in conflict of interest or that result in personal gain at the expense of the best interest of the patient.
  • Respect for others is the essence of humanism, and humanism is central to professionalism. This respect extends to all spheres of contact, including but not limited to patients, families, other physicians, and professional colleagues, including nurses, residents, fellows, and medical students. One must treat all persons with respect and regard for their individual worth and dignity. One must listen attentively and respond humanely to the concerns of patients and family members. Appropriate empathy for and relief of pain, discomfort, and anxiety should be part of the daily practice of medicine. One must be fair and nondiscriminatory and be aware of emotional, personal, family, and cultural influences on patient well-being and patients' rights and choices of medical care. It is also a professional obligation to respect appropriate patient confidentiality.

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Medical Students and Leadership

Over the past several years a number of leadership training programs have developed throughout the School of Medicine and Medical Center. For example, the Office of Leadership and Diversity, led by Dr. Hannah Valantine, has initiated a number of programs for faculty, including the Faculty Fellows Program, the Physician-Faculty Leadership Program (done jointly with LPCH), Skills Building Workshops and the Women's Faculty Network, among others. Both SHC and LPCH have also instituted important leadership development programs; taken together, they offer a number of opportunities for our faculty to acquire news skills and to explore new career pathways.

We also seek to promote leadership development for our students through courses and programs that foster their personal and professional growth and success. Thus, I was particularly pleased to note that two of our students (Tiffany Castillo, SMS III and Matt Goldstein, SMS IV, the current and past presidents of the Stanford Medical Student Association [SMSA]) have collaborated with UCSF Surgery Resident Dr. Bernard Palmer, who is pursuing a Master's in Education at Stanford focused on leadership training, to develop a student-led course on leadership. They and 12 fellow-students participated in weekly presentations and discussions by invited leaders throughout the Medical Center, who shared their personal journeys and lessons learned about leadership. They focused on topics such as defining leadership, how to provide influence, the value of teams, communication and emotional intelligence, diversity, and conflict management, among others. From this they distilled some very different styles of leadership as well as some common themes – including the importance of vision, a passion for change, the ability to learn from mistakes and the value of approaching one's career with integrity and honesty – as guideposts for leadership.

There is often a debate as to whether leaders are born or whether they can be educated for the roles they assume. Like most issues, it seems evident that certain personality characteristics and experiences are more successful than others for the rigors of leadership. But it is also clear that effective leaders do learn – from their experiences, from others, and from mentorship – about the best approaches to leadership. It is likely that effective leaders are suited for some roles but not others. For example, the measures of success in medicine or academic life are likely different from those in business or government. But there are no absolutes, and one domain and discipline can inform others.

What is also clear is that our students are eager to become leaders and that they are finding ways of acquiring the skills to become more successful and effective. This is quite exciting and gratifying, and it gives us all hope for the future.

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Transitions in Graduate Medical Education

A critically important bridge between undergraduate medical education and the assumption of a career as a junior faculty member or practicing physician or scientist is the interlude known as graduate medical education, postdoctoral and/or fellowship training. If the time to attain an MD or PhD degree approximates 4-5 years, the time in post-degree training can range from 3 to more than 10 additional years. For MD graduates, this is the period of differentiation and the time when the course of a career as a physician or physician-scientists/scholar is defined.

The continuity and coordination between undergraduate medical education and graduate/postgraduate training is often limited – which is one of the reasons I created the Office of Graduate Medical Education and Continuing Medical Education, which has been led by Dr. Myriam Curet, Professor of Surgery. Dr. Curet developed a number of integrating programs during the past three years, and I am grateful to her for those achievements. However, she has recently informed me that she has decided to take an administrative leave to pursue special interests in surgical education and training. Please join me in thanking Dr. Curet for her wonderful contributions to education – in surgery, for medical students and residents, and nationally in a number of professional organizations. She is a highly respected medical educator, and I appreciate all that she has done for Stanford and beyond – we look forward to welcoming her back in the not too distant future.

Given these changes, I have decided to reorganize the functions of Dr. Curet's office to provide even greater continuity between undergraduate and graduate medical education. Accordingly, Dr. Charles Prober, current Senior Associate Dean for Medical Student Education, will assume oversight over graduate medical education programs. In doing so he will work closely with Dr. Larry Shuer, Professor of Neurosurgery and Associate Dean for Graduate Medical Education. He will also be working with clinical department chairs, program directors and others to foster opportunities for career development of Residents and Clinical Fellows. These will be modeled on the themes of our Scholarly Concentrations and will take the form of networking programs for residents interested in a wide range of career options. These new opportunities will also bring together residents and clinical fellows from various medical, pediatric, diagnostic and surgical specialties who share common interests in medicine, science, health policy, etc.

As you also know, we are undergoing a number of changes in Continuing Medical Education (CME), which is now being led by Dr. Rob Jackler, Edward C. and Amy H. Sewall Professor and Chair of Otolaryngology/Head & Neck Surgery and Associate Dean for CME. During these transitions, Dr. Jackler's team will report to me and will work closely with Dr. Harry Greenberg, Senior Associate Dean for Research, and Dr. Kathy Gillam, Senior Advisor to the Dean.

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Environmental Venture Project Funding Opportunity

The Wood Institute for the Environment invites all Stanford faculty to submit letters of intent for the 2009 Woods Environmental Venture Projects (EVP) grant program. EVP grants provide seed funding for interdisciplinary research projects that lead to practical solutions promoting an environmentally sustainable world. The EVP research committee will consider projects with budgets up to $100,000 per year for up to two years. Proposals from all disciplines are encouraged, and the Lead PI must be a member of the Academic Council. Letters can be submitted online by January 9, 2009, at http://woods.stanford.edu/research/evp.html. Please contact Paula Wetzel at with any questions.

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Awards and Honors

In addition to congratulating the two winners I also want to thank the SUPA for creating this important award, which underscores and honors faculty who have contributed to the successful mentoring of postdoctoral fellows.

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Appointments and Promotions

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A downloadable Microsoft Word version of the newsletter is available. If clicking on this following link does not initiate a download, right-click (Windows) or click-and-hold (Mac), then use the command most similar to "Download Link To Disk" or "Save This Link As" and save the Word file to your disk.

Microsoft Word version: DeanNews12-01-08.doc

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