CU Department of Family Medicine - History, Mission, Future: An Introduction by ucdenver10

University of Colorado School of Medicine

Department of Family Medicine History, Mission, Future: An Introduction

Department of Family Medicine History, Mission, Future: An Introduction Frank Verloin deGruy III, MD, MSFM

TABLE OF CONTENTS Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1. History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2. Mission, Vision, Values, Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3. Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 4. Size & Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 5. Budget . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 6. Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 7. Strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 8. Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 9. The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Frank Verloin deGruy III, MD, MSFM

PURPOSE Every year the chair of this department prepares and delivers an annual state of the department address. This address generally includes information about the department’s financial and programmatic health as well as significant changes from the previous year, signal achievements, new risks, and opportunities ahead. For reasons I will explain directly, this year we have prepared a greatly expanded version of this address. The document you are reading now is the introduction to that version.This self-study has been prepared and written by a host of faculty and staff leaders in the department. The credit for compiling all this material is theirs. As this department’s chair, I (and a few others) have edited the whole thing for consistency in tone and emphasis. I have written a few sections de novo, including this introductory section, which is an overview of the department as a whole. The intent is to describe the overall character of the department and not my idiosyncratic views on our leadership, values, and culture. It goes without saying that my own ideas, values, and priorities figure into these features, but they are by no means determinative. Everyone who works here has a say in how we conduct ourselves, what we value, and what we choose to pursue. I have served as chair of this department for 20 years, since July 1999, and intend to step down from this position upon the appointment of a successor by the dean of the school of medicine.

This transition will bring about new resources, and new energy, but some things could get lost: • two decades of accumulated knowledge about how we conduct our business, • why we do things the way we do, • what has and has not worked along the way, • who our most important friends and allies are, • the historical antecedents and rationale for, certain of our actions, and, • other information about what we are like, how we got this way, and where the hidden lines of our future are pointing. To fill in some of these gaps, this document goes beyond the usual annual department update. It is written to be most useful for those charged with understanding this department in order to help it succeed: the members of this department, the search committee for the next chair, the dean and other school leaders, leaders in our affiliated hospitals, and candidates for the position of chair.

This report begins with this Introduction, which also serves as an executive summary of sorts. The Introduction is an extended overview of the department, broken into sections dealing with: 1. our history 2. o ur mission, vision, and values, and the culture of this department that we have consciously adopted and inculcated 3. our school, state, and national context 4. o ur size, shape, structure, and constituent programs 5. our budgets 6. our leaders and philosophy of leadership 7. our strengths 8. a few of the knotty challenges we still face 9. our trajectory into the future

Following this introduction, a subsequent publication will detail chapters focusing on the clinical, educational, research, behavioral, and community mission areas. Most of our programs, such as Sports Medicine or Palliative Care, cut across mission areas, and several of these programs are described in their own sections. We will conclude with a few appendices for those who want more detail.

1. HISTORY Family medicine emerged as the 20th distinct medical specialty in 1969 as the heir to general practice. In the 1940s Denver General Hospital began offering a two-year general practice residency training program, just at the time many doctors returning from World War II were using their GI benefits to receive training in newly formed medical and surgical specialties. Family medicine got its first foothold at the University of Colorado as a division of family practice within the department of internal medicine; the first family practice resident began training here in 1969. By 1975 this division became a fullfledged department, and soon thereafter the Rose Medical Center, then led by Joel Edelman, hosted the department’s first University of Colorado Family Medicine Residency Program. For decades, Rose Hospital remained one of the department’s earliest and most steadfast supporters, thanks in large part to Mr. Edelman’s vision and leadership. Another early supporter came on the scene in 1977, when the AF Williams Family Foundation purchased our first home, the AF Williams Family Medicine Center, at 1180 Clermont, adjacent to Rose Hospital and the medical school campus. 2

This was the first of many gifts from the AF Williams Family Foundation. During these early years the department was small and its scope limited, but it developed national prominence by virtue of two early commitments: to practice-based information systems that made it possible to observe and record the content of clinical care in family practices, and to practice-based research networks that made it possible to rigorously research community-based clinical problems. By the early 1980s the department had become integrated into the school’s overall educational mission, and the clinic joined the faculty practice plan. In the 1990s the clinic moved to larger quarters at 5250 Leetsdale. The department opened two new residency training programs, at Swedish Hospital and at University Hospital, opened a new urban residency training track at Denver Health, and committed to research as a core mission. By 1999, when the current chair Dr. deGruy arrived, the department had been under the leadership of Dr. Larry Green for 14 years, and had grown to 74 faculty, three residency programs (one

2. MISSION, VISION, VALUES, CULTURE Recently we revised our mission, vision, and values statements, and put them on our website. They are paraphrased here for your convenience.

a coordinated, integrated fashion, to be available to our patients and to stick with them over time, and to take into account their families and communities.

I encourage you to read this paragraph again, and carefully — we take each of these Our fundamental mission is to help slowly elements of our mission seriously, and they shine through all our work. Incidentally, these facets of people be healthier. our mission align with the quadruple aim — to We aim to do this in two specific ways. The first provide a high quality of care, at an affordable price, is through the practice of exemplary primary care. to ensure that our patients and their communities We know that primary care practiced at its best are healthy, and to design this care such that produces high quality, affordable care; healthier practicing like this is rewarding. patients and communities; and improvements in health equity across communities. Hence, we strive to practice primary care at its best — to address most or all of our patients’ health care concerns in

with an urban track), a clinic with a visit volume of 24,000/yr., and $400,000/yr. of extramural research. Since that time our fundamental structure as a freestanding clinical department in the School of Medicine, as well as a fully vested member of the university practice plan and a core partner with the University of Colorado Hospital, has remained unchanged, but the department has experienced explosive growth, has become more deeply integrated with others, and has assumed a more prominent national leadership role in our field.

The second specific way we approach our mission of helping people be healthier is by acknowledging our particular context: we do not just practice high-quality primary care; we are an academic department of family medicine, a statement loaded with additional implications. First, family medicine is more than primary care. We practice in hospitals, nursing homes, specialty clinics, other primary care sites, and on athletic fields. And we do much more than practice. As part of an academic health center, our mission includes educating all health professionals about the place and value of family medicine, training the primary care workforce, and discovering ways to help patients, families, and communities become healthier. We regard these mission areas — patient care, education and training, and research and innovation — not as independent, but as interdependent, synergistic. Our classrooms are clinics, and our research labs are networks of 3

clinics and communities; what we discover should apply directly and immediately to improved care. Our learners practice and learn in clinics that are beds of discovery and improvement. Thus, our mission areas converge.

As to values, there are several words we use a lot around here: service, innovation, collaboration, perseverance. We value diversity, equity, and inclusion of all people â&#x20AC;&#x201D; the best teams are diverse teams.

We are not only a member of the university family, but we are also part of the community around us â&#x20AC;&#x201D; all our clinics are located in the community, off our campus. In fact, we consciously serve as a bridge between the campus and community, bringing the resources of each to the other. We believe that an academic health center should participate in the life of the community in which it is embedded, and that we should grow and succeed together. As to vision, we imagine building and operating clinical practices and community programs that serve our patients and their communities. We envision these scaled to meet the primary healthcare needs of all the patients our academic health center serves with state-of-the-art primary care. We envision doing this in partnership with the other primary care disciplines and all others in the primary care workforce. We envision doing this in such a way that all our efforts, whether clinical, educational or research-related, result in benefit to our patients and communities. We envision a workforce that is fully committed to lifelong learning and professional development. Finally, we envision a department that is comprised of diverse and inclusive teams that reflect the makeup of the communities we serve.

We encourage the passionate pursuit of individual goals driven by curiosity, but tracking within the traces of our collective purpose. This balance between individual initiative and collective vision will be developed below. We believe a bold and decisive effort is almost always superior to a timid, incremental effort.

We value big, smart failures, and strive to learn everything we can from them. Partnership trumps ownership. Attraction trumps coercion. Permanence trumps prominence. Hard work should be leavened with respite and recreation. It is possible to create a specific organizational culture, and we have consciously tried to do so in this department with some success, even though this is a never-ending process. The elements of culture we address most explicitly are described in the section on leadership, below.

3. CONTEXT This department has been fortunate to live in a permissive, enabling environment with several powerful allies and supports close at hand. Several features are worth mentioning.

Rose Hospital and Joel Edelman Joel, who still meets occasionally with Larry Green and Frank deGruy, was the president and CEO of Rose Community Hospital before it was acquired by the Hospital Corporation of America (HCA). He understood the value of and need for family medicine early on, and supported the nascent department with dollars and a host hospital for our first residency program. This program ran as a hybrid university-community program until 2018.

The AF Williams Family Foundation This is a small family foundation headquartered

in Fort Morgan, Colorado. They have been incredibly generous to us; it is fair to say that we would not be nearly as secure or prosperous as we are today were it not for our friends at the AF Williams Family Foundation.

university residency program, and our four main clinics are operated by them. This hospital has been financially very successful over the years, and they have been quite generous in their support of our clinics and residency programs.

Practice Plan in the Black Our practice plan, CU Medicine, is likewise financially solid and has been unstinting in its support of our programs.

Primary Care Compensation Plan Our negotiated contracts with payors are insufficient for reasonably productive primary care clinics to break even. Accordingly, beginning in 2001, the University Hospital and CU Medicine (then called UPI) each supplemented in equal measure our clinical income sufficient that if we are prudent and productive, we can enjoy a modest margin. I should mention that half of the practice plan’s contribution comes directly from the nonprimary care departments.

Two Supportive Deans Dean Krugman was head of this school for a

They bought a building and deeded it to the department for use as a clinic and administrative headquarters; when the campus moved, we sold the building and the funds rolled into the department’s accounts for use at our discretion.

quarter century, until about three years ago. He was most supportive of family medicine, with dollars, advice, and initiatives; and we prospered greatly under his leadership.

They have given the dollars for all four of our named endowed chairs: The WoodwardChisholm Chair occupied by the department head; the Green-Edelman Chair for Practice-Based Research, currently occupied by Don Nease; the Epperson-Zorn Chair for Innovation in Family Medicine, currently occupied by Larry Green; and the Patrick and Kathleen Thompson Chair for Rural Health, which resides in the Dean’s office, currently occupied by Mark Deutchman.

Three years ago, Dr. John Reilly succeeded Dr. Krugman as dean and vice chancellor for health affairs, and has quickly proven to be strongly supportive of family medicine as well. He stood with us during a wrenching divorce from Rose Hospital/ HealthONE, supporting the residents’ and faculty’s transitions, provided financial support during one particularly challenging financial crisis, and has committed to build additional residency programs. His support has been unwavering.

They have supported a number of smaller projects with gifts over the years, and most recently made a pledge of three million dollars toward a ten million dollar fundraising effort to endow the department as a whole. I hope we will soon be known as the AF Williams Department of Family Medicine.

Hospital in the Black The University of Colorado Hospital hosts our

The Colorado Clinical and Translational Sciences Institute’s (CCTSI) Community Engagement Core

Colorado’s Clinical and Translational Sciences Award has an unusually strong community engagement core, headed by Don Nease, that has positioned us well to undertake a whole range of community-based projects. 5

The Adult and Child Consortium for Health Outcomes Research and Delivery Service (ACCORDS)

Partnership with the American Academy of Family Physicians’ National Research Network (NRN)

This is our campus’s health outcomes research center, previously known as COHO, a program that has existed in one form or another for two decades. We are intimately connected with this research shop; at one time, in fact, our vice chair for research was concurrently this center’s director.

Jen Carroll, the director of the 2336-clinician, 50-state network, has her primary faculty appointment in this department, and divides her time evenly between the NRN in Kansas City, and this department, where she is the associate vice chair for research. The NRN does tens of millions of dollars of extramural research, and we share principal investigators, faculty, and staff with that network.

ACCORDS hosts our PBRN infrastructure, many of our mixed-methods scientists, the implementation science center, and a full stable of scientists, methodologists, and other technical support personnel that we share and use extensively. We administer many of our grants through ACCORDS.

The List Goes On These are high points, but by no means does this list exhaust the quarters from which we draw support here.

4. SIZE & STRUCTURE The department has about 250 paid faculty (including 37 PhDs, 9 PsyDs, 18 MPHs, and others) and about 600 volunteer clinical faculty. The department extends secondary appointments to 86 additional faculty. It is easy but misleading to describe our department as organized into mission areas — patient care, education and training, research and innovation, and community, each with a vice chair responsible for the programs therein. The problem is that our most important programs usually cut across mission areas. Thus, the organization chart more resembles a matrix than a pyramid, but even that doesn’t do justice to the rich interconnections due to the extensive partnerships we have forged over the years. The department operates four primary care clinics that see about 90,000 visits per year, with clinicians in more than a dozen additional clinical settings. Our clinics are all advanced, patient-centered medical homes, practicing team-based care.

The flagship clinic, the AF Williams Family Medicine Center, has recently been named the nation’s most innovative academic family practice. 6

The clinical team there consists of embedded behavioral clinicians, clinical pharmacists, social workers, care managers, telepsychiatrists, advanced practice nurses, and others. The family physicians there practice fullspectrum family medicine, including sports medicine, palliative care, obstetrics, and inpatient care. Our clinical revenues have been supplemented since 2001, and renewed periodically without controversy, with dollars from our university hospital and our practice plan — including our specialist colleagues. This financial support is emblematic of the general high regard we enjoy among our colleagues and partners. The department has an extensive presence in undergraduate medical education, including about 80 undergraduates enrolled with us in longitudinal community-based scholarly projects. We operate two family medicine residencies (one of which has a rural track and an urban underserved track) and are in the planning stages for a new residency program in partnership with a local federally qualified health center (FQHC) system and for a possible residency program in a new suburban university hospital. We also host and staff a preventive medicine and an occupational medicine residency program for the Colorado School of Public Health. We offer fellowship training in primary care sports medicine, which we lead but share with the

departments of physical medicine and rehabilitation (PM&R), emergency medicine, pediatrics, and internal medicine, palliative care (shared with general internal medicine), geriatrics (shared with internal medicine geriatrics), and addiction medicine (in close collaboration with psychiatry’s addiction psychiatry fellowship), and host a primary care psychology internship.

All of our residency graduates are offered an optional fourth-year, non-ACGME fellowship in an area of their choosing. Every year two or three residents accept this offer for additional training in advanced practice transformation, policy work, research training, community health training, and other areas. Our research portfolio is extensive; three faculty have served as principal investigators or other lead positions involving extramural grants for more than $100 million of extramural grants (Wilson Pace, David West, and Perry Dickinson), and have a fourth on the way to that mark (Jen Carroll). We operate five practice-based research networks, consisting of community practices pulled together into study laboratories, and, as mentioned above, we partner with the AAFP NRN. The NRN director, a member of our department, is also associate vice-chair of research.

Two of our faculty, in partnership with the campus’ health outcomes shop, lead one of the nation’s most advanced implementation science programs that includes a recently-awarded P50 grant.

We have recently opened up a new mission area — Community — to accommodate our burgeoning footprint in community-based research, community health partnerships, and community-based education. The department has established the Eugene S. Farley, Jr. Health Policy Center, a campuswide resource dedicated to researching, advising, consulting, and evaluating health policy, particularly state-level policy related to behavioral and community health. For more than two decades, the department has been committed to weaving the integration of behavioral health into the fabric of our clinical, educational, and research pursuits. This work, a signature feature of our department, has strengthened the effectiveness of primary care.

5. BUDGETS The department’s overall annual budget is about $40 million, exclusive of an extensive set of jointly administered research projects.* Most years the department enjoys a modest margin — enough to reward productivity, support innovative programs, and contribute to faculty and staff professional development. The department has three endowed chairs, and shares another (rural health) with the dean’s office. There are an additional $4 million in endowment funds in the department’s foundation accounts, and clinical reserves comfortably beyond, as required by our practice plan.

A $10 million fundraising campaign is underway to endow the department as a whole.

*Watch a comprehensive video accounting of our budgets. CLICK HERE

6. LEADERSHIP Four Cardinal Principles of Leadership 1. The business of leading this or any other department is a group effort; many people in the department are engaged in leading. It’s a team effort. I don’t make decisions without involving the department’s leaders and those affected by the decision.

4. We operate in a complex adaptive system. This fourth principle is very important. We’ve spent a lot of time trying to learn the operating principles of complex adaptive systems, and how to lead within a complex adaptive system. It has incredibly important implications, like understanding that change is never-ending, and adaptability is the key to life.

2. The position of chair is a middle management position. It might look like the apex of a pyramid, but I spend much of my time with deans, hospital CEOs, and vice presidents of this or that.

Our work life is a beta version of our personal life. Some things are not just unknown but unknowable, there’s no guideline, and you just have to try stuff and see what happens. You will fail a lot in order to succeed.

We are part of their system. We are not an autonomous department. So I spend time learning who they are, how they operate, what resources they command, what they care about — figuring out how to further our mission in such a way that it advances theirs at the same time. “They want to help us, they just don’t know it yet.” 3. We are members of a service profession; service and professionalism are key elements to successful leadership at a place like this. • Service is rendered by a servant. Look up Servant Leadership, by Robert Greenleaf, 1977. Or Give & Take, by Robert Grant. “How can I help you?” First comes service. First be a servant. We think about this every day, probably every hour. • A professional is a member of a community of people with special knowledge and skills, granted special privileges, dedicated to doing good, operating under a covenant. A professional is self-regulating, pledged to good behavior, dedicated to preserve and protect the covenant. • My covenant with the members of this department is exactly as my covenant with patients. Humility. Respect. Generosity. Integrity. Discipline. Competence. Kindness. Courage. These are old-fashioned notions that we ought to hold as our highest values and live by.

Five Basic Responsibilities I Assume as a Leader in this Department 1. Speak the vision. Point to the polestar. We have a direction. A goal. A polestar. A true north. My job, as the department chair, is to foster agreement about it (because we formulate it together), to know exactly what it is, and to say it over and over again, until everyone here can say it. In my case, “I’m here to help people be a little healthier.” Every single thing we do must be measured against that. There are literally millions of ways to retain fidelity to that polestar, but we must remain faithful. We do this in the context of a university that renders care (we practice), that prepares a certain part of the healthcare workforce (we educate and train), that learns better and better ways to render that care (we research). We are constrained by those things in the specific ways we try to help people become healthier, but that still leaves us an almost infinite number of options about what we do, how we move. Among my jobs is to keep my eye on that distant star and make sure that, no matter what we take on, we’re progressing toward it. What’s “in-mission,” and what’s out? How do we decide which ways of helping people become healthier are for us, and which aren’t? We go by the 1994 Institute of Medicine (IOM) definition of primary care.

“ Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” It’s all right there. These are all things that, if we do them well, will help people be healthier. If we’re working on improving access, by whatever means, that’s in-mission. If we’re working on the personal clinical relationship, that’s in-mission. If it’s attending to comprehensiveness, that’s in. Practicing in the context of family and community, in-mission. If it has to do with learning more about the problems our patients commonly have, in-mission. If it has to do with testing a new medication for refractory schizophrenia, then that’s probably someone else’s fire to tend. So one of my jobs is to make sure that we’ve all been magnetized to true north, that we’re all pulling in the same direction. 2. Learn to see far into the distance. The farther ahead you can see, the better you can be at threading the best path to our city on the hill, due north of us. We have to look out beyond our department, beyond our discipline, beyond healthcare itself, far into the future, to see what has not yet come up over the horizon, so that when it does come up, we’ve already made adjustments and we’re ready for it. My job is to anticipate. There’s another kind of “expanded vision” that comes into play here. Not just out into the future, but up into the structure of our greater systems. When I first got here, I spent almost a year meeting every dean in the dean’s office, all the chancellors, the vice chancellors, all the leaders in our practice plan, all the hospital leaders, so I’d know who they were, what they did, what they

expected from me and us, and what they were good for. This was reading the context. I’d like to give some examples of how this business of trying to see into the distance plays out. EXAMPLE A — Rural Health In 2001, I was having breakfast with Lloyd Michener, then the chair of community and family medicine at Duke, and Dean Krugman. Lloyd asked Dean Krugman what he wanted me to do for him. Dick immediately said, “rural health.” At that time, family medicine was doing very little for rural Colorado. The AHEC program was directed by someone in another school. Most rural clinicians regarded us as arrogant and inaccessible, and didn’t use us for anything. We had difficulty finding and keeping community preceptors. The legislature was annoyed with us for doing so little for the state. At that time I wasn’t going on about how we needed a rural health program. This was Dean Krugman’s problem, and he just sat there that morning and handed it over to me. It was not my idea, but it fit with our mission, and my boss asked me to do something about it. So we laid out a few programs that could fit under the rural health umbrella, and set about doing them, thinking it would take five or ten years to develop a comprehensive rural health program. Jack Westfall directed the High Plains Research Network, and he actually needed very little, but we made sure he had what he needed to keep growing, producing answers, and deepening the relationship with the rural workforce out there. Dick agreed to move the AHEC program into the school of medicine, appointed me to chair the search for a new director, and we put a family doctor in as the director. A couple of years later the school revised its curriculum, and Dick honored our request to institute a rural track as part of the new curriculum. He overrode the scattered faculty resistance to developing such a thing, and funded it. Larry Green and I went out to the AF Williams Foundation and asked for two million dollars to endow a new chair, the associate dean for rural health, thereby permanently making rural health a part of this school’s core business. 9

Some things we tried failed — we did not succeed at funding a rural health research center. We did not succeed, as we had hoped, for a seamless track from our school to rural residency training, although we eventually succeeded at developing a rural residency training track in Fort Morgan. That produced an unexpectedly rich relationship with Salud, which is paying off in other ways we couldn’t have seen then. So my job is not to do each of these steps, or even think of the ideas in the first place, but if it passes the mission test, as this does, and has institutional support, as this does, my job is to speak a coherent draft of a vision, to find people who want to work on it, to find resources, to fan the flames from time to time, and to get out of the way. EXAMPLE B — Community and Population Health Institute This one is by no means done. Our effectiveness as primary care clinicians depends on “practicing in the context of family and community.” We know the social determinants of health matter to people’s overall health even more than high quality clinical care.

Our future depends on making serious partnerships with communities and their health efforts. This sounds difficult — maybe 20-25 years to accomplish.

Sciences Institute (CCTSI), he asked whether we might have any ideas about who could do a community engagement core, and we made recommendations. We took in the preventive medicine and the occupational medicine residency programs from the school of public health, and staffed them, as a way of binding ourselves to public health, and to fortify our prevention efforts. We still have not integrated preventive medicine into family medicine anywhere near as fully as we should, but we are looking at new models of residency training. The school of public health has waived tuition for a family medicine faculty person each year to earn an MPH with them, which has the effect of creating a joint faculty. We have failed at winning intramural infrastructure dollars for a research institute, but we haven’t given up on that. We have breathtaking community-based mentored scholarly activity projects. the university residency program has a nationally recognized community health curriculum. we are developing joint conferences with public health. I have no idea what the ultimate shape of this thing will be, but we have enough lines of pursuit out there to assure some kind of community/ population health program in the future. My job is to keep the lines with a future alive, to weave them together, and to inspire faculty to take up residence in this mission area. 3. Hire the right people and get out of their way

So when we moved the AF Williams clinic from Leetsdale, we chose Stapleton, and the surrounding neighborhoods as “our” neighborhoods to partner with. We developed 2040 Partners for Health. (BTW, that’s not a refractive error, that’s a date — 2040 is how long we thought it would take before we knew if we were doing any good.) We wrote a report for our chancellor about the need for our new campus to partner with its new neighborhood as part of our mission, and persuaded the school, the hospitals, and the practice plan to contribute money to the Community-Campus Partnership. When Ron Sokol was designated as the first director of the Colorado Clinical and Translational 10

Here’s what I mean by the right people: talented, shared values and priorities, selfless, honest, team players, hard workers, humble. Find the people who can do the job, or can learn to do the job. Who like to work with us. Who are in it for cause.

I used to do all the recruiting and hiring personally, but we’ve gotten too big, and now all of this is shared. We’ve hired a lot of people in the last 20 years. It’s not slowing down. This is so, so important. It’s important to refine our skill at recognizing talent and compatibility, then carefully assessing for true fit in the event, then continuously shaping the position to take best advantage of previously unrecognized talents. Perhaps even more important than hiring the right people is equipping them with what they need to succeed, and then getting out of their way. People either have or find their own way of getting things done. Humble, teachable people will ask for help and accept suggestions, and leaders in a complex adaptive system learn by making mistakes and correcting them. My job is to ensure that we don’t make fatal mistakes, or crush our tender culture, but otherwise to let people lead according to their own lights. 4. Shape the culture A culture is comprised of the beliefs, behaviors, opinions, customs, and attitudes that characterize a group of people — in this case a department. Most of us acquired a set of cultural norms implicitly, while growing up in a particular family, in a particular region or state, at a particular time. Much of our larger life culture is tacit and relatively inaccessible to easy modification. This is not true of more local cultures, such as in the cockpit of an airliner, or a Navy SEAL team, or a department. A local culture can, within limits, be established and changed consciously. This is done mostly in three ways: by saying what we value and what we do not; by behaving according to our values and pointing out examples of value-informed behavior amongst ourselves; and by setting up the rules and workflows of our programs so that it is easier to do the right thing than not — by tempting people to do the right thing. A few examples:

EXAMPLE B — Words of Inspiration We also have sayings, posters, and desk signs that remind us of what’s important, how to behave, and what to strive for. A few examples:

Remember why we’re here: to help people become a little healthier. • Expect problems. Welcome them as a sign that we’re alive and trying. • Speak up. Speak the truth and have no fear. • Be kind. Kindness trumps cleverness every time. • Try something, anything, then fine-tune it. Life is a beta test. • Did it make our patients healthier? • Listen closely to what people say and how they say it. Write the best of it down. • Be cold and objective in judging whether it works. In the world of actual things, nothing works perfectly, and nothing works forever. • The hard stuff we do right away. It’s the impossible stuff that takes a little time. • Bite off more than you can chew. Then offer — offer — some of it to your neighbor. • Conflict is good. Not war, conflict. It brings people together. • Let yourself be disturbed but not abused. • A lot of the time, you’re just wrong. It’s a sign of taking a position. Own it and adjust. • Set things right before they arise. Anticipate problems. Have a long time horizon. • Unless we go to extremes, we’ll never get anywhere. Tackle hard problems, and try radical solutions. Solve hard.

EXAMPLE A — Gallery of Patients We have pictures on our walls, photographs of patients at each year of age, from unborn to 100 years old, to remind us of who we work for and why we’re here.

• Expect surprises. This is not an oxymoron. • Sometimes the answers lie outside our world. • Get in the mix. Let your partners disturb your ideas. Too much time behind a closed door is bad. • That fix is temporary. No matter how well it works, it will only work for so long. Don’t be too attached to your clever solution. • You’re the best person to do certain jobs. Do those jobs. Do what nobody but you can do. • Be stable but flexible. This is not an oxymoron. • Yes, you are a kid in a candy store. Learn things. Try stuff. Enjoy yourself. But remember: candy is not one of the basic food groups. We’ve got work to do around here. • Plan but be spontaneous. This is not an oxymoron. • Respect your partners and celebrate their successes. • Never stop thinking about how to do it better.

Don’t let little problems persist. Small nagging problems corrode morale. Fix them. 5. Mentoring I spend 15-20 hours a week meeting oneon-one with people to see if I can help with their professional development. Some of these folks are chairs from other places, some are faculty in other departments, but mostly they are faculty and staff right here in this department (from vicechairs to residents, fellows, newly-minted faculty, and PRAs).

We have these bright, brave, imaginative, hardworking young people around here who are going to change the world.

They are so inspiring and reassuring to me. They just need to know a little more about how the world works, how this place works, who to talk to about something, how to respond to problems and disappointments and frustrations. How to check things out, how to learn how it works. They ask for a little advice, ask a few questions. It is so rewarding to sit with these people.

Listen: the kids are all right — the world will soon be in better hands.

7. STRENGTHS As our history suggests, the department has grown drastically. For the most part, this growth has been smart — based on trial and error, using brilliant people and their ideas, and jostling support from amazing collaborators and partners.

• More than two decades of substantial support from our university hospital and our practice plan for our clinical enterprise

Because of this growth and, sometimes, in spite of it, our strengths are many and multiplying.

• Nationally recognized innovative training programs

• Deep local and national experience with advanced forms of primary care, of practice transformation, and of team-based care — particularly of integrated teams, including behavioral clinicians

• The Eugene S. Farley, Jr. Health Policy Center

• Faculty with extensive leadership experience in national family medicine organizations • Substantial partnerships with our institution’s health outcomes center, Colorado Clinical & Translational Sciences Institute, and the American Academy of Family Physician’s National Research Network

• One of the most extensive research portfolios in family medicine

• Four faculty (one retired) in the National Academy of Medicine • An excellent and stable senior leadership team — vice chairs, director of finance and administration, and program directors • A beautiful, stable, relationship with the AF Williams Family Foundation • Adequate reserves • Four endowed chairs (one shared with dean’s office)

8. CHALLENGES To stay strong, the department of family medicine must face — head-on — the barriers that stand in our way.

• Rising salaries of community family physicians is difficult to keep up with, given our stable/ stagnant compensation structure

Some are systematic, some are cultural, some evade labeling. But none is insurmountable.

• Faculty diversity still falls far short of our goals

• Recruitment of clinician-researchers and clinician-educators is limited by unavailability of practice sites — we need another practice

• Insufficient resources for the professional development of rising researchers in the department • Continued fundraising to reach $10 million to endow the department

9. THE FUTURE We will spend a lot of time during the next decade working with and in communities.

Many people, agencies, and programs are committed to these same issues, and we will be focusing our efforts and designing programs that foster partnerships among those with similar goals — within and outside the health care system.

Notwithstanding that we are a stable department, that many of our programs will continue along their already-established lines, our work to date has prepared us to take the next big steps toward becoming truly effective as agents of health.

We have a unique responsibility to connect this expanded, ramified web of community health connections to the health care system, and we will serve this bridge function.

High quality primary care definitely helps people (and their families and communities) become healthier, but it is only one of many elements that contribute to this effect — and not necessarily the most important one. We know that high-quality primary care reduces inequities in health care and health outcomes, and we will be focusing our efforts and designing programs specifically aimed at achieving health equity. We know that one of the best investments we can make is in prevention, and we will be focusing our efforts and designing programs that prevent the kind of childhood experiences that lead to mental, emotional, and behavioral problems.

We will efface, even remove, the walls of our clinics, and do more of our work where our patients live and work and learn and play. Accordingly, we have created a new Community mission area, headed by vice chair Don Nease, and we expect to populate this mission area with structures, resources, initiatives and programs that serve our conviction that family medicine cannot reach its full potential, its full value, until it is “practiced in the context of family and community.” We are actively participating in the planning of a large partnership with Salud, a local FQHC system, to develop a comprehensive health “commons,” consisting of a clinic and 25 acres of land devoted to addressing housing, food insecurity, and other social determinants of health in a coherent fashion, for 60-thousand of the most underserved people in the state. This site will also offer innovative, integrated training for family physicians, general internists, med-peds residents, other health professionals, and the non-professional primary care workforce. The Eugene S. Farley, Jr. Health Policy Center is developing a campus-wide footprint and a state focus, in addition to previous priorities of behavioral health policy and community health policy. We anticipate a great deal of new activity in this sphere. We anticipate opening a residency program at the Highlands Ranch Hospital. Finally, we will almost certainly foster an expansion of our research portfolio. We have a large stable of early career researchers and have been successful at recruiting mid-career research leaders.

This is about as bright a future as any department of family medicine can hope for. We have had good years here at the University of Colorado, but our best years are surely ahead.

We are here to help people be healthier. Find us at

https://medschool.cuanschutz.edu/family-medicine

12631 E 17th Ave, Aurora, CO 80045 (303) 724-9700 https://medschool.cuanschutz.edu/family-medicine