Conversations: Darrell Kirch, M.D., President of AAMC

What is the "change imperative?" What are the most vexing problems facing academic medicine? Why MOOCs (massive open online courses) aren't threats, they're opportunities. Vivian S. Lee, M.D., Ph.D., M.B.A, senior vice president for health sciences at the University of Utah, interviews Darrell Kirch, M.D., president and chief executive officer of the Association of American Medical Colleges, about the most important issues in academic medicine today.

To hear the entire conversation, listen here:


Kirch: There are situations what's called for is a disruptive innovation.

Announcer: Dr. Darrell Kirch, president of the AAMC, and Dr. Vivian Lee, senior vice president for Health Sciences at University of Utah. A conversation, coming up.

These are the conversations happening inside health care, that are going to transform health care. The Health Care Insider is on The Scope.

Lee: Thanks so much for joining us Darrell. Why did the AAMC choose The Change Imperative for this year's theme?

Kirch: Well the theme of this year's meeting, The Change Imperative actually derives from what we're observing around the country especially at places like the University of Utah. I think more and more of the leaders in academic medicine as well as front line faculty, staff, students, residents, are realizing that the status quo isn't serving our patients well, it isn't serving our nation well. We have a health care system that is increasingly unaffordable, and yet at the same time not giving us the outcomes that we want. I don't meet anyone who wants to maintain that situation, so that makes change an imperative.

What everybody is struggling with is what really will be the innovations that will help us get out of this cycle of high cost, but falling short on the quality that we want.

Lee: How do you think we can tap into that innovation?

Kirch: One element is I think we're breaking down the traditional academic hierarchies, as well as the kind of fragmentation, the notion of each of us being in our silos with our particular discipline or specialty. I think that's making a huge difference, because that then leads to empowering individuals who are on the front lines.

I recently had an opportunity actually to look at your most report about your own innovation efforts at Utah, and the things that struck me most about that report was how you found individuals who have not only expertise, but have deep passion about particular change initiatives. It appears to me that part of your success is that you've removed the traditional obstacles that the rigid hierarchy would put in place for those individuals, and thereby you've empowered them to really do some exceptionally creative work.

I think that's very different. Academic medicine, universities in general have tended to be very rigid organizations and slow to change, but the demands we face really require that we break out of that mold.

Lee: One of the real opportunities for us I think also is in our role in trainees and students, and I'm curious about what you're seeing across the country in terms of initiatives to really engage trainees, and students in this change imperative?

Kirch: I think an increasing number of academic medical centers have come to the realization that some of the greatest innovative power lies in this upcoming generation of medical students residents, graduate students and other trainees. These are people who are comfortable working in teams, they're comfortable with complexity, and they certainly are comfortable tapping into the power of technology.

All of these things in a way my, the physicians of my generation, simply aren't comfortable. And so I'm very struck by how I see this generational energy translating into practice in our institutions that I and many of my contemporaries have struggled with over time.

The upcoming generation of trainees is ready and willing to take on. So you see institutions around the country where really the driving force, for example in their quality improvement programs is coming at the trainee level, as opposed to the faculty level. In my view that's wonderful, that means that at an early point in their careers these individuals are honing their leadership skills.

Lee: I see this year there's also an emphasis on technology as you say in medical education and innovation, and I'm interested in your thoughts about the future of technology in medical education. We see mooks popping up all over outside of medical education, but what do you think is going to happen within health sciences and medicine?

Kirch: One of our main speakers at the upcoming annual meeting is Daphne Koller, she is one of the co-founders of Coursera. Coursera is one of the leading organizations to develop so-called mooks or massive open online courses, they've had a global impact. Now they started in areas of engineering and computer science, but one of the reasons she was enthusiastic about joining our meeting, and speaking at our meeting is she sees some of the greatest potential, not just within our country, but globally. This potential in using this kind of technology to not only improve the quality of medical education around the globe, but to make it more cost effective, more efficient.

I think that used intelligently, we can take advantage of learning technologies whether it's online content, whether it's using technology to do simulation and improve competencies in the simulation lab, whatever we do, I think this both can improve our outcomes and decrease our cost. This again though will require a whole cohort of existing faculty members to understand that this is not a threat to them, this is a huge opportunity. It's a huge opportunity to improve the quality of learning and assessment. So I think we're just on the leading edge of this.

I would not be a bit surprised if 10 years from now I attend an annual meeting, and instead of viewing this as experimental, the use of these kinds of technologies has become mainstream in medicine.

The other point I wanted to make, because the shift toward the use of social media has also been so striking, is medicine for centuries was a very individualistic activity, as it becomes more team based, and more interprofessional, it also becomes more social. I think the power of connectivity through social media is not just a way of keeping people in touch with one another, but I think it's going to become an integral part of improving the doctor/patient relationship, and relationships within the inner professional team.

So I'm very bullish on what lies ahead and I'm going to enjoy seeing it all move from experiment to practice.

Lee: As you say I also think the interconnectivity of people in social media, and also the opportunities through simulation to bring people together will drive for the interprofessional education initiatives, and I think that's also very exciting.

Kirch: It's absolutely true and the places that have a distinct advantage in this regard are the major universities like Utah, where you have the benefit of having multiple health professional schools on the same campus. Those will be the laboratories where I think the best early work in this is already happening.

Lee: One of the challenges for us though is going to be how do we train the educators to adopt these new models of education, and so I think meetings like the AAMC are just so critical for us to get together and learn best practices.

Kirch: Well the demand is certainly there, we are part of the interprofessional education collaborative with nursing, dentistry, public health and others, recognizing this need for more faculty to be trained in how they can enhance interprofessional education. We started offering faculty development programs. I believe now we're on the fourth round of these programs, and every time one is announced within hours it is fully subscribed, and we have to start turning people away.

Lee: That's great.

Kirch: And for me that's clear evidence that there's a need for this faculty development, but even more gratifying is the fact that so many people are interested.

Lee: I want to switch gears just a little bit Darrell, and I want to ask you about this theme that we've been pondering, which is the impossible questions, the impossible problems that we're facing in academic medicine, the great challenges. And we've talked a little bit in our own inner reports, and in other venue's about some of the impossible problems that we've been facing at the University of Utah. What about from your perspective looking at all of the academic medical centers, what's the problem that has surprised you?

Kirch: The beauty of the way you framed your approach to impossible problems is the moment you label something that way. We work with such bright accomplished people. They refuse to accept that it's impossible, and they set themselves to work to find solutions. And I think it's a very powerful concept that the simple fact of identifying something is impossible. We work with a kind of people who've refused to accept that.

Lee: We do.

Kirch: And we'll immediately set to work. I think that some of our biggest challenges are not resources. Often when I visit campuses they talk about how there just isn't enough research funding, enough state support and so on, and I understand that we have experienced very real decreases on those fronts, and that they've made it more difficult for our colleagues. But the fact remains the average medical school budget, just a school, not the health system the average medical school budget in this country is well over half a billion dollars. We spend nearly $3 trillion in aggregate on health care. Those are a lot of resources.

I think the biggest obstacle we face is not that we are constrained by our resources. I think we're constrained by our inertia and our failures to mobilize our imagination. This circles back to the notion of impossible problems. That concept is catalytic in stimulating people's imaginations. If I in aggregate look at the dozens upon dozens of academic medical centers that I visit every year, it's our own internal constraints, it's the way we've limited ourselves.

I think our biggest challenge is just freeing those innovative and creative instincts among ourselves and our colleagues.

Lee: Do you think there's something intrinsic in the way that we conduct a medical education, and training that leads to a constrained thinking?

Kirch: When Abraham Flexner moved to medical education back to its scientific foundations, that was absolutely necessary. There also was a corollary of that in some ways hold us back that we tended to become, so scientifically granted, so wedded to the traditional scientific method with its rigor, it's inherent incrementalism. Most science moves forward in small steps not in breakthroughs. And I'm not in any way advocating that we abandon our commitment to scientific foundation, but I would like to see us balance it with more unrestrained creativity.

There are situations where what's called for isn't a controlled experiment. What's called for is a disruptive innovation, and we need to be able to preserve our ties to science, but be much, much more permissive especially in education about that kind of disruptive innovation.

Lee: One of the initiatives that I inherited when I came here to the University of Utah is a bench to bedside competition, which was launched by students. They formed teams with the business students and the engineering students in a device competition, and every year we discover or identify students who just run with this idea.

And there's something that we're tapping into by encouraging their innovative spirit, entrepreneurial spirit that I wish I had when I was in medical school, and I wonder if maybe this might be an example of the kind of initiative that medical schools or even residency programs could start to think about, not to replace traditional education, but to complement it.

Kirch: I couldn't agree more. I was in many ways in hindsight very tightly scripted around what was expected in my career, the steps I would take. In hindsight though the things that I think represented the best moments in my career were the times when I went off script, when I did something that didn't seem to fit the prescribed to pathway, and to the degree that, again I'm not advocating abandoning science, I'm not advocating for chaos.

What I'm just encouraging us to be is less rigid, less constrained, much more accepting of the incredible diversity, the diversity of ideas, diversity of career paths, that in the end will make us a stronger community in academic medicine.

Lee: I want to ask you about how you yourself derive energy from and come up with all these amazing ideas that you do. How do you stay inspired?

Kirch: My job as much as any in the world really is one of true servant leadership. What I view myself as is somebody who can synthesize the best ideas I see emerging in our communities, and give them a voice and be a cheerleader, that's what I try to do personally and I think that's the role of the AAMC. We are a very different kind of association. Many associations look much more like trade unions, just trying to defend the status quo. We've become an association that I think is trying to be the champion for the best emerging ideas coming out of our community.

It's exciting for me and it's a privilege for me to be in that role.

Lee: Well we are so fortunate to have you in this role and I really want to thank you Darrell for being willing to be interviewed with us.

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