The Wexner Center's new chief medical officer talks about work-life balance, collaborating with Columbus's hospital executives and how a business education turns doctors into leaders.
Business skills are crucial for medical professionals in today's healthcare environment. Dr. Steven Gabbe, chief executive officer for the Ohio State University Medical Center, says that dual credentials in medicine and business are what set his chief medical officer, Dr. Andy Thomas, apart from the crowd.
"He really understands the business of medicine," says Gabbe. "I think that Andy represents someone with very unique skills. He represents the very best of what I would call the next generation of medical leaders."
Thomas was appointed CMO following the retirement of his mentor, Dr. Hagop Mekhjian. "Having seen him do the job as his right-hand person for 15 years does make it easier to take on the role, because I've seen an expert do it," says Thomas.
"Dr. Andy," as he's known to his patients in the Wexner Medical Center Executive Health program, spends 20 percent of his time as a general internist. The bulk of his work is spent overseeing medical services across the medical center's five hospitals, outpatient clinics and specialized care facilities.
"I was always a member of the team before but now it's my team. I tend to be team-focused. I try to make it not about me--it's about what we all do together," says Thomas. He's excited to have stepped into the position at a "really, really exciting time" for the medical center.
The new James cancer hospital and critical care tower is scheduled to open in about 11 months. Thomas is focused on leading his staff through a smooth transition into the new 1million-square-foot hospital. The move comes at a time of enormous changes in the healthcare business as well as advances in medical technology. Here, Thomas discusses his plan to meet these challenges head-on.
What inspired you to pursue a career in medicine?
I can't remember a time when I didn't want to be a doctor. It's a little bit hard to remember. The best I can remember, there were two or three things. One was some of the TV shows of the 1970s. Emergency and MASH--those shows that, when you're a little kid, you see how they presented what medicine was.
I lived about three blocks from my grandparents growing up. They were in their 60s and 70s, and it seemed like every holiday for three or four years in row some family member was in the hospital, or one of my grandparents had to be in the hospital. I remember 6- , 7-, 8-, 9-years-old being in the hospital visiting them, and I'd see this team of doctors come in and talk to them. It seemed like a very interesting job.
The thing that really got me the most was that my grandparents both just loved their primary care doctor. The way they spoke about their doctor--I loved my grandparents and I respected them--for them to respect someone this much, that person must have had a really important job.
How do you think the role of the primary care physician has changed from then to now?
I think it's changed a little in that certainly doctors' practices are busier. The typical outpatient doctor will see three to four patients an hour, (they) move relatively quickly. Part of that is due to the demand of patients that need to be seen. Part of it's due to the reimbursement model, where the face-to-face time (is) the time that a doctor gets reimbursed for.
In the reimbursement model, we're reimbursed really only for face-to-face time. I think looking forward over the next 10 to 20 years, the model's already changing… .So the doctor (will get) paid for the patient's care for, say, a year regardless of if the patient comes in twice or 10 times. The doctor gets paid a set amount to care for the patient for the year. All the incentives--for which patients you see to how often you see them--change.
The model of who needs to be seen and how often will change if the reimbursement model changes. Essentially, you're being paid to care for the patient not just when they're sitting in your exam room but all year long. So if there's a patient that's really motivated and works hard to keep their blood pressure controlled and they send me their blood pressure every two weeks, why do I need to see them in the office to check their blood pressure?
It's a lot more convenient for patients, for parents, for people with jobs to communicate with their doctor in a different way than taking time off to go see them in the office.
Do you think people are becoming a more engaged in their own health?
I think on average, yes. For whatever reason, there always will be a group of people who are either not interested in their health or are just making bad lifestyle choices, whether it's alcohol or substance abuse, or those sorts of thing. But on average, in general, yes. I think people have a lot more information at their fingertips.
Does the Wexner Medical Center have a resource on the Internet that you'd recommend for patients?
There's a variety of those. We have a lot of our patient education documents, handouts that we would normally print and hand to a patient, to actually online for patient approves and look at….Bedside at OSU tablets are given to inpatients. They have the opportunity to peruse things in the hospital and correspond with their healthcare team.
How is technology changing the training your students receive?
Luckily most of our students and staff are relatively tech savvy, which is good. I think that it's a matter of changing their workflow through the day. Obviously when you're coming out of college or coming out of medical school you need training on how to use the system.
It does change the workflow a little bit. The MyChart Bedside (online patient portal) for example: In some cases the patient may get a set of results to the MyChart Bedside, and the team may or may not have looked at it yet. It's new to us, there's a risk of that, that the patient may see the results as the team is getting around.
There's a change in workflow that will happen because of that, but I think that's positive. All of our focus is trying to put the patient at the center of what we do--not the doctors and nurses and the patient has to work around our schedule. No hospital's perfect at that yet, but I think that certainly is the direction most hospitals are moving.
Whether it's personalizing the actual treatments that we're providing to patients, or personalizing their experience (we) try and meet their needs. If their wife or husband can only come in at four in the afternoon, and that's the only time you can meet with them, that's when we try to be there.
So when do doctors sleep? Does this profession have downtime?
We have three kids at home; they're 18, 16 and 6. My general routine is I go to bed when our 6-year-old goes to bed. I'm usually in bed between 8:30 and 9 with the exception of something like last night (when he stayed up late to watch the OSU basketball game).
It's a full-time job just to stay balanced.
Folks in healthcare, because our schedules are more likely to be 24/7, when our patients need us we need to be there. I think most of my colleagues would say the same thing--physicians and nurses-- we couldn't do what we do without our spouses and without our kids being incredibly patient with us. Being able to recognize that, as much as we love our families, sometimes we have to put other people ahead of them.
It is a daily chore to make sure I stay balanced, because it's very easy to put both feet a work, because the work is never-ending in reality.
I have an incredibly supportive spouse, Lisa Wilkins Doran, who is a vice president (of internal operations) at Salon Lofts. She's got a major job in her own right. They're rapidly expanding and she's flying all over the country doing things. I try to do my share…but in reality, at the end of the day, the default falls back on her to be the person home for dinner. Because oftentimes I just can't be there. Without that sort of support, with kids and a great spouse, I wouldn't be able to do what I do.
What have the two of you got in common between your business and hers?
We try not the talk a lot about work or home, but to be honest, I don't have any better person to bounce ideas off of than her. We trust each other implicitly, so we do sometimes serve as each other's therapist when it comes to business things.
Is work-life balance something that you try to impart to your students and staff?
We try. There's a variety of programs that we put on around that topic. For example, just this past summer we had Wayne and Mary Sotile here. They are experts both in physician wellness, provider wellness in general, and also what's called 'resilience.' (Physician resilience is) the idea that everyone has stressful times, it's about how you roll with the punches to get through stress instead of trying to avoid stress.
We also have a Health and Wellness Council. The focus is on four things: fitness, nutrition, cancer prevention and minimizing stress and burnout. Part of the stress and burnout program is the STAR program--the Stress, Trauma and Resilience program. It's geared around when difficult things happen: A young patient who dies, a mother who loses a baby, a young cancer patient that passes away of a horrible disease.
The impact on our staff of what's actually, in the trauma literature, called the 'second victim of trauma.' If you're a surgical ICU nurse and you see car accident after car accident after car accident, eventually it numbs you and makes you less satisfied with your work. The STAR program does outreach to those high-risk areas. It helps them with their own job satisfaction.
Have you experienced one of those situations in your own practice? If so, how did you overcome it?
I certainly have. It's not always the young patients. I have patients that are 80 when they pass away. Patients, over time when you care for them for years and years and years, you have to have some objectivity but they do become close. You meet their kids, they come in with the grandkids and you tell stories about your kids, all those things. When those patients pass away, it's difficult.
One of the more difficult ones I had was probably six weeks after my own mom passed away. I wasn't able to be there when she passed away. I was with her a lot when she was ill, but not when she passed away. It was a really odd feeling to be able to be there then to help someone else, and it was kind of closure for me in that moment.
Let's shift gears and talk about your short-and long-term goals as the chief medical officer.
Being new in my role, at the same time the former person in this role (retired CMO, Dr. Hagop Mekhjian) was my mentor. He was really a huge role model for me. Having seen him do the job as his right-hand person for 15 years does make it easier to take on the role, because I've seen an expert do it. Part of it, for me, is creating a new pace for myself. Certainly back-filling some of my other previous roles with good people (is important), so we're in the midst of recruiting those folks to bring them on board.
I was always a member of the team before but now it's my team. I tend to be team-focused. I try to make it not about me--it's about what we all do together. Sending this message to people about how we're going to work and how they work together is important for me and my role.
In terms of the organization, this is a really, really exciting time here at the medical center. We're opening a new hospital (the new James cancer hospital and critical care tower) in about 11 months…There's so much work that's going into that to prepare and to retrain people. Obviously everything is going to be in different places and rooms, it's a 1,000,000 square-foot building. So just helping so people don't get lost is going to be important. There's so much effort going towards that.
Once that happens, then there's an entire backfill that happens with some renovation: Moving parts of University Hospital into the old James building, renovating parts of University Hospital. The project keeps going on for at least another two- to two-and-a half years.
Our long-term goal that we hope to get to probably sometime in 2017, is to have all private rooms and to really use the best of our space…so that our patients are having the best experience possible. There's a huge effort being put into the new hospital, but then we'll just continue to go from there.
Can you tell us about the growth of the medical center's robotics program and, more broadly, how you think robotics programs are changing the work of physicians and surgeon?
We've had probably one of the most advanced robotic surgery programs in the country. In the late 1990s, we did some of the first robotic heart surgery with the da Vinci heart robot, done anywhere in the United States.
Originally, open heart surgery was kind of the first field that developed a robot, and we've now developed what's called the Center for Minimally Invasive Surgery. We have doctors from all over the country who come here to be trained on how to use both laparoscopic as well as robotic techniques (in) general surgery, gynecologic oncology, gynecology, urology (is) certainly a large robotic field. We've been excited to impart our knowledge and help train others. It's really been a wonderful piece of technology for us to use, not only for patients, but to train others as an academic organization is always a big part of our mission.
In what ways do you work with the Fisher College of Business to produce more professionals who, like you, hold both an MD and an MBA?
We actually have a joint degree program that's been in place, I want to say around 2003 we started. Medical students do the first two years of medical school and then do a year of MBA. It's essentially a five-year program. So then they do a year and a half of rotations, and then another semester of business school, in five years to get both degrees.
I help with the program on the medical school side. All of those students spend the summer with me between their second year of medical school and their first year of MBA. They do an eight week internship with me.
I did the MBA in the late 90s. I remember (when) I first went over to the business school, I was in my lab coat as I was running late, I was a resident. The first person I met with said, 'Why would a doctor want to get an MBA?' It was kind of a rhetorical question, but at the same time they were really struggling to find out why you'd want to take two years off to do this. And now, I think no one would ask that question and it's only 15, 16 years later.
I've always told students, 'If you just want to run a private practice better, getting an MBA is probably overkill.' But to work in a large organization--understand we have a budget of over $2 billion dollars a year. For me to sit around the table with administrators, with business folks…for me to be able to talk the language and understand what they're saying, it gives me a lot more credibility. (That's) partly because I'm just perceived as having punched a ticket, but partly because I actually have technical knowledge that the average doctor who hasn't focused on (business) doesn't have.
For the people on the front lines during the surgery--taking care of patients, seeing people in the ER--who don't have an interest in business, they perceive that there are physicians around the table who are representing them.
When people ask me what I do as chief medical officer, I really boil it down to five or six things. I facilitate things for people. We're a really large organization. We have over 2,000 physicians here, 600-plus nurse practitioners, physicians' assistants, et cetera. Within someone's area they tend to know how to do everything. But when you are in the heart program and you need help in the cancer program, you may not know all the people that I know. You may not know how to get a certain test done, or a certain consult done. So part of my job is to facilitate getting things done.
Part of my job is to advocate for physicians around the business table, around organizational strategy.
Part of my job is to mediate disputes. Obviously healthcare is a growing field. Specialties are changing. Things that only one group of doctors did 10 years ago, now other groups of doctors are able to do. Trying to mediate who does what and how we collaborate together as a care team is an important part of my job.
I mentor people. For example, in my medical director role, the medical director of the emergency department for the ICU or endoscopy suite reported to me. Trying to mentor them, to help them in their job (and) certainly educating students and residents is a big part of what we do here.
Lastly, what I do is enforce the rules. I always tell people that if I'm spending more than 10 to 15 percent of my time enforcing the rules, we have a problem. There's something structurally wrong or functionally wrong.
How much time do you spend enforcing the rules?
Probably five percent, but part of the problem in healthcare is the rules could change. The federal government will come out with a new piece of regulation, the state will come out with a new piece of regulation, insurance companies change their practices (and) different evidence comes out of the literature.
It's trying to make sure that we are using our best practices in keeping people current about what we should be doing. That's probably more the type of rule enforcing that I mean. It's a matter of making sure that people are following the right guidelines and keeping up on things.
Does the physician part of you ever bump up against your administrative role? Are these two domains ever in conflict?
In my own personal practice no. I still see patients a couple days a week, so probably 20 percent of my time I still see patients.
In my administrative job, I don't think they (conflict) as much as people probably perceive they would. I think when you watch some TV shows like House, it seems like the doctors are always fighting with the administration and there's always a lot of chaos. In general we have a very, I feel, enlightened group of folks that run our medical center. They do try to put the patient first.
We are a not-for-profit organization. We don't have shareholders to be beholden to. At the same time, if we don't have a margin, we can't reinvest in the programs that we need, the recruitment that we need, the buildings we need. You have to have a balance. We may not be for-profit, but we're not for loss, either.
It's always a balance, but we do our best to put the patient first. And then if we're struggling in an area--for example in psychiatry or behavioral health--in general in the community there are problems of capacity. There aren't enough hospital beds for psychiatric patients whether in the state hospital system or in a private hospital system.
Instead of saying, 'This is just a problem that's unsolvable,' over 10 years ago we actually got together with all of the other health systems in town the ADAMH board and with Netcare, which is a community resource, to try to say, 'This is a problem for all of us. Not any one person can solve this and together we might not even be able to solve it all, but we should try.'
We've created things like the bed board….There are psychiatric patients in emergency departments around the city, every day there's a phone call of all the behavioral health facilities and they try to do the best triage: Which patients are the sickest, who has beds? If there's a patient in the ER at Riverside who's the sickest and we have an open bed, we take him here even though we might have patients in our own ER and they need the bed.
We try to work at this as a community. I think it's one of a number of initiatives that we have done to try and say, when you have really difficult problems, you probably can't solve them yourself. You really have to work with others.
Where would you like to see mental health care improve in the future?
Part of it comes down to insurance coverage and people having the resources to get the medication and the care that they need. I think that's improved to a degree. There are certainly mental health parity laws and things now that make that a little better if you to have coverage.
There is an unfortunate relationship between substance abuse and mental health that makes it more difficult to care for some of those patients.
I think the resources in the community for outpatient treatment are better than the used to be, but they probably can still be better yet. I think the model at Children's Hospital, for example, where they've worked to try to become…a medical home to those young patients in our community who need mental health services, it's a great model. I think it probably does need more investment, either from the state or from someone to provide a little bit more infrastructure. But I think as long as people are willing to partner and work together we will continue to improve.
How do you work with the city's other chief medical officers?
We have a group that started with a handful of folks getting together for breakfast routinely, well over 10 years ago, through the Ohio Hospital Association. It initially was the Franklin County Hospital Quality Collaborative; now that we've brought in the community hospitals in each of the contiguous counties we call it the Central Ohio Hospital Quality Collaborative. It includes all three adult systems: Mount Carmel, OhioHealth and ourselves; Nationwide Children's and the community hospitals in Newark, in Lancaster, in Circleville and Marysville.
We get together quarterly for a breakfast meeting for about an hour and a half. We have over the last 10 years had a variety of projects that we've worked on. Several years ago, we had a large heart failure initiative trying to share data about how we take care of heart failure patients and ensure best practices.
We had a similar project where we got all the cath lab directors in the city together to each bring their best initiatives that they were doing, whether it was getting patients from the ER to the cath lab more quickly.
We always like to say that we don't make any more money or I don't get paid more if more people die at another hospital. My goal is to improve the health of the community. Part of this, I think, is our bent as an academic organization. We're always looking to publish our knowledge. So sharing knowledge with other paid people, if it helps patients get better care somewhere else or learning from another organization, is beneficial.
We all share the same struggles and helped with some of the same solutions.
How is the role of chief medical officer changing as the healthcare landscape changes?
My role spans across the entire medical center, so inpatient, outpatient, ER, (to the medical directors and physicians in) each of our hospitals: University Hospital, James, Ross, East and Harding. …It allows us as an organization to be a little more aligned.
I do want to make it clear, I am not the CEO. We do have a CEO, who is my boss, Dr. Steven Gabbe. Things come down to his ultimate decision, but they include someone representing the physicians and the medical staff at the c-suite level. I think it's a model that works well, both from an alignment perspective as well as a physician perspective in the c-suite.
What's your working relationship with Dr. Gabbe like?
He lives about the same schedule that I live. It's not uncommon, one or two times a week (that) we've already talked on the phone before 6 a.m.
One of our difficulties here is space constraints. Obviously there's a reason why we're building a large new hospital. We routinely open the day with 98, 96, 95 percent of our beds full. Most hospitals like to run in the sweet spot of between 85 and 90 percent of their beds full. Once you get above 95 percent, you start to have inefficiencies crop into the system because you're at such full capacity. For about the last two years we've routinely been struggling with our ICUs, our step-down units and some of our more critical-care units running at well over 90 percent capacity on a routine basis. The cancer hospital is enlarging and expanding with the new building; they routinely run the same capacity constraints.
(Dr. Gabbe's) very engaged. One thing that's really fun to do with Dr. Gabbe is he likes to round and see patients….He is someone who's not in some ivory tower distant from the operations of the place. He still goes and sees patients himself at our high-risk OB clinic, that's his specialty. He's certainly more an executive than he is a physician these days, but at the same time he both prioritizes and recognizes the contributions that our front-line caregivers make on a daily basis in a way that is not routine in healthcare for a place the size of ours.
Is there anything you'd like mention that we didn't cover?
In terms of the collaborations with others in the city, to have another leader and another institution on your speed dial and to know that they will take your call when you have a problem, or you can call them when you know they have a problem, is an incredibly powerful resource in a position like mine. There are a lot of cities in this country where you can't get people to the table together--whether it's the leaders in the city, in the community who have made that a priority, whether it's the leaders of organizations who make that a priority.
For example, the first Monday in January when it was so cold there was the water-main break….Our transfer center got a call from a group called Central Ohio Trauma Center that's run out of the Medical Association. They were calling around letting people know that Grant (Medical Center) was at risk of needing to evacuate. Our transfer center folks called me immediately, I was actually driving home. They let me know what was going on. Within 30 seconds, I had Dr. Bruce Vanderhoff, who is my counterpart at OhioHealth, on the phone.
Luckily they ended up not needing to evacuate the hospital. But I've been in that situation where we have an issue before, and people have reached out to me and asked, 'How can I help?' If you go to Chicago or New York or Boston, you can even get people in the same room, much less willing and able to communicate and to help each other.
It's not just a special place here at Ohio State, I think we have a very special medical community. From the community leaders, down to the medical center leaders, down to the people who work at our hospitals that really work well together. It's very unique. We probably take it for granted more than we should.
Seems like that would be a given in the medical profession.
It seems second nature to me, and I think certainly there are been examples in New York, like super-storm Sandy, when other people came up and helped each other. But I think they were making it up as they went.
We see it as second nature, we would know how to do it. I don't understand why it's not this way everywhere.