Monday, July 14, 2014

A New Vision for the UC Davis Health System and Health Care Delivery in the Sacramento Region

A Conversation with Dr. Julie Freischlag

Vice Chancellor for Health and Human Services and Dean of the School of Medicine at UC Davis Health System Speaks Candidly

JULIE A. FREISCHLAG, MD ASSUMED her new post in February 2014, most recently serving as professor, chair of the surgery department and surgeon-in-chief at Johns Hopkins Medical Institutions. Freischlag has more than 30 years of experience leading patient-care services and education and training programs as chief of surgery or vascular surgery at nationally-ranked hospitals and top medical schools.

Her national leadership includes serving as a former governor and secretary of the Board of Governors and a regent and present chair of the Board of Regents of the American College of Surgeons. She is the current president of the Society for Vascular Surgery and a past president of the Association of Veterans Administration Surgeons and the Society for Surgical chairs. Freischlag is the editor of JAMA Surgery and a member of the editorial boards of the Annals of Vascular SurgeryJournal of the American College of Surgeons, and British Journal of Surgery.

Baltimore Magazine named her “Top Doctor” and Working Mother Magazine selected her as one of the “10 most powerful moms in health care.” Freischlag received a bachelor’s degree in biology from the University of Illinois and a medical degree from Rush University Medical College in Chicago. She completed her surgical residency and post-residency vascular fellowship at the David Geffen School of Medicine at the University of California, Los Angeles.

•How has your transition to Sacramento been so far?
So far it has been very pleasant. We’ve been here for a month now, and bought a house about four miles from here. One of our sons is a freshman in college at the University of Maryland, and he even decided to do spring break here! The one who had the toughest time was the dog, but I think he is now finally acclimated and is enjoying the warm weather. We have very friendly neighbors and there are so many great neighborhoods. I’m getting adjusted to the health system and the medical center, and every day I’m trying to meet everyone at their place of work to see how they operate. 

•What has surprised you most about UC Davis?
I’m so encouraged by all of the great energy and impressed by the sense of pride of everyone I’ve met. People are very proud to tell me what’s great about our health system, but then are also able to identify what can be improved upon. I’m happy to see that our community is putting their trust in me very quickly, and I think I’m most impressed with the attitudes I’ve encountered. There are so many great things going on in the Medical Center and School of Medicine that I’m still getting acquainted with.
The best gift I received was the success of the LCME visit, which will allow our efforts in medical education to be more creative in the future as opposed to corrective. I want to continue learning from our students in the short term as well including our regular Lunch with the dean, and I’m planning to visit all the student runs clinics.

•How have your past experiences prepared you, how does that mold your vision?
My strengths stem from my experiences at many centers, including training at UCLA and young faculty at UCSD, working at the VA, and hospitals in Milwaukee and Baltimore. I try to collect the good things that these health systems do, but also identify experiences to improve upon. I like to think of myself as an “inside-outside person,” someone who understands and loves UC from within while bringing in my other experiences as well.

I’m very excited by the new effort and unique opportunity to create a unified UC health effort, and I’m already speaking with the other UC deans on parallel issues that we can address statewide such as patient care, saving money or clinical research. I’ve also been a chair, running a specialty division in multi-disciplinary clinics which helps me understand some of the institutes and centers better. I’ve done research and I still see patients which keeps me involved on the front line.

•How much clinical work do you anticipate undertaking?
I’ll probably see patients and operate a couple of times a month in clinic and I plan to partner with another vascular surgeon. I specialize in thoracic outlet patients, treating athletes from all over the country. I’ll be doing some teaching with the vascular residents, and I’m also planning on implementing leadership training for the medical students and faculty. My biggest mantra is everyone should be a leader in something, whether it’s your office or research lab or clinic, you should be striving to make things work better, with a focus on what we all can do to take better care of the patient. We used to be trained around the notion of “when is the doctor available,” but today it needs to be “when is the patient available” and how can the health care team address their needs?

•How can we bridge the divide of “interdisciplinary care efforts” with the complications we see today in “protecting turf and scope of practice”?
We’re now looking at value-based care in the era of ACOs, and we will eventually see administrators and companies paying for the entire event of care, reimbursing everyone involved, as opposed to paying for individual services. Until that time, framing it as “how would you want it if it was you?” is the most helpful. If you had liver cancer, would you rather come back three times to see the radiation therapist, oncologist, and surgeon for three different plans, or would you rather things be delivered together through coordinated teams on the same page in one place, from looking at the pictures to hearing what it is like to have surgery, in conjunction with education with a nutritionist?

Centralizing the payments around how the patient does will drive much of this. Looking ahead, we’ll choose three or four types of diagnoses to work on this. Some are already working well, like cardiovascular care and our cancer centers. Letting our chairs choose areas to enhance will allow teams to develop better and allow departments to drive their success stories.

•How can we empower technology in training to improve patient care?
One of the things that impressed me the most is the advances in telemedicine and communication through our Technology Center, and we are way ahead of the curve on that in training and in care for patients. I think the best thing about technological advances is the ability to expand our reach, looking at patients long term, and the fact that we do have outcomes data now to assess the risks and benefits of procedures and treatments.

•Two of the biggest issues UC students face today are increasing tuition costs and a constant threat to Graduate Medical Education (GME) funding for residency slots. How do you see this being rectified in the future?
The one thing I can do in my position is continue to look for more scholarships and monies to help you do what you want to do, helping those in need, but also creating new ways to reward students who do great things, making sure students understand the implications of debt, finding ways to manage and defray them so the debt doesn’t drive what you want to do in your career. For GME, it will be participatory in why we need training in primary and specialty care, particularly in areas like mental health and the combined training programs.

I think our innovative program to accelerate training is the way to go, and to have other streamlined programs makes a lot of sense for those who are surer so they can focus their efforts. GME is going to be tough because they aren’t going to give us more years to train, so enhancing education with what we have now, innovating, and being vocal about the fact that decreasing GME now will have effects 10-15 years later.

•In the era of health reform, how can UCD best position itself as a better provider in the community?
California is leading the way, not because we are necessarily faster, but because most other states are slow. The key is there won’t be that many more resources, so decreasing costs, keeping up value and efficiency are central, and with that we need a lot of healthy people. The push to make California the healthiest state in the next 10 years is the right way to go, teaching patients how to stay healthy, teaching about the genetic diseases they inherit, looking at obesity and what we eat, teaching all the people we serve in this region to be more healthy. It will take education, and as a surgeon I know that we love fixing disease, but there will always be patients to take care of.

Having the patient and their family understand what they can do for early diagnosis and early treatment is more important. For providers, it is being able to focus on prevention as well as treatment since we often forget that aspect, using social media and making sure people can access information as opposed to just being told. And focusing on the patients of tomorrow, educating kids in middle school about the importance of healthy behavior, is a real opportunity.

•What kind of future do you see for our student-run clinics?
That’s one thing that really impressed the LCME from an educational standpoint. Students tell me the patients love it because it gets the patients in the door for care, with avenues to more specialized care, if needed. I can see more availability of educational tools at our clinics like lectures, videos, discussions, where we can talk to patients to do more education. I hope to visit all the clinics soon to see where they may already be doing these kinds of things, and who may be amenable to expanding these efforts.

•Any comments on the primary care vs. specialty care divide in relation to health care cost growth?
Primary care is critical, that is “your doctor” and really the person who helps you figure it all out, who refers and educates, considering what kinds of things need treatment or not. The toughest part is when the most appropriate response is to do nothing. We all like something, even expect an intervention, but there are times when none of that is superior. From overuse of antibiotics, to advanced cancer or vascular disease where there is nothing else to be done that will help. We know how much is done in the last year of life; some of it is successful, but much is not. I think the primary care interaction with the doctor that knows you and you trust can help the family make those decisions with the specialists to assess risk and benefit.

The next step where the PCP is central is the concept of appropriateness, not “can we” but “should we” and what is going to happen if and when we do it. Making sure we know what the patient actually wants, that they understand what the intervention is going to cost them in pain, hospital days, etc., versus what it will actually give them later.

•Looking ahead for UC Davis Health System, what is our next horizon?
I’m doing a lot of homework to see what people are passionate about, where they want to go. We need to develop five to seven signature programs of excellence that when people say the word, they immediately think “Oh, that’s UC Davis.” We need to continue our community outreach, and create a network outside the tertiary hospital, finding places where outpatient procedures can take place, increasing primary care access throughout the community, and integrating a network of care throughout the region. Focusing on those “hard to find and touch” is essential, and I think getting students involved in outreach and education to improve access to appropriate care can accelerate this, and building on that to focus on prevention.