Leaders and Leadership in Hospital Medicine: The Story Behind the IPC-UCSF Fellowship

This is a tale of leaders and leadership. And about keeping an open mind.

I first met Adam Singer in 1996, when the hospitalist field still had its training wheels on. A pulmonary/critical care physician by training, Adam had become a physician-entrepreneur and was now focused on making his new enterprise, IPC, the nation’s preeminent hospitalist company. I found him engaging and energetic, but also brash and opinionated. He had strong views—on how hospitalists should be organized, what the field’s professional society should be doing, and what a hospitalist really was—and he shared them often and vigorously. I admired his moxie and drive, and I’m pretty sure he admired my academic contributions, but our styles and ambitions diverged sufficiently that we didn’t interact much for the next dozen years.

But I couldn’t help but notice IPC’s meteoric growth, culminating with its initial public offering—it’s now the only publicly traded hospitalist company—in 2008. While I was impressed by this market success, I remained skeptical of IPC’s model. My strong belief is that one of hospital medicine’s great contributions was the unusual degree of integration between doctors and hospitals it promoted—driven to a large degree by hospitals’ financial support for hospitalists. IPC’s credo, on the other hand, was to eschew hospital support and emphasize the private practice model and physician autonomy.

This was a strategic choice. Adam believed that physician independence was needed to create doctors who hustled and didn’t adopt an “intern mentality”—by which he meant drawing a salary for simply showing up. He also worried about getting entangled in hospital politics and bureaucracy. I understood his rationale, but I believed that physicians and hospitals would ultimately need to work arm-in-arm, and that our field could be a trailblazer for integration. Over time, my view of IPC was shaped both by my bias against its autonomy paradigm, and by the company’s widely held reputation in the hospitalist field as focusing more on physician productivity than quality.

Then, in late 2009, something remarkable happened. My colleague Arpana Vidyarthi attended a Society of Hospital Medicine-sponsored quality improvement (Project BOOST) meeting in St. Louis; she was mentoring a group of IPC hospitalists based there. “I remember your telling me that you weren’t too fond of the company,” Arpana told me upon her return. “But I thought they were very impressive.” She ticked off the St. Louis group’s successes in promoting early-day discharges and its geographic-based unit and multidisciplinary rounds, as well as IPC’s longstanding practice of calling patients after discharge (begun well before this became a common practice driven by Medicare readmission penalties). She was also impressed by the group’s physician leader, Phil Vaidyan.

At such moments, worlds sometimes change. Only a couple of months earlier, I had written a blog about Adam Singer’s selection by Modern Physician magazine as Physician Entrepreneur of the Year. Although I was genuine in praising his contributions to our field, I also took a few pot shots at his leadership style. What I heard from Arpana told me that, just maybe, something had changed, both in Adam and in IPC. I left a message with Jeff Taylor, an attorney by training who, as IPC’s president, is Adam’s highly effective sidekick (Adam is Chairman and CEO), sharing what I heard from Arpana and offering my congratulations on the work that they seemed to be doing with the company.

Jeff promptly returned my call, telling me that “he and Adam” wanted to come up to San Francisco to bounce some ideas around. (I recently learned that this wasn’t precisely true: Adam was not overjoyed at the thought of meeting with me, which is understandable, but Jeff pushed him to consider the opportunities that might come from collaborating with UCSF, in the context of broad discussions within IPC regarding the need to develop a hospital engagement strategy.)

We met a few weeks later, in December 2009, at a small restaurant on San Francisco’s Market Street. Adam and Jeff told me about their evolving vision for IPC. They had come to realize that their focus on physician autonomy, which had worked so well in the early years, now threatened to lead to lost opportunities and could ultimately pose an existential threat to the company. In a value-based purchasing world, they recognized that their physicians needed to be—and be seen as—leaders in quality and safety. But they sensed that their doctors lacked the skills to meet this challenge.

In this, I saw an extraordinary opportunity for collaboration. As it happened, both Arpana and another talented faculty member in my division, Niraj Sehgal, had recently become passionate about leadership training; after taking courses themselves, they were now collaborating with Professor Ed O’Neil and UCSF’s Center for the Health Professions to teach and design physician leadership programs. Working closely with the IPC leadership, we rapidly hammered out a plan: to create the IPC-UCSF Fellowship for Hospitalist Leaders, an intensive year-long program for 40 of IPC’s practice group leaders.

The fellowship went far beyond your typical Leadership 101 course. In addition to four 2-3 day on-site meetings, we also conducted twice-monthly distance learning sessions, mentored quality improvement projects, provided one-on-one executive coaching, and more. The goal was for the IPC physician leaders to develop a new set of competencies, including self-awareness of their strengths and gaps as leaders, in negotiation and conflict resolution, in running meetings and giving oral and written presentations, and in innovating. We also taught quality improvement, patient safety, and project management, along with the basics of health policy and health economics for the hospitalist leader.

As important as the discrete skills and topics were, the course was also designed to help these physicians appreciate their roles as leaders, armed with the confidence to make real what both Adam and I have championed from the beginning: hospitalists need to be not only great at caring for patients one at a time, but in making their groups and hospitals work better. Before we began, most of the fellowship participants had heard that charge, but few knew how to address it effectively. One of our main goals was to change that.

Last week in Tiburon, just north of San Francisco, we held the fourth and final session of the first year fellowship cohort, along with the first session for 40 new physicians in Cohort II. I can’t remember attending a more positive, energetic gathering of physicians. The folks completing their fellowship weren’t just talking about the skills they had gained, but also about how the program had changed their view of medicine and life. Many called it the most positive experience they’d had in their professional careers. In a survey, all 40 of the participants gave the fellowship stellar ratings, and every single one answered with a resounding “yes” to the question, “Would you recommend this program to a colleague?”

IPC-UCSF Leadership Fellowship First Graduating Class (w/ Adam Singer in jacket, Jeff Taylor in red shirt)

Before the graduation ceremony for Cohort I, several of the participants gave brief oral presentations describing their year-long projects. Ken Donovan, inspired by the death of a close relative, launched a palliative care program at his hospital. Dennis Deruelle built a national web-based quality improvement network for IPC, called SHINE (Sharing Healthcare Innovation for Nationwide Excellence). The background music for his PowerPoint presentation was a compelling song that—I later learned—he had written and performed.

And Sarada Sripada, a diminutive woman with an outsized passion for improvement, focused her project on patient satisfaction. When the fellowship began, her group’s patient satisfaction survey results were abysmal, in the bottom decile of Press Ganey’s national database. The fellowship taught her that she needed to set an improvement goal. To me, a goal of reaching the 50th percentile would have been fine, and a goal of the 75th percentile would have been highly ambitious. But Sarada thinks big—her audacious goal was to reach the 90th percentile. By working with her team, collaborating effectively with other departments at her hospital, and using the skills she learned in the fellowship, she achieved her goal, a jaw dropping achievement. The audience of about 100—Cohort I’s 40 participants, the 40 new participants in Cohort II, IPC’s executive leadership and several of its board members, and our UCSF faculty—overflowed with excitement and pride, and several of the presentations received standing ovations.

Traditionally, academic physicians have spent their time seeing patients, teaching trainees, and publishing papers and books. This program—focused on improving the leadership skills of doctors in community practice—pushed us out of our academic cocoon. Leaving one’s silo is always challenging and a bit risky, and I’d be lying if I said I didn’t have trepidations before we began the program.

But if anyone can think of a better thing for our exceptionally talented faculty to be doing than teaching scores of community-based hospitalists how to be more effective leaders, I’d love to hear it. This program is already improving quality, safety, satisfaction, and efficiency at dozens of hospitals around the nation, and that effect will multiply as we train future cohorts and as the graduates work with the hundreds of physicians in their groups. I couldn’t have been prouder of my team, particularly Arpana and Niraj: the program they developed and delivered wasn’t just good, it was exceptional.

(For non-IPC physicians interested in leadership training, Arpana runs a similar program, the UCSF Institute for Physician Leadership; the Society of Hospital Medicine offers several excellent leadership training programs as well.)

The experience also gave me an inside view of IPC, and I came away impressed. Sure, this is a publicly traded company that needs to create shareholder value. And any company that explodes from a few dozen doctors to nearly 2000 over a decade is bound to have some growing pains and take a few missteps. But this is a company that, at its core, is trying to do the right thing for patients. One doesn’t make this kind of investment in money and time (and not only the time for all the participants; Adam and Jeff attended nearly every on-site meeting) driven solely by the results of a return-on-investment spreadsheet.

As for Adam Singer, my admiration for him has grown immensely over the past two years. As Apple CEO Tim Cook told Steve Jobs biographer Walter Issacson, “What I learned about Steve was that people mistook some of his comments as ranting or negativism, but it was really just the way he showed passion…” IPC is not Apple (and Adam’s “rants” can’t hold a candle to Jobs’s), but in our little world of hospital medicine, Adam has built the top company, no easy feat. His passion—including his passion for training tomorrow’s leaders—is much to be admired.

13 Responses to “Leaders and Leadership in Hospital Medicine: The Story Behind the IPC-UCSF Fellowship”

  1. Betty Till November 18, 2011 at 6:33 pm #

    Hi Bob,
    Great article! As one of the executive coaches in this program, I found the participants engaged and truly wanting to become better leaders. They recognized that leadership is more than making sure the schedule is filled and everyone gets as much work as they want and the time off they want. I’ve now had nurses tell me that the best thing that’s happened to medicine is having hospitalist physicians. These same physicians now have the tools to collaborate and their ability to work as a team will only increase their voice in changing and improving healthcare.

  2. Skip Strauchman November 18, 2011 at 9:18 pm #

    Good Afternoon Dr Wachter,

    As an Executive Director for IPC I am extremely thankful that Jeff called you back and push Adam onto the plane.
    I was particulary intrigued by the enthusiasm I witnessed last week both by our physicians and your staff. The understanding these 40 individuals now have as to what their role is as hospitalists and leaders is priceless. I also noticed the excitement of the physicians enrolled in cohort II after witnessing the presentations and graduation event.
    We are well on our way to showing the advantages of what a true hospitalist/hospital partnership can be.

    Thank you so much,
    Skip

    By the way, who picked up the tab for lunch, you or Adam?

  3. Hospital Doctor November 19, 2011 at 4:28 pm #

    I Progress note For Cash (IPC) doctors number nearly 1,500. They are not subsidized by Hospitals since they see lots of patients and “carefully “bill them all with IPC Link. Is the Medicare fraud investigation over? The company turns a profit with poor outcomes and poor patient satisfaction. Their doctors can’t leave because of Non compete agreements and so the program grows.What hospital CEO would really outsource their primary service to doctors with no real interest in the hospital ?
    Bob, do you know why your tune has changed? Could it be the million Dollar Grant given to UCSF by IPC for all of the “training.” You can pretend that they are investing in better doctors if that makes it easier to swallow, but we all know that they just bought a commercial.First impressions are most accurate. Adam “Spinner” is it? The true passion is for money no matter how many good people get lost or unwittingly help along the way.Patients deserve better.

  4. AD November 19, 2011 at 5:30 pm #

    It is refreshing to realize that an entrepreneur may be the future leader of hospital medicine. When the physician has skin in the game good things happen.
    This model of hospital medicine is truly the future. It is run by physicians and only physicians can understand the needs of patients and other physicians
    Unfortunately this model is ignored in community hospitals. There inept administrators now employ and control poorly functioning physicians with attitudes of unionized mill-workers waiting for the siren to herald the end of shift. To perpetuate their control selected are weak leaders, you can guess who,suffers.
    I hope that the leaders of the large hospital system where I practice call Adam Singer 911

  5. Richard Rohr November 20, 2011 at 12:29 am #

    Adam Singer is going to have the last laugh on all of us, as the subsidies in most programs have reached an unsupportable level, and will be even less supportable as revenues ratchet down. I’ve heard all the knocks about IPC, but I call hospitalists all around the country each day to discuss medical necessity; IPC is the one group that makes sure that its doctors call back, and their folks seem to know what is going on with the patients, more so than the average hospitalist. IPC doctors have to produce, but Singer gives them productivity tools seldom seen elsewhere. Singer has built the better mousetrap and deserves to profit from it.

  6. Hospital Doctor November 20, 2011 at 4:25 pm #

    He is already laughing Richard. The only group who doesn’t think it is funny is the patients.It is simple Math. IPC makes around $30,000 a year on each doctor. The profit doesn’t come from Quality incentives from superior performance,it is derived from patient billing after expenses. Why can’t other Hospitalists (The >90% who require a subsidy)perform the same trick? Must be because they are lazy, don’t “know”how to extract cash by billing, or are focusing on other issues (Like Quality and Safety).The experience to help hospitals build their own program is readilly available.They are wising up. A few more misplaced UCSF “commercials” will slow their learning curve. Transparency could resolve the issue. Bob could release the financial details of the IPC arrangement with UCSF. I suspect he won’t. Transparency in healthcare seems to be more important when related to Quality and Saftey issues…….. let’s leave the money out of it.

    • AD November 22, 2011 at 12:43 am #

      It is extremely unfortunate that comments on Dr. Singer have led some to question the integrity of the author of the blog. Such comments when posted anonymously are inappropriate.
      If IPC invested the sum alleged to improve the quality of their personnel, it is commendable.
      Can the author of the post above name any other organization that has expended resources to improve results

  7. Romel Navarro November 20, 2011 at 10:44 pm #

    It’s easy to talk brazenly when you’re anonymous.

  8. Hospital MD November 23, 2011 at 2:49 am #

    The post reminds me of a scenario that was commonplace about 10 years ago. Pharma company invites academic doc to introduce community docs to the latest drug. The setting is a fine restaurant. Slides, academic papers are supplied by the sponsor. Speaker gives two thumbs up to the drug. Inconvenient questions by the audience are given the cold shoulder or silent glare. Community doc gets a free meal; and perhaps an hour of free ‘CME’.

    There are inherent conflicts of interest in accepting moolah from a for-profit entity. At the very least, it makes one’s credibility somewhat suspect. Call me old fashioned, but physician leaders aspiring to climb the executive ladder should be doing so on their own nickel. There are plenty of high-quality, affordable, physician-centered and effective business/healthcare programs out there

    As the latest goings-on in college football prove, even the greatest of leaders have blind spots. The ultimate test of leadership is to be cognizant of these and to listen to contrarian
    viewpoints. Wish I would see more of such leaders in healthcare.

    Peter Drucker, where art thou?

  9. john geanes November 28, 2011 at 9:16 pm #

    Dr Wachter,
    I am managerially responsible for the “Greater Florida” division of IPC, and have been with IPC for about eight years now. The event in Tiburon was terrrific, and I am very proud to be a small part of an organization that has the commitment that IPC has always had, and, the ability to select leaders such as you and your team to help us lead in a field that still has a number of challenges and opportunities ahead. Again, thanks for the splendid program and for the enthusiasm it has created within the four physicians from our region.
    Best wishes for you and your UCSF team’s continued success.
    John Geanes

  10. Mary Jo Gorman December 12, 2011 at 7:44 pm #

    IPC has a long history of investing in its physician work force. Since its early days, all new physicians were brought to headquarters for team building, training and understanding the role of the hospitalist in healthcare delivery. As the practice matured, physician practice leaders have attended a wide variety of leadership programs, those customized for IPC by leading consultants as well as those provided by SHM and ACPE. It is terrific to see this commitment continuing with a partnership with UCSF. The ability to train effective physician leaders is key to making meaningful changes in a healthcare system that fails to deliver top results for its citizens.

  11. VS March 9, 2012 at 4:25 am #

    Looks like Hospital Doctor had some issues with IPC. If it is so bad, how come so many practices join IPC. Its well managed and efficient in its overheads. Medicine is noble but also a business in USA. Like any business, if u do not know where your money is coming from or leaking away, the practice will fold. Thats where IPC excels. It also nurtures physician growth, autonomy and engagement with the hospital administration. How many times I hear ” SHift based- slave – hospitalists” slogging it out without a say on how their work flow is designed.

  12. hospital MD December 13, 2013 at 3:03 am #

    Medicare fraud investigation will show you the real face of IPC corporation
    http://www.justice.gov/opa/pr/2013/December/13-civ-1294.html

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