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?”
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.