Leaders in Medical Education

Dr. James Madara, CEO of the American Medical Association

Alice Ferng
Published on Feb 3, 2016. Updated on Invalid date.

Dr. James Madara is a distinguished academic pathologist, medical scientist and administrator. He has published over 200 original papers and chapters, and is an authority on epithelial cell biology and on gastrointestinal disease. Prior to joining the AMA, Dr. Madara served as Timmie Professor and chair of pathology and laboratory medicine at the Emory University School of Medicine before he took on the Thompson Distinguished Service Professorship and deanship at the University of Chicago Pritzker School of Medicine. While at Chicago, Dr. Madara also served as CEO of the University of Chicago Medical Center, bringing together the university's biomedical research, teaching and clinical activities. As CEO, he was integral in engineering significant new affiliations with community hospitals, teaching hospital systems, community Federally Qualified Health Centers on Chicago’s South Side, as well as with national research organizations. Of course, these are only some of his many accomplishments and snapshots of the important things he is doing to help improve healthcare and education in our country. We are very excited to share this interview with Dr. Madara with you!

What was your background and how did that lead you to decide on pursuing a career in medicine?
I grew up in a small town in central Pennsylvania and had an accident on the basketball court when I was in 6th grade and ended up with a serious injury. I was then taken to Philadelphia and spent a few months in a hospital there. The first 2-3 weeks were very painful, but I had a good time once I got out of isolation and in the children’s ward with my physician and his team, which is what got me interested in medicine.

Why did you pick pathology as a specialty?
I bounced around a lot when I was in medical school thinking about what I was going to do; everything from orthopedics to pediatrics to psychiatry. I ended up having a fair amount of exposure during an elective to radiation oncology. I decided that I wanted to do radiation oncology and that it would be a good idea to have pathology training so that I could speak to the pathology department about diagnoses. So I ended up having some time in the pathology department at Harvard, and really like it. I guess what I liked about it was that I was interested in science, but not formally trained. What we talked about was pathobiology, disease at the molecular level. So I decided to stay in pathology, and that took me to an investigative direction. I did a research fellowship in cell biology there, and went on that way as an investigator and someone that did GI pathology as well. One of the things I learned was that everyone can construct a logical story, why they did this that and the other thing--but it’s usually not true. What it is is actually a series of random events that allows opportunities in one director or another, and they are often highly influenced by either a personal wish (in my case, for a more scientific treatment of medicine), or a mentor. I had both. I had a mentor that was a fantastic person on the faculty there who I just got along with really well. He was a fabulous mentor. A lot of times, those kinds of things are what determines where you are ultimately and where you land.

How did you choose where you went to medical school, residency, and beyond?
Medical school was more based on being close to home. Residency was a process of interacting with mentors who would suggest places that I would enjoy and things I should do, such as that if I had a practice in radiation oncology, then learning pathology in depth would give me a leg up. Then, again, doing pathology and getting exposed to the science of disease, having a fabulous mentor, led to the subsequent steps.

What got you interested in taking on active administrative roles such as being a Dean at the University of Chicago and now CEO of the AMA?
All of that happened through influences of people around me. I started building a lab at Harvard, and that lab became sizeable. I really liked the operating component of it—the interactions with postdocs and students. I didn’t mind writing the grants to get funding, and then I was asked to direct the Harvard Digestive Diseases Center when I was fairly young then. Younger than anyone else on the executive committee, so that was a learning experience in how to deal with people far senior to you in a respectful way. I liked that, so I thought I would do something outside of the Harvard system and I went to Emory as the chair of pathology for 5 years. I liked that, so I thought I would stay there, but then I got a call from the University of Chicago who had a very captivating president named Don Randall. I just loved interacting with him, and the medical center there needed a lot of work. The entire physical plant needed to be rebuilt. A lot of people had drifted off, so there was a lot of recruiting to do. There was a real job there to do that was of scale, so I was partnered with Don, who I thought would just be a blast to work with. That’s essentially what took me there.

What does it mean to be a leader in medicine today? What qualities does it take to be a leader among physicians? What is most challenging about this?
I think leaders have to project and think through a vision. What is a future state that would be exciting? You have to build a team, and trust that team, support that team, and get everyone on the same page. I always like to think of having some simple guideposts. They are just simple phrases that when you are dealing with a difficult situation, sometimes these phrases can help you out, and everyone can have their own phrases. Mine are:

“Don’t be afraid of being caught in the truth.”

Everyone occasionally in their career is going to do something that they wish they hadn’t done that is just boneheaded in retrospect—but that’s okay. You can’t fear being caught in the truth.

“Long-term trumps short-term.”

Doing what’s simple sometimes will take care of a short term, but that’s not looking at the long term. Sometimes the long term requires a little more work.

“Always take the high road.”

That kind of sounds like you’re not saying anything, and that it’s very squishy and subjective, but if you have a difficult problem that you are trying to sort through, or it’s a problem of institutional relationships, then you sit back and say to yourself, “which one of these paths is the high road?” It’s virtually always clear which one is.

“Life is too short.”

If you aren’t having a few laughs, you don’t enjoy the team that you built and the people you are interacting with, and you aren’t having legitimate fun, then you are doing the wrong thing.

“Don't mistake either a misunderstanding or miscommunication or dropped ball as some kind of evil plot of one group against the other.”

People aren’t actually very good at evil plots, but we drop the ball all the time. Sometimes people fall into the habit of misinterpreting that for something that it is not. Always hear out the other side. Listen and probe. Most often, the things that appear virulent at first blush tend to be completely benign and explicable.

What do you think about the rising healthcare insurance costs and the consolidation of insurance stakeholders?
Part of the rising healthcare costs of insurance and otherwise is due to the fact that we are structure largely for acute disease, and what we are dealing with is chronic disease. Chronic disease constitutes 80% of the 3 trillion dollar healthcare costs.

With respect to consolidation of the insurance stakeholders and of the insurance industries, there is an argument among those wishing to merge and acquire that this larger size will facilitate lower costs and better care through increased efficiency. Unfortunately, the empiric evidence shows that this is just not the case—in fact, the opposite happens when markets consolidate where premiums go up, and patients get left on the hook for that. We always think of dealing with things in healthcare in an evidence-based way, and if we can deal with the insurance mergers in an evidence-based way, then the Department of Justice would intercede.

How is AMA involved in bringing these decisions to the forefront?
Yes, in fact, we have interacted with the Department of Justice. Our interaction with this department is truly based on evidence. We recite the evidence and give examples of where the consolidation has occurred and what the facts of that are, and then we recite the Department of Justice’s own guidelines and principles of how they decide whether a merger is helping consumers (in this case, patients) or harming them. I think we have a pretty good fact-based argument that this is something that would not be in the best interests of healthcare in the United States.

What are 2 or 3 changes you'd like to see in the healthcare system of the United States moving forward?
We show what the changes are and what we think the changes have to be by the work that we are doing. We are focused in 3 areas. The reason we are focused in these 3 areas relates to something I’ve mentioned before: we have gone from a country that deals with acute disease burden that was inpatient to a country that now deals with a largely chronic disease burden that is outpatient. Yet, we are still structured more for acute than we are for chronic.

The three areas that we focus in:

1: Phrased as a question: How should a society think about and deal with chronic disease?

If the disease is largely playing out in the community, wouldn’t you expect that there have to be community assets that can be used in a sustainable way as part of the solution? If that’s the case, those community assets have to be able to be wired in some effective way to the healthcare system. A lot of this is behavioral. How do you deal with that aspect in a complex society like ours? So we’ve used prediabetes and hypertension that is not under our control as models. The hypertension work, in part, has been done in collaboration with the Armstrong Institute at Johns Hopkins. The prediabetes work is being done in collaboration with the CDC, the YMCAs, and a couple of others. We have done a series of pilots around major cities and are now scaling that work in the state of Michigan. To give you an idea of what we think it will take, in Michigan, we have 40 organizations that include the governor’s office, public health, employers, community organizations, hospital systems, and physician groups to map out pathways for prevention of diabetes arising from prediabetes. The reason we picked that is because there are 86 million Americans that currently have prediabetes but only 10% know it. Those 10% don’t even know what to do about it, yet there are very effective diabetes prevention programs. Although we are talking about diabetes and prediabetes, what we are actually talking about is an example of chronic disease and its huge burden. In the case of diabetes, how you attenuate the conversion to real disease from prediabetes into a disease condition.

In the case of hypertension, it is how you treat existing hypertension where a person is being seen by a provider, and yet it is still not under control.

2: Medical school education

We largely still train as the individual rather than as a team. Most of the clinical training that occurs is still in the inpatient setting, and it isn’t in the outpatient setting. And that which is in the outpatient setting often does not have continuity and educational handoffs. There is a new field of “health systems science.” When we look at physician practices, physicians want to have more time with patients, and there are approaches that they can take to free up their time. Modules have been produced for that. That is why we are working to transform medical education. We’re reshaping the way future physicians are being trained to ensure they are better equipped to practice in the evolving 21st century health care system

We have awarded $12.5 million dollars to stand up a Consortium of 32 medical schools, each of which have a piece of innovation. They come together regularly throughout the year to share information and best practices for implementing innovative curricula changes. We started by giving $11 million to 11 medical schools back in 2013 to launch the Consortium. When we put out the request for proposals (RFP) for this, more than 110 medical schools applied – more than 80 percent of the country’s medical schools, so everyone was ready for this. We just expanded that recently to 32 schools. We are now at the critical mass of 32 schools where we can start doing things very differently.

3: How we get practices to be more sustainable, and how we make the thrill of practice come back to medicine.

We’ve worked with RAND Health and looked quantitatively and qualitatively at practices in a variety of markets. We measured satisfiers and dissatisfiers in practice, and are producing tools to deal with all of those. One really good message that came out of this was that in all practices types, in all modes of practice, the primary satisfier was hands-down face-to-face time with patients. The dissatisfiers, which were numerous, were all things that got away with attenuated face-time with patients. Some of those were “internalities” and others were “externalities”. When we think about the changes we’d like to see in the United States, we’d like this to work as a system because the problem with chronic disease does not work like a system. We would like our physicians to be educated so that they can practice in the system, and we want existing practices to be sustainable by using these techniques that allow physicians to do what they want, which is to interact with patients.

Do you have any words of wisdom for those trying to pursue future leadership roles in medicine and/or medical education?
Don't be confused by high quality problems that you face. What I mean by that is: there are many divergent points that people face in their careers. I’m going to join this field, or that field, or this, that, and the other thing. Understand both, but also understand that at the end of the day you have a high-class problem, meaning that you can choose any of these 3 pathways and be highly successful. Don’t sweat it if you have really good opportunities. They are each good. There is not one that is good, and the other two that are mistakes.

Focus on what your interests are and what you like. Don’t dilute that by trying to make yourself broader and try to do and learn everything. Sometimes people will know what they really like and what their passion is, which in my mind means that they can be a leader in that area. But they fear that if they don’t cover 1st, 2nd, and 3rd base with some other skill sets or activities that they will be less marketable. They train broadly, and this decreases the chance that they will actually end up in the perfect position that they actually enjoy. Follow your instincts. You won’t make mistakes in this field. You’re more likely to be a leader if you get into an area that you’re actually passionate about.