We Will Emerge Stronger - Dr. Peter Buckley, Dean, Virginia Commonwealth University School of Medicine

SHIV GAGLANI: Hi. I'm Shiv Gaglani. Today on Raise the Line, I'm privileged to be joined by Dr. Peter Buckley. Dr. Buckley is a psychiatrist and expert in schizophrenia who became Dean of the Virginia Commonwealth University School of Medicine in 2017 and served as interim CEO of the VCU Health System from January to September of this year. Prior to coming to VCU, Dr. Buckley also served as Dean of the Medical College of Georgia at Augusta University from 2010 to 2017. In addition, he serves as a member of the Board of Directors of the Association of American Medical Colleges, the AAMC, and as Chair of the Administrative Board of the Council of Deans of the AAMC. With that, Dr. Buckley, thanks so much for taking the time to be with us today. 

DR. PETER BUCKLEY: Shiv, it is a real privilege. I look forward to chatting with you.

SHIV GAGLANI: We like to ask our guests in their own words what attracted them to medicine. Specifically, you have a pretty amazing background at the intersection of neurobiology and schizophrenia. We'd love to hear about how you chose not only medicine but then psychiatry as well.

DR. PETER BUCKLEY: Great. Shiv, let me be brief. I come from a medical background. It turns out my grandfather was dean of a medical school in Ireland, which didn't make a lot of significance to me when I was younger. Both my parents were doctors, so I kind of fell into medicine, and then my father was a family practitioner, and I really felt that I would end up --in fact, it was planned that I might end up -- taking over his family practice. That seemed to be my destiny until I did my medical student internship in psychiatry, and I was extremely taken by just how debilitating mental illnesses were and also just how significant they were on their impact in society and on individual lives. I was particularly drawn to the issue of schizophrenia for both those reasons that I'd already stated, but also because the science of schizophrenia was really quite...it remains remarkable, but it also seemed just captivating to me as a medical student. 

So I had a kind of epiphany that I was going into family medicine, made a U-turn and went into psychiatry. I have to tell you, it's maybe a little embarrassing, but for my Christmas present, my mother gave me a textbook on psychiatry and a book on the psychopathology of mental illness. And I lapped it up. Ever since then, I had my focus on schizophrenia and was fortunate to be able to pursue that, and then was extremely fortunate to be able to go from Ireland at the end of my training, having had the schizophrenia fellowship, to go to Case Western Reserve University. You won't know this, but within three months of me getting there, one of our patients was on the front page of Time Magazine, and there was a six-page article about mental health and schizophrenia in our program, so I was just captivated by the decision and by the focus on schizophrenia. In a nutshell, that's the journey, and I feel very fortunate to have had those opportunities. Still disappointed that we're not where we should be in both the ability to understand the biology and to treat schizophrenia, however.

SHIV GAGLANI: It's a fascinating condition, obviously quite debilitating. Before I went to med school at Johns Hopkins, I read this book called “Crazy Like Us”by Ethan Watters, whose wife, I'm sure you know, is a psychiatrist at UCSF, Rebecca Watters. It was about how the cultures we're raised in will influence how the psychiatric conditions, whether it's anorexia or schizophrenia, will manifest and how outcomes could be even better in some places that have less biomedical frameworks like Tanzania, where apparently people with schizophrenia do better. So when I saw that in your bio, I was pretty excited and interested to hear your take on how psychiatry has evolved and before getting into medical education, part of your experience, your take on how much more important mental health is now because of COVID.

DR. PETER BUCKLEY: That's a fantastic question. The CDC did an evaluation of thousands of people in early June, and they found that 41% of people had either negative mental health or a behavioral symptom, and about 30% had anxiety, depression, or trauma, and about 10% of the population were suicidal. So, we knew to begin with that there is a lot of mental illness. Schizophrenia turns out as one of the least common of mental illnesses, but depression, anxiety, and trauma are ubiquitous human phenomena that unfortunately result in mental illness but now compounding that is this kind of public health disease, if you like, that represents anxiety, loneliness and also depression and suicidality directly attributable to coronavirus.  In the long run, Shiv, it may turn out like 9/11, where the long-term morbidity is actually more mental health than physical health. Obviously, time will tell with that.

SHIV GAGLANI: Yes. It's the second or third-order effects of what we see right now. 

DR. PETER BUCKLEY: Exactly.

SHIV GAGLANI: Switching gears, I know we'll get back into mental health, especially in your role as the dean of medical school, but can you tell us how you got from being a world-renowned researcher and psychiatrist into academic leadership, not only of the medical school but of an entire health system earlier this year?

DR. PETER BUCKLEY: Sure. I told you I was fortunate to go to Case Western, and then I ended up being medical director of a state hospital while I was at Case Western. I was very young in my career and young in age, and it was a phenomenal opportunity. I was so fortunate to get that, and my mentors had really kind of set the stage for me. After about six years of that, I had the opportunity to go to the Medical College of Georgia. I got to tell you, Shiv, it wasn't the best job advertised in America, because the prior chair of the department had been incarcerated for 15 years for research fraud, so it was a department that was in the doldrums. I was able and fortunate to be competitive enough to get that job at the stage of my career, and then we embarked on the remarkable turnaround of that department, which was really quite invigorating in itself from a leadership perspective. 

We also worked with the state of Georgia, which had a lot of mental health problems as well as additional scandals, and we were able to help the state improve its mental health system. All of that gave me a lot more experience in administration, quite frankly, than I deserved for the stage of career I was at. Then we got a new president, and I had the opportunity of becoming Interim Dean of the Medical School, and I didn't see it coming. I said, “I’ll go as an interim and try it out and see,” and I was fortunate to be appointed permanently. That's how I came into that role. 

There was one positive wrinkle to it, as a slight deviation. A couple of years before that, I had a job as an Associate and then Senior Associate Dean for Leadership Development in addition to being Chair of Psychiatry. I basically ran executive searches, which turned out to be a fantastic experience. As part of that, I got nominated and was fortunate to be accepted into a council of dean’s fellowship at the Association for American Medical Colleges, which you mentioned at the onset. That was a kind of boot camp for trying out whether you'd like to be a dean or not, and that was another very formative experience. So for people that are listening in, I always think about careers as some mixture of careful career planning and then leaving tremendous amounts of space for serendipity because you never know. Here I am in Richmond, Virginia, and I'm originally from Dublin, Ireland. Who knew!

SHIV GAGLANI: Yes, I love that. We have a term I really like, it is “engineered serendipity.”  You're in Virginia and up the road from where you are, in Charlottesville, Thomas Jefferson famously wrote, “I'm a firm believer in luck, and I find that the harder I work, the more of it I have.” So I imagine some of the serendipity we’re hearing about is because of the great work you've been doing. We've had several deans of medical schools -- Mark Schweitzer at Wayne State, Mark Schuster at Kaiser Permanente, George Daley at Harvard Med -- on Raise the Line. One of the questions we like to ask all of them is how they see COVID. What immediate changes you have to make as a Dean of a medical school due to COVID and what are some of the longer-lasting changes you think will stay both for medical education as well as for healthcare as a whole, as a result of this pandemic?

DR. PETER BUCKLEY: Yes. Fantastic question. We're very much struck with our responsibility to train the professionals that we had going through our medical school. None of us had the opportunity to take a year out or take months out, so we had to pivot. Like the other colleagues that you mentioned and their schools, we had to pivot to online training to make sure that we kept the trajectory of training going. I think that's been mixed, but I do think there are elements of online training that we will keep, that are here to stay in medicine. I'll give you a fantastic example. Of course, like any other medical school, we do our admissions process and interview people. Of course, this year, we couldn't interview them in person, so we had to interview them virtually. Well, when we got that far and when we had, let's say about two-thirds of the class created, we actually had a Zoom meeting with all the people that had decided to come to our school. 

A lot of them hadn't quite decided, but we were able to do one more sell of our school, and that's worked for those that were already sold, as well as those that were making up their mind. I'm thinking we must do this every year. This is a good thing to do. It was born out of that crisis and the management of admissions, but in fact, this is a good practice. We need to continue that.  I think we're going to see some of those throughout the curriculum. We've clearly implemented changes in the curriculum already. Obviously, crisis management, population, health disparities, how could we not inculcate them more into our medical student training given the year that we've had, because these are not one-offs. We've just been made so clear that these are so formative and important. That is an example. 

Pre-COVID, we were seeing about 80 people a week by telemedicine. Enter COVID, we flipped to telemedicine, and we've now been doing on average about 4,500 visits a week, so that's here to stay. The nuances of it may change, but that's here to stay. That means as we train our medical students and our residents, it's no longer something that is like a boutique or “good to have.” That's a must-have. It's the equivalent of what was the stethoscope, and right now with the ultrasound, but it's something that has to be part of our training. I see a lot of that, very much those changes, and then also I think our profile of large classes to small classes...medical school was shifting already from the kind of 200, 300 classroom format to more interactive individual learning. I think that's going to accelerate that further, and then the other issue, of course, is the whole transition from medical school training to residency. That's been disrupted mightily this year. 

The story isn't told yet, but there'll be changes out of that for sure that will probably impact fourth-year and through the first year of residency. When you look three to five years out, I think medical school training's going to be very different as a result of this pandemic, and I'm optimistic that it will be better, not worse.

SHIV GAGLANI: Yes, that's great. It's been a forcing function obviously, as you mentioned, with telehealth, which is one example. Another area that I know is of deep interest...we had Michael Gustafson, the President of UMass Memorial Medical Center, on the podcast a couple of weeks ago, and he talked about how at UMass, in the midst of the pandemic, half of their fourth-year medical students graduated early and became interns or super interns. Can you share what the VCU experience was as well as what you think about the idea of the scope of practice changes such as nurses being able to do more of what the primary care docs do and so on.  Also I’m curious to have you comment on changes in interstate compacts.

DR. PETER BUCKLEY: Sure. The issue with the scope of practice... telemedicine is an obvious area where you redefine that. A  lot of how we're beginning to try to figure this out is sometimes people will have a telemedicine visit an APP or a nurse first and then with the physician and then follow up with a physician or with a nurse, and so it allows much greater flexibility. I think we're going to see more of that. I also think we're going to see more involvement of allied health professionals. As you know, telemedicine itself begs the question of “what is the difference between practicing in Richmond to Charlotte versus Richmond to Malibu,” so those interstate compacts will make a big difference. 

Shiv, I'm very reminded as a doctor who's come from another country, that this is still very much the United States of America, so it's highly regulated within each state. That's obviously to protect the public and to ensure accountability and regulation, but some of these disruptions beg the question as to why something -- if it's a standard of care in one state -- why is it not right in the next state? I think we're going to see more of that. There was a first part of your question that I'd like to return to... 

SHIV GAGLANI: Yes, I was just asking about some schools who graduated their students early. 

DR. PETER BUCKLEY: Yes, exactly. We were, again, doing this like other schools. We have a third-year into a residency program that we've been doing as a pilot for about the last two years. It's gone very well. Again, I could see that because, as you correctly said, people graduated early and put on their full white coat rather than the mini coat, and they went to work to battle against a pandemic, so that's pushed that issue further forward. We are in the process of looking at that further. We've been doing it systematically. I think we'll just have to wait to see how that plays out, but I would not be surprised if that chips away at that fourth year, which is different as to how valuable it is across all health systems. Some medical schools are further along in terms of that, and so it seems like it is something that might make its way. The other thing to point to Shiv is, again, a lot of the fourth-year was people going on electives to other institutions, and also spending time interviewing and getting on planes to go to whatever institutions. We're not doing any of that these days, so lots of potential for change, and it's not all bad.

SHIV GAGLANI: Yes, I agree. We've seen that across remote work. At Osmosis, we've been a distributed work environment from the start, but a lot of our newer colleagues who weren’t used to that are saying, “You know, it's actually really nice not to have to commute and save that money.” I think it levels the playing field because I know people applying to medical school or applying to residency often have to choose how many places they apply to, or interviews they take because it's expensive to fly around. I remember when I was applying to med school.

DR. PETER BUCKLEY:  You're so right. There's less expense on the student, but there's also less reason for them not to apply to 70 odd places, which is 70 more applications that the particular program director has to evaluate and then interview them through a Zoom, so it's going to be very interesting to see how this year plays out. 

SHIV GAGLANI: You're very active at the AAMC. I mentioned it, and we talked about David Skorton being a guest of Osmosis. There are two topics that I'd love to get your thoughts on. The first is the Wall Street Journal reported that there's been a 20% increase in applications to medical school, which maybe is driven by the fact COVID has made people even more excited about being able to be in this much-needed healthcare heroic position. I'd love to hear your take on more enrollments in med school. There's still going to be shortages. There's still a GME shortage. If we increase the number of med students' seats, can we actually increase the number of physicians out there? 

And then the second is student debt, which obviously has played a big role as AAMC has continued to show the median student debt has increased year over year and now is over $200,000. My hope is that as a society, we will realize that we shouldn't be saddling our healthcare heroes with this much debt and figure out more sustainable ways to train clinicians. So any commentary you can provide on both of those would be very interesting.

DR. PETER BUCKLEY: Yes. They're terrifically salient points. On the first issue of more people going into medicine, I think it's a terrific profession and obviously, so do lots of people and more each year, but a couple of months ago, there was a public survey on comparing the public trust in various professions, and doctors and nurses scored higher than any other profession at 85%. Quite frankly, higher than any time in decades, so we're riding on an all-time high, as you said, the kind of healthcare heroes, the excitement of medicine, the ability to be altruistic and do good, the marriage of science and then healthcare, and then population health -- our whole discussion around drugs to market for COVID and vaccines and the race and how science is informing that -- imagine if you were a younger person seeing that, how mesmerizing, how enticing that could be as a healthcare profession. I think we already see the rebound of that. I think we're going to continue. 

Obviously, from an industrial point of view, healthcare is a huge business, something about 17.5% of the GDP, so it's always an area of growth, and there's job security. Physicians are fortunate to have job security. It's a very worthy profession that I think this has all attracted additional interest to. 

Your comment about the debt is very correct. It's a perplexing issue. I think I'm more optimistic, as you've already seen in this interview, but I think there's a silver lining here. I've been very impressed by the altruism shown to medical schools over the last number of years. When I was in the Medical College of Georgia, we had an alumnus that gave $10 million towards a new medical school building that we were very grateful for, and then in his bequest, we have a $66 million gift to scholarships for medical students and endowed chairs. 

So I think Shiv, as you see the public perception of the value of health and the value of healthcare workers, we could see beyond alumni, like the individual in Georgia, we could see wealthy people in the community really wanting to invest in medical schools and scholarships as an investment in the health of the nation. I think that may provide an opportunity for us in the role of deans to extend our efforts and scholarships. We've been very grateful for some of the coronavirus donations that we've had from the community, but we're also looking to pivot back to our regular philanthropy. One of them is the opportunity around scholarship and the opportunity to raise more money that can, again, feed that support and interest that you alluded to earlier.

SHIV GAGLANI: I will echo that by just saying that we worked with NYU and had the opportunity to get to know Kenneth Langone, and he and his colleagues have done a tremendous job of making that a debt-free class for a couple of years now, The second example is Morehouse. Bloomberg Philanthropies just donated  $100 million to Historically Black Colleges and Universities, including our collaborators at Morehouse, to drive diversity in medicine, which is a tremendous gift.

DR. PETER BUCKLEY: These are not one-offs. These represent a change in our field and in our society and a different viewpoint of the investment in scholarships, so we're hoping to work with that as well.

SHIV GAGLANI:  I'm respectful of your time, so I just have two last questions for you. The first is, you have a career as a researcher, a physician, academic leader, health system leader. We would love to hear the advice you would give to people right now, considering careers in healthcare as a result of the pandemic or not.

DR. PETER BUCKLEY: Sure. Before COVID it was a great time to go into healthcare. It will remain a great time. I think we're going to see more transformation now over the next five years than we've seen over the last 10 years, and there are phenomenal career opportunities. You asked me about my own experience and how I got to where I got to from Dublin, Ireland. I also had the opportunity of going back to Ireland, but I chose to remain in America because of healthcare and professional opportunities. They are boundless. I'm full of excitement for our own medical students and our residents for what's ahead of them. I think we have yet to see the greatest generation of doctors come as a result of this experience, and the opportunities are phenomenal. Phenomenal.

SHIV GAGLANI: I love that optimism. Do you have anything else you'd like our audience of millions of current and future healthcare professionals to know about you, about VCU, about meeting the crisis of the COVID moment or beyond?

DR. PETER BUCKLEY: This is a remarkable experience that we are going through and have gone through. It's obviously not one that we would wish to have, but there is an opportunity to learn, opportunity to grow, opportunity to make our health system better. I will tell you, Shiv, as a doctor that's been doing this for decades, I've never experienced a degree of public support and just high regard for healthcare professions. We're on an all-time high, and that's an opportunity for our colleagues to come in and to set their expectations for their careers. 

I think we will do very well over the long haul. We're stuck in the middle of a disappointing and distressing pandemic. But it will have its day, and then we will be left with the great American resilience that characterizes this country. We will be left with a workforce whose own resilience has carried them through in their training and in the early years as doctors in these healthcare professions. I believe that when the die is finally cast, and everything is added up, I believe that we will emerge much stronger as a nation and as healthcare providers as a result of this pandemic.

SHIV GAGLANI: I know you're extremely busy running a medical school and contributing to the health system so thanks for taking all the time to be with us,  and for what you do to raise the line and improve our healthcare system capacity.

DR. PETER BUCKLEY: Thank you, Shiv, and I wish you all the best. Thank you.

SHIV GAGLANI: With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to flatten the curve and raise the line since we're all in this together. Take care.