Key Lessons on Effective Leadership: Dr. John Tomkowiak, Washington State University Elson S. Floyd College of Medicine

Dr. Rishi Desai: Hi. I'm Rishi Desai. It has been a very busy couple of months for today's guest. As founding dean of the Elson S. Floyd School of Medicine at Washington State University in Spokane, Dr. John Tomkowiak presided over the school's first graduation and first Match Day, and also welcomed the news of its first family medicine residency program being accredited. 

Dr. Tomkowiak has a long record of developing community-based education programs, and I'll be asking him about that approach and how he sizes up the current and future state of medical education. Thanks so much for being with us today. 

Dr. John Tomkowiak: Thanks for having me. 

Dr. Desai: Well, let me just start out by asking you a little bit more about what got you started in medicine, and specifically, psychiatry

Dr. John Tomkowiak: Winston Churchill said, "We make a living by what we get. We make a life by what we give" and that has really been the case for me. I've had some amazing mentors that have guided me across my career, and that's really how I got into medicine. I was working at the University of Illinois in a circadian rhythm lab under Evelyn Satinoff, a PhD researcher. I remember she invited me into her office and said, "John, I know you're thinking about medical school and also research, and I think you should go into medicine". I was like, "Wow!". And she's like, "Well, we always need doctors that are good researchers. But once you become a researcher, it's really hard to become a doctor". 

So, with that, somewhat surprising advice, I applied to medical school and I got there. Once I was in medicine, I really was interested in surgery and did all the necessary things to apply to a surgical residency. I had one-half credit left to complete my MD degree and the only offering at my school, which was Southern Illinois University, was what they call an extended elective. It was an elective that you have to do a half-day, every week, for 6 months. The only one they had was in the department of psychiatry, and it was a psychotherapy elective. I got engaged with a patient who had a condition called retinitis pigmentosa, which is a degenerative eye disease. In some cases, you go blind, and that was exactly what was happening to my patient. She was a 31-year-old, mother of two. For the next 6 months, I did psychotherapy sessions with her as she was becoming blind and her courageousness and her determination to do the best she could for her family and herself really inspired me to pursue psychiatry. I changed up everything, and I decided to do psychiatry.

Dr. Desai: A couple of really interesting points you just brought up like that piece of advice. I just want to go back to it for a moment. What do you think that meant...the idea that if you're doing research, it's hard to go into medicine or become a doctor? What was the takeaway for you from that comment? 

Dr. John Tomkowiak: Well, I think she was really trying to encourage me that you can always do research if you've chosen to be a doctor, but once you choose the life of research and pursuing a Ph.D....I mean it's not impossible to go back to school to become a doctor, but you're probably not going to be able to take care of patients. She really saw in me that that was something that inspired me. It was just so surprising because she was a Ph.D. researcher. She spent her whole life and career in it and was world-renowned for her research. And, you know, I really expected her to say "follow in my footsteps." So I thought it was pretty amazing that she really was thinking about me and my needs in giving me that advice.

Dr. Desai: And then the second sort of anecdote with the woman that was losing her vision, you mentioned psychotherapy, and that's not the thing that jumped out in my mind. In my mind, I'm thinking, "Oh, my gosh. She's losing her vision. That's got to be debilitating. How she going to keep a job? How she can take care of her family?" So, I'm just curious, how is it that you came around to recognizing that was a core need of hers and how did that psychotherapy play out in broad terms? I obviously don't want to get the specifics of her case. 

Dr. John Tomkowiak: Well, it really took the form of more cognitive therapy and helped her work through many of the issues that she was dealing with on an emotional level and translate them into action steps that she could take while she still had her eyesight and prepare and do things to eventually help her deal with the impact that her blindness would have on her and her family. Once she was able to turn the corner and accept that she actually could do a lot of things to prepare herself and make things better, it was like this amazing switch went on, and she just really became courageous and proceeded to do all these things that bettered herself and her family. 

Dr. Desai: I guess on some level, all of us are losing our physical capabilities, really. That's the normal way of life. Obviously, it's more acute in the setting you described, and maybe more poignant for that reason, but certainly an adaptation that we all must reckon with at some point, so that make sense.

Dr. John Tomkowiak: Well, and it's something I talked to my students about all the time. Once you get to that next, best level of yourself, you better be working on the next best level. I think as physicians, we owe that to our future patients...that we're always taking that next step to be better.

Dr. Desai: I'm going to come back around to asking what steps you're taking right now, John. I'll tell you a couple I'm taking right now. We're just on the physical domain of swimming and it has been really, really interesting and humbling to realize how challenging it can be to swim properly. So that's been my big next step. 

In terms of professional steps, you've transitioned a few times. You just talked about research, going into clinical practice, and then you transitioned into and administrative role. What drew you to that, and what challenges were there for you as you're transitioning into that piece? 

Dr. John Tomkowiak: Well, this really happened because of another great mentor that I had. I went to medical school and did my residency at Southern Illinois University. The dean of that school was a psychiatrist by the name of Carl Getto and I had the opportunity to have him supervise me as I was a resident physician, which meant for the patients that I saw, he was the clinically responsible attending physician. 

During that time, he really saw in me how much I love to teach, and I had a lot of ideas about what I wanted to do and was getting frustrated that these things weren't happening. And he said, "Well, why don't you become a part of the solution". So, slowly over time, he gave me some opportunities to be a leader, and it ended up being on a task force to redo the whole curriculum at Southern Illinois. That led to my first real administrative position as a co-director of the entire second year of medical school. Once that happened, it was off to the races because I really enjoyed being able to have some of my ideas come to life, and work with other people to really advance medical education. 

From there, I ended up going to Florida State to help them start a brand-new medical school. That was around the year 2000, and it was once again Carl Getto my mentor who said, "Hey, if you're going to keep going on this administrative track, you need some additional credentials." I said, "You know, I've looked into MBAs and masters of public health and they don't really inspire me." He, on his own, found me a program that was a masters of organizational leadership at Gonzaga. That was a bricks and mortars program that had just turned into an online program. He says, "I think, I found the program for you". I did that program. It was life-changing and that really gave me the skills and tools I needed to advance further in leadership. 

Dr. Desai: It's really interesting. Talk to me about that. What did you learn in that program, that was life-changing? Did it kind of change your mindset? Did you meet certain people? What did you gain from it? 

Dr. John Tomkowiak: Yes, to all of that. I mean, the first realization I had which I really felt humbled about was that leadership is a science, just like medicine, and there are theories and facts and best practices in leadership that we know work. If you understand them, then you can become a better leader. I had never really thought about leadership as a science. So, that was the first thing. 

The second thing is that the program I was in brought in folks from all sorts of disciplines. I had policeman, K-12 teachers, military folks, folks that were in businesses. I appreciated that, as they were talking about the leadership challenges that they were dealing with, many of them were the same ones that we were dealing with in healthcare. In some cases, industries had solved some of those problems that we hadn't yet solved in healthcare. So, it was this great, a-ha moment for me that, "Wow, there's a lot to learn about how we should be leading in medical education and healthcare from other disciplines and other industries." That was game-changing for me. 

Dr. Desai: Do you feel like that's happening a bit more now? And if so, what would you say is the one industry we borrow the most from nowadays that wasn't happening maybe a decade or two ago?

Dr. John Tomkowiak: I would say Big Tech has had such an influence on healthcare. I think what we are seeing now -- and I hope this is the trend -- is that Big Tech's willingness to take risks to tackle problems that maybe people think they shouldn't be in, should inspire those of us who are already in healthcare to really re-examine how we're approaching the advancement of what we're doing. You know, our own research, the way we're applying that research either to patient care or education, the outcomes that then we're getting. Big Tech has a really great way of making that all work and doing it at scale. I think we're just now realizing the importance of that strategy in really bettering healthcare for everyone. So, I'm inspired and I really love that Big Tech is trying to get into the healthcare space. 

Dr. Desai: Now transition into specifically your experience in medical education. I'd love to really understand from your perspective what are the key lessons you've learned in medical education and how has that informed how you think about the Elson S. Floyd School of Medicine?

Dr. John Tomkowiak: Well, Darrell Kirch, who used to be the CEO of the AAMC, would say something frequently in conversations and in public forums. He would say, "Culture eats strategy for lunch." That has never been truer in academic institutions, particularly medical ones, where you can have really great ideas and plans for how you want to change things, but there's a heavy baggage that has to be lifted and gone through in order to make those changes happen. If you don't understand the culture of the organizations that you have, and the influences acting on that culture, it's really hard to make change happen. So, I would say that's one of the first lessons that has really been paramount in me really having some success in the organizations that I've worked with, is really number one, working on making a great culture.

There's a gentleman by the name of Dr. Kevin Grigsby who is a cultural anthropologist at the AAMC and he introduced me to this idea about sequencing. He doesn't like to talk about having priorities because the word priority often implies some weight or importance and often times in healthcare, or in health care education, there are many values that have equal importance but yet we have to choose how we go about tackling them. Thus, this idea of sequencing. And sequencing, for me has become a real klaxon in terms of how we get the job done. Most of what we are doing is really important and so we avoid these words like priorities. We talk about how do we in sequence do all the important things we need to do. For me, those two things -- focusing on the culture and making sure we get it right, and then make sure we do things in the right sequence -- generally leads to great results.

Dr. Desai: A big part of culture is the people of course. How has that affected attracting folks in your hiring practices, and retaining folks as well? What are the things that you're doing that may be a little bit different from how normally it's done, and folks might take some tips away from that and say, "Hey, maybe we should try that our organization as well."

Dr. John Tomkowiak: Well, the first thing we did when we were a very small organization at our new medical school here, was we decided that for our culture, we did want to have three priorities. Now, I just said we don't use the word priorities. The only time we use them is in this context, and we decided that the number one priority for everyone would always be personal health, and that would be physical or mental. The second priority would be our family and friends, and the idea here is if you have family and friends that are hurting, you cannot focus 100% on your job. So, take care of them first. Third is the job. So, if you take care of your personal health -- both your physical and mental -- then you take care of your family and friends, you will come to work and do amazing things. So, we built that into our culture from day one. That phrase is used at every orientation session. We repeat it in every public forum that I do. I talk about that. We make sure that that happens with our students, with our staff...everyone in the organization knows about these priorities. 

The second thing is we ask everybody to hold each other accountable. This isn't just a leadership thing that leadership is going to make sure we do all this. We make sure that every person in the organization not only focuses on themselves, but helps each other out in this regard. That has been a really important thing that we've done. Another thing is when we first started the medical school and recruited our first group of students, we gave them Liz Wiseman's book, Multipliers. I think that's an another really great example of how we need to empower those around us to do more and better. That was a really important concept, and we continue to do that going forward. 

Dr. Desai: So, you're a huge proponent of community-based medical education, and I'm just curious how what you just described -- in terms of the philosophy around the key priorities being the self, the family, and then after that the job -- how does that extend to community-based medical education? What is the overlap there in terms of the cultural ways in which that plays out? 

Dr. John Tomkowiak: I will admit up front, I'm biased towards community medical education. I've spent my entire career at five different community-based medical schools. I think it's so important that as we train the physicians of the future, they really understand the people in the communities that were working in. It's not like it used to be where we were solely focused on the individual patient that's sitting in the office. We realize that there are so many other factors -- environmental, socioeconomic factors -- that affect the health outcomes of patients. And to really understand those, you need to understand the environment and the community that our patients live in. So, I think it's really important as we prepare the future physician to understand what the needs of communities are in the patients within those communities, so we can best serve them. I think the pandemic is just a great example of how maybe we haven't done such a great job in that area, and there are lots of opportunities to do better going forward. 

Dr. Desai: That was my next question...we're still in this COVID pandemic, and obviously a lot of the focus has been on how to do a better job in specific communities because the pandemic has affected people unequally. What are your thoughts on that? What are some areas where you think that we can do better to prevent the next pandemic?

Dr. John Tomkowiak: I think we really need to understand the importance of communication and trust with our patients and the populations that we serve. That has played out time and time again in the pandemic, where there has been conflicting information that has been given to people and there came a point in time when I think the population said "I'm not sure if we can trust different sources." This idea of being a trusted site for healthcare is so important and all of us in healthcare should be considered a trusted site for healthcare information. But somehow, I feel, we've lost a little bit of that and I think part of that is we've become disconnected from the communities that we serve. 

We need to understand what are the needs of these communities, you know? How are they thinking or what are their concerns about it, and really address those directly. That can be done at many different levels. It should be done at the one-to-one level, but also at the community, regional and national level. Teaching our students how to communicate clearly and how to build trust with not only their individual patients but within the communities that they serve is incredibly important. 

I would say that the second thing that we've learned is the ability to be agile and to take new information, act on it quickly, change what we do, and then look at it the next week and do that process all over again. It's really taking continuous quality improvement and applying it every day and we need to do that in the public health sector just like we do it in the everyday practice of taking care of individual patients.

Dr. Desai: Bringing that back to training, do you feel like that's something that is happening in medical education today...that feedback loop around quality improvement?

Dr. John Tomkowiak: Well, I certainly think that it's happening in certain places, and I think the pandemic has shown a bright light on the importance of the processes. It really leads to this other idea that we know is so important, which is continuous learning over a lifetime for those of us in healthcare. This same idea about continuous quality improvement...we should always be making ourselves the next best version, and to do that, we have to be constantly in a feedback loop of what did we do last time? How can we make it better? I believe that we're in a good place now where medical institutions are saying, "Yes, this is a core feature of what we need to teach the future physician workforce." 

Dr. Desai: Are there other lasting impacts of COVID on medical education in addition to enforcing or reinforcing the need for that? Are there other things that you're seeing already? 

Dr. John Tomkowiak: We were forced into doing things differently during the time of COVID in how we are educating our students and I think we've learned some really valuable lessons. One of those lessons is the need to be more flexible in what we do. There are many different learning styles for our students that are out there. I think the pandemic helped us explore those in ways that we had not done before. Certainly, the use of virtual or tele technology to engage them in their learning became way more prevalent. We see that as an important part of education going forward. Even if the pandemic was totally resolved and we could all go back to doing things the way we did, we wouldn't want to because we've discovered there are some better ways to do that going forward. One of those is the engagement of learners at a distance. For example, being able to monitor them in a tele environment while they're engaged in-patient encounters and giving them feedback when a faculty member might be in a city 200 miles away, and they can be somewhere else. We can do that in our work just as well and sometimes it's better because we can see more patients that way. So, I'm really hopeful that we don't leave in the dust many of the lessons that we've taken away from this very difficult time.

Dr. Desai: Speaking of lessons, we have so many students and early career health professionals in our audience. I'm curious to get your advice to them about meeting the challenges of this moment and approaching their career in healthcare more broadly.

Dr. John Tomkowiak: Well, I think healthcare is like a marathon and when you start the race, you definitely have a lot of energy. You're raring to go. But you need to understand it's a long game and even after you become a physician, if you're going to stay in the game for a long time, you have to take care of yourself. So, I would say those priorities that I talked about earlier that have helped our organization be so successful -- about taking care of your physical and mental health, taking care of your loved ones, and then focusing on the job -- I think that's really the key for those learners who want to be in healthcare. They need to develop those habits right from the get-go because it is a long game, it's a long run, and we need our clinicians to be healthy for a long time, and to be fully invested in the job because there's a lot of work for us to do, and I know that we're up for it.

Dr. Desai: That's a very inspiring and uplifting message. I appreciate you sharing that with us, and for being with us on the program today. Thank you.

Dr. John Tomkowiak: Thanks for having me. 

Dr. Desai: I'm Rishi Desai. Thank you for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.