Author + information
- Lisa M. Fleming, MD∗ ()
- ↵∗Address correspondence to:
Dr. Lisa M. Fleming, Tufts Medical Center, Cardiology Department, 800 Washington Street, Box #5931, Boston, Massachusetts 02111.
To be good at medicine, you need to follow a specific trajectory: excel in high school science, major in pre-med courses in undergraduate school, attend medical school, match into an internal medicine residency, subspecialize, publish, and start a career. This track worked well for me until I developed a new interest: quality.
Fortunately, for residency I chose a somewhat unique department of medicine that was happy to have me focus on quality improvement projects, offering up both academic mentors and protected time for health services research. During my training, I developed quality initiatives, and with the help of dedicated medicine faculty, published some of my work (1). Now, I had devised my new and improved life plan: 1) learn a subspecialty; 2) work at an academic institution; 3) develop quality improvement initiatives; 4) publish my data; and 5) get promoted.
Next entered fellowship applications.
“Just don’t say you’re interested in quality improvement,” my adviser recommended. “Cardiologists are more interested in hearing about your research.” I wondered why quality innovation wasn’t valued, but cardiology is competitive, so I followed the rules. At each interview, I stated my goal to stay within academic cardiology and pursue clinical research. The strategy worked, and I matched into fellowship. Although I had followed the rules, I felt less certain about my newly established path.
Soon after the match, the director of the quality improvement elective at our hospital gave us a history of the quality improvement movement, starting with the British Navy’s success in combating scurvy and culminating with the report on quality of care from the Institute of Medicine (2). He then contrasted the concept of “plan, do, study, act” with randomized trials. From these lessons, I began to question if my work would result in publication and, perhaps as important, promotion. So, I went to the literature. Using PubMed, I found 27 papers that combined “academic promotion” and “quality improvement.” The majority of publications were focused in general medical journals, with not a single cardiology-related journal represented. Most fell into the “perspective” section of the journal, with just a handful presenting hard data. This was hardly a concrete answer about my future chances of promotion, especially as an academic cardiologist.
Fortunately, my current chief of medicine had published 1 of the most cited papers from my list. He posited that “innovators” should have protected time, research training, and resources to fund investigation. He also advocated that they should then be promoted for achieving success. He suggested that peer-reviewed journals could help promote this activity by setting aside space for publication of quality initiative–based research (3). Ten years later, chiefs from various departments of medicine answered a survey about promotion criteria for quality improvement leaders. The criteria included publications, leadership, service on national committees, and dissemination of innovations. Although 78% agreed that physicians should be promoted using these criteria, 62% acknowledged no one had been promoted based on these criteria (4). Apparently, change in academics moves slowly.
My mentors pointed me to the examples of several clinicians (none with subspecialty training) whose innovations outside of academia have increased job satisfaction, improved care, and even earned national admiration—successes perhaps more important than academic promotion. For instance, Dr. Richard Baron revamped his electronic medical record and drastically improved patient care in his primary care practice (5), and Dr. Christine Sinsky increased her patients’ satisfaction without compromising efficiency or effectiveness (6,7). Other examples abound.
Some institutions, including my own training program, have started to develop academic quality tracks within the departments of general internal medicine (8). These programs include not only traditional elements of success in academics like local and national presentations, publications, and mentorship, but also insert the essential ingredient for an innovator’s success by encouraging a culture of quality within the institution. As I witnessed at my own institution, this culture translates into academic respect.
Taking a nod from our generalist colleagues, maybe there are evolving roles for new brands of quality improvement in academic subspecialties. Indeed, the American College of Cardiology has developed registries to track performance measures (9). However, the path through quality improvement to academic success in the subspecialties still remains undefined. My generation of cardiologists needs a plan. We may want to focus clinically more than generalists, but we also want to diminish the gaps, improve efficiency, and practice in a healthcare system that rewards quality. Our dedication to improvement should result in academic success.
Thus, when I interview for my first faculty position, I will look for institutions that offer the factors instrumental to my future success:
1. Leadership that supports quality improvement in the same way it supports clinical research, including protected time and funding;
2. Support for physicians, in all fields, to gain training in biostatistics and parative effectiveness in order to pursue rigorous data analysis of innovation projects when possible;
3. Mentorship that enables trainees to develop quality improvement innovations and supports publication of their data;
4. Promotion criteria that include and reward quality improvement initiatives as much as traditional research; and
5. An institutional culture that supports and respects quality improvement.
The author wishes to thank Tom Delbanco, MD, and Mark Aronson, MD, for their help with the preparation of this paper.
- American College of Cardiology Foundation
- Battaglia L.,
- Aronson M.D.,
- Neeman N.,
- Chang J.D.
- Sinsky C.A.,
- Sinsky T.A.,
- Althaus D.,
- Tranel J.,
- Thiltgen M.
- Brindis R.G.,
- Fitzgerald S.,
- Anderson H.V.,
- Shaw R.E.,
- Weintraub W.S.,
- Williams J.F.