By Mark Couch
(December 2015) John J. Reilly, Jr., MD, became Dean of the School of Medicine and the University’s Vice Chancellor for Health Affairs in April. Prior to joining the University of Colorado, he was at the University of Pittsburgh School of Medicine beginning in 2008. In 2011, he was appointed the Jack D. Myers Professor and Chair for Pittsburgh’s Department of Medicine. Reilly’s education and training include an undergraduate degree in chemistry from Dartmouth College and a medical degree from Harvard Medical School, with postgraduate work at Brigham and Women’s Hospital in Boston and at Intermountain Healthcare in Salt Lake City.
While at the University of Pittsburgh, Reilly oversaw the grants administration enterprise for the Department of Medicine, providing a broad view of academic research there and shaping his ideas for the elements of success in research. His personal research activities are focused on pulmonary diseases, including emphysema, chronic obstructive pulmonary disease and lung cancer.
In addition to his participation in multidisciplinary research, Reilly has extensive experience in creating and working in multidisciplinary clinical programs. He participated in the founding of the Lung Transplant program at Brigham and Women’s Hospital in 1992, and since then he has worked in a comprehensive lung cancer program, a multidisciplinary critical care service running a surgical intensive care unit and two lung volume reduction surgery programs. In his role as department chair at the University of Pittsburgh, he reorganized the liver and renal transplant areas to a more integrated model functioning as a unified team.
In this Q&A, Reilly talks about his background and offers his perspective on the future of academic medicine and the University of Colorado School of Medicine.
Did you always want to be a doctor?
According to my mother, yes. There’s actually no good reason for that. There are no doctors in my family before me and we didn’t have particularly close social relationships with any physicians. I guess I was attracted to what my concept was of being a doctor, which was not grounded in any reality of what being a doctor is actually like.
Do you have siblings who went on to become doctors?
I’m the oldest of eight kids. I have two younger brothers, No. 3 and No. 8 in the lineup, who are physicians. They both went to Dartmouth like I did. My brother Jeffrey, he’s the third of the eight, is a vascular surgeon in Atlanta, Georgia, which is where we went to high school and is where his wife is from. My youngest brother, Philip, who just turned 50, so he’s eight years younger than me, is a family practice doctor in Seattle. He manages one of the county health clinics there that primarily cares for immigrants from Mexico and Central America.
What did you parents do?
My father worked for IBM, primarily in marketing and sales, and was quite successful, so we moved a lot. My mother left the workforce when she had me and then pretty much had her hands full with eight kids in eight years.
You went to Dartmouth. Why did you choose Dartmouth?
It was a different time back then. I think I applied to three colleges. I didn’t know anything about Dartmouth. I didn’t know anybody from Dartmouth. And I didn’t visit Dartmouth until my first day there. I was interested in math at the time and Dartmouth sent a recruiter through our high school in Atlanta who talked about the math department. And Dartmouth was a really long distance from Atlanta and I was interested in attending school a really long distance from Atlanta.
Because it was Atlanta or because you were ready to get out of the house?
The answer to your question is yes.
When did you graduate from Dartmouth?
I graduated from Dartmouth in ’77 and I did not major in math after all. I majored in chemistry. I finished early at Dartmouth, in December. The next fall, I started at Harvard Medical School.
And you stayed there.
I did my internal medicine residency at Brigham and Women’s Hospital in Boston. And then my pulmonary and critical care fellowship in the Harvard Fellowship Program, which was at Brigham, Beth Israel Deaconess and the VA.
Did you always want to stay in Boston?
No, we were always going to move. We were going to move after medical school, but my wife, Lise, had just been promoted and it wasn’t like there was a shortage of good residencies in Boston, right? Then we were going to move after residency, but my wife had just been promoted again. And then we were going to move after fellowship, but it wasn’t a great time to move. We decided we weren’t going to ask our kids to move in the middle of high school. And then all of the sudden, it was 30 years. Wasn’t it John Lennon who said ‘Life is what happens you’re busy making plans?’
After residency and working in Boston, you went to Pittsburgh. What made that an attractive move for you?
I think a couple of things. One is our youngest son was off to college. Literally the day I drove him to Georgetown, the moving van pulled up to the front door of our house in Wellesley. The attractions to Pittsburgh were several. One is the guy who recruited me there, Steve Shapiro. I had worked for him in Boston and we got along really well and I liked working with him. The second was actually a few years before, Lise and I sat down and decided that we wanted to try someplace new. I was interested in someplace new professionally. I loved the Brigham. I loved my time there. But I was ready to try someplace new. I was just turning 50 and I could see what the next 10 years looked like and it wasn’t bad, but it was kind of predictable. I was interested in seeing what I could do in a new environment.
What kinds of things did you think you wanted to do in Pittsburgh?
There were some good research collaboration opportunities there, but the primary thing was being able to do some interesting things around clinical-care delivery, to move away from departmentally focused programs to doing things that were more centered around patient problems and assembling teams to take care of people with those problems. I think transplant is a good example of that.
How challenging was that to do?
Actually, it’s a good example of something I say to people who work for me or people who are really concerned about what their title is or what their place in the organizational chart is: ‘If you have leadership that shares the same values and is aligned around the same strategy, you can make any structure work. And if you have leadership that is not aligned around the same goals and strategy, you can’t fix that with structure or an organizational chart.’
We capitalized on the fact that there was new surgical leadership in transplantation who had a different attitude about team organization and care delivery. The classic view was ‘I’m the surgeon. I’m in charge of the show. Everybody works for me.’ The work on my part was not convincing him to change. The work on my part was convincing all the people in my department that he was different than his predecessor.
What made coming to CU School of Medicine an attractive opportunity for you?
The sense of opportunity and the trajectory of the Anschutz Medical Campus. The challenges in Pittsburgh from a department leadership perspective were different than the challenges here. In Pittsburgh, we had overwhelming clinical market share. We were in an environment where clinical revenues were probably going to go down just because of utilization patterns across the U.S. and because western Pennsylvania has historically been a high utilizing area. As it comes down toward the mean, it means that clinical revenue drops. Because most of the clinical revenue in town was ours, our clinical revenue was going to drop. The NIH is pretty flat. Philanthropy in Pittsburgh wasn’t great. So the management challenge there was how to maintain a department that’s recognized nationally for its excellence in research and clinical care in the face of shrinking resources. That is an interesting challenge, but it’s actually more fun to think about hiring good talent to scale up to meet the demand. It’s more fun to hire people than it is to fire people and to be in a position where you can get all the different departments to play in the sandbox together.
Do you think that that combination of declining federal support and the change in emphasis in how providers are compensated by the federal government are going to have adverse effects here?
On the research front, I think there’s going to be sort of a Darwinian process in the marketplace and that there will be a much smaller number of research-oriented academic medical centers. You can have a debate about whether it’s 25 or 30 or 35 or even 50, but there will be a much smaller number than there are now. The places that currently have a modest or small amount of research will, 10 or 15 years from now, probably be virtually 100 percent clinical. I think the rich get richer, strength begets strength, and if you look at how the historically strong academic institutions have done during research-funding downturns, percentage-wise they tend to lose much less than the average. When the funding starts to get tight, it’s the mid- and small-sized places that don’t have that critical mass that get disproportionally hit and I think that trend will continue.
On the clinical front, I do think the change in the way the society in the United States pays for health care – away from fee-for-service towards other mechanisms – means that academic medical centers have to think carefully about how they position themselves in that marketplace. In my personal opinion, and I’m far from alone in this, I think the strategy of being a free-standing, independent academic medical center that relies on the community to refer complex cases is not a viable long-term strategy. I think you have to be part of a larger network that includes practitioners in the community and community hospitals so that you’re included in the insurance networks that are developing across the U.S. Viewed in isolation, academic medical centers are expensive and therefore are likely to be excluded from narrow network products. The challenge for academic medical centers is to become parts of networks because they are widely publicly recognized for their excellence of care and therefore nobody wants to exclude them from their network products.
One of the things that you’ve talked about since coming to Colorado is behavioral health. Tell me what you mean by addressing behavioral health at the community level.
It’s clear that people with a spectrum of behavioral health diagnoses, ranging from psychosis and serious mental illness to the more common ones of depression and anxiety and substance abuse, are poorly served by the way our health care system is organized. They are put in a different class conceptually, by the general population and by certain aspects of medicine, from people who have ‘physical’ diseases. They are often high utilizers of health care. I think there is a mission imperative, if our goal as physicians is to improve function, relieve suffering, and increase longevity, to address behavioral health.
There also are some very pragmatic economic reasons, for society and employers and health insurance companies, to address behavioral health effectively because it’s less expensive.
At UPMC, we had an insurance company and therefore I had access to claims data. We could look in our general internal medicine practice and find the frequent fliers. Our general internal medicine practice there took care of about 22,000 people and about half of those were people we insured. We took a look at that population to see who the high-utilizers were and then we looked at those patients to see who we thought we could change utilization. We built a practice model where we embedded behavioral health and more robust case management services and home visits and 24/7 access to the clinicians for patients to see if we could change those utilization patterns. We used our data and then built a different primary care model around it. Then I went to our insurer and basically said this is what we’re going to do and rather than getting paid fee-for-service for every office visit, I want a cut if we reduce utilization. It’s what they call a shared-savings model.
Let’s talk a little bit about research priorities for an institution. How should academic medical centers proceed? How do we proceed going forward with regard to setting research priorities?
Well, there are two ends of the spectrum on that. One is to let it function as a natural ecosystem where people pursue their interests and then you see what comes out of that. A lot of academic medical centers have been built largely in that model. The opposite end of the spectrum is a command-and-control system, where the person with the checkbook has decided that we’re going to have a program in disease X or this particular scientific area. The proponents of a more centralized strategic plan and investment strategy would argue that you can build programs of deeper excellence.
We need an approach that tries to achieve the goals of the central command-and-control system, but also takes advantage of the strengths that we already have. Our strategic plan is to build a small number of programs in which we can invest substantial resources to maximize our chances of assembling a critical mass of talent that will produce first-class science and will give CU a national and international profile. To choose those programs, we will solicit proposals from people on campus and then choose the strongest of those proposals to put substantial resources in.
We are going to balance our portfolio so that not all of our resources are going just into those strategic investments. This effort will not be at the expense of other constituents on the campus. I am in a fortunate position thanks in large part to the stewardship of Dick Krugman and Lilly Marks and the hard work and success of the faculty here. That allows us the luxury of providing the necessary resources for our departments and also to do the kind of program building that we’re talking about.
How important is diversity among faculty, students and staff going forward and how do we address what issues you may see there?
I think it’s very important. There are a couple of reasons. Some are laudable and some pragmatic. If you think our missions here are to be the best educators, the best researchers, and provide the best clinical care, it’s pretty clear that a diverse workforce does that better than a non-diverse one. I think we take better care of patients if the workforce taking care of patients resembles the make-up of the population of patients for whom we’re providing care. In terms of research innovation and creativity, a diversity of viewpoints produces better science and better original work.
It is also the right thing to do. This is a meritocracy, ideally. You could argue that we in the U.S. sometimes fall short of being a meritocracy. But the fact that many people still want to come here for an education and to pursue careers suggests that the rest of the world still views us as a meritocracy and we want the best and the brightest. And the best and the brightest are not all white males. It’s pretty straight-forward. I stayed in academic medicine because I liked working with smart, talented people. I came here with the goal of working with the smart, talented people who are here and attracting more of them to come here, and they come in all sizes, shapes, colors and orientations.