Clay Johnston, the first dean of Austin’s medical school, has a scant two years to satisfy an array of constituents and solve a daunting set of complications. July 2016 is his deadline for opening the Dell Medical School at the University of Texas.
First, he has to create it.
Johnston’s partners include Central Health, the public hospital district providing $35 million a year from Travis County taxpayers, and the Seton Healthcare Family, which plans to break ground this summer on a $295 million teaching hospital.
UT is building a $334 million complex consisting of an education and administration building, a research facility, a medical office building and a parking garage.
For Johnston, making a medical school from scratch is a “once-in-a-century opportunity.” He envisions a place where doctors are educated and trained to keep people well, instead of mainly reacting to illness. It’s a big change for a system that pays doctors based on how many patients they see and procedures they perform.
Johnston, 49, is navigating a system in which the public medical school will work side-by-side with the Catholic-owned Seton, whose rules bar birth control, abortions and other procedures. He also must satisfy the UT System Board of Regents, which is embroiled in an unprecedented impeachment process involving a regent’s review of UT-Austin records and a challenge of its leadership.
At the same time, he must cultivate the goodwill of local doctors — some of whom have deep concerns about the medical school-Seton relationship — to help teach and innovate.
He comes to Austin from one of the nation’s leading health science centers, the University of California, San Francisco, where he was associate vice chancellor of research. Johnston, a neurologist, spoke with the American-Statesman earlier this month. An edited version of his remarks follows:
You have to please local organizations and, ultimately, the state Legislature because UT’s a public university. Do you have as free a hand as you had hoped?
Actually, yes. UCSF and other academic medical centers are highly invested in the status quo, and here we’re not. The partners … know, too, that it has to be done differently. They’re not sure how to do it, I’m not sure how to do it, but together we can create a system in which we can test different alternatives, different approaches.
What’s wrong that the medical school might fix?
Health care is unbelievably expensive. Why should it be so much more expensive than in just about any other country in the world, and the health of the American population is no better? So, how do we create a system that’s more focused on what patients want, or what people want before they become patients? That doesn’t mean that you try something like socialized medicine in Austin. Could you experiment with making hypertension treatment free for the population and simplifying how that’s delivered? There are all sorts of things we could do within the current health care system that could really promote health and save us money at the same time.
Do you anticipate turning out half primary care doctors and half specialists?
I would like to train more primary care docs and fewer specialists. In order to do that, we have to make primary care more attractive.
What positions are you recruiting for now?
We’re really focused on chairs of departments — pediatrics, internal medicine, surgical services, OB-GYN and neurology. In the next wave we’ll do psychiatry and population health. Hopefully we’ll have (almost) everybody identified by the fall.
How many faculty members will there be? And which ones will be UT employees and which will be Seton employees?
We should be at 70 faculty members within a couple years. Those are the UT employees. The ones that are employed by Seton — it could be 300.
Currently, Seton has employed the clinical faculty who do the teaching in their hospitals. And so their salary line comes from Seton. But the key thing is for us to say, OK, we and Seton are working together on this health care delivery mission, and whether a faculty member’s paycheck comes from one group or the other shouldn’t matter. They should all be following the same rules. But how we get to that — it’s not clear.
Do you tell the faculty you’re recruiting about the Seton relationship and has that caused any concerns?
Not so much the relationship with Seton. The concern — and this is also a concern of our community physicians — is how we add academic physicians to an environment that currently includes only community physicians, mostly in large practices. Do we come in and compete, and do we take the high-margin clinical activities away from them?
The people we recruit don’t want to be in … this battle between the two. And we don’t want to put ourselves in that position, either. How we navigate to a system in which academia co-exists with community care — that’s the key.
Will the clinical faculty who are Seton employees now and credentialed under the UT Southwestern Medical Center in Dallas be credentialed by UT-Austin?
Initially we will accept their current faculty appointments as UT appointments. They’re not tenured faculty. Once we have chairs, the chairs will create the standards for (Seton-paid) faculty.
Will UT have a say over who these people are even though Seton pays their stipend?
Absolutely. That’s all our determination of whether they have a faculty position.
Do you see any conflict on Seton’s part as a leading provider of medical care having a say in priorities for indigent care in Central Texas?
I think it’s remarkable that Seton is so invested in indigent care. The fact that they stepped forward and said, “This is a key part of our mission and we’ll pay hundreds of millions of dollars a year in order to meet this mission” — that’s fabulous.
Every single hospital that takes on care of the uninsured and under-insured has to still balance its books. So there has to be a way in which it uses profits from another area to cross-fund. Otherwise it can’t survive.
Let’s say somebody from St. David’s wanted to teach. St. David’s and Seton have no-compete clauses in their physician contracts. Does that create problems for you?
It’s not uncommon actually for contracts to strongly affiliate physicians with certain care settings. It gets a little more complicated for us because for faculty we want a little more fluidity, particularly in terms of research and where they do their community work. This is something that we’re discussing with Seton now.
So, do you envision having St. David’s physicians as faculty?
We are in the process of working out what we’re allowed to do, but I would say bringing the physicians in Austin who are devoted to teaching and research in as partners with the medical school is one of our goals.
If you have a St. David’s doctor who is providing, say, women’s health care that Seton is forbidden to provide, would that doctor be able to have a faculty appointment?
We have to provide a full range of women’s health services in order to be accredited. If we can’t do that with Seton we’ll do it elsewhere. I’m trying to dance around this because we’re right at the point where we’re negotiating this.
Are the Catholic Ethical and Religious Directives a stumbling block in recruitment and do they infringe on academic freedom?
People do a double-take on it. But when we describe how we envision working within those directives, people are reassured, so I don’t think it’s going to ultimately impact our recruitment. The freedom to do the research part, the innovation part, that will not be in any way impaired by the relationship with Seton.
Would your faculty be permitted to teach at A&M’s medical campus in Round Rock?
Yes, absolutely. We’re not here just to create a little island of isolationism.
What’s the most difficult challenge you’re facing right now?
It would be easy to come here and create a medical school in the model of existing medical schools. So the biggest challenge then is coming in and saying we should question everything that we take for granted as being required in setting up a new academic medical center.
In doing that, it opens up a huge range of ways in which you could really get things right and create a whole brand new model but also a whole mess of ways in which you can get it wrong. So then the key is balancing these risks and potential benefits. I would say the only way to do that is to create a system that’s nimble enough that you can quickly change course when you’re getting something wrong.
On the compensation side, what are you trying to achieve that’s different?
The usual model is that docs get paid for the number of office visits and the number of procedures that they do. What that does is it incentivizes them to do more. But more isn’t always better. What we’re trying to do is envision a system in which we get paid for keeping people healthier and for providing better health care with better outcomes at hopefully a lower cost.
What’s keeping you awake at night?
I’m most worried about how we work in this large community of physicians because the model that we choose today will determine our success downstream decades from now. What I’m hoping to do is set up a system in which we are fully integrated with the community physicians as opposed to being an us-or-them system. But how we do that and whether we can then have enough influence to move care forward, to change the community — that’s the critical thing that I worry a lot about.