Upstream Learning & Downstream Dysfunction: How to Train Leaders for a New Future


“The arrogance of success is to think that what you did yesterday is sufficient for tomorrow.” – William Pollard

In health care right now, lots of people are talking about innovation as a generic way to describe the new holy grail to some of medicine’s biggest problems. Of course this line of logic might lead some to think medicine is in some state of “innovation-deficiency,”¬† a condition for which innovation replacement therapy is the clear and sole treatment. While this obviously isn’t always true, introducing new technologies and processes, if done the right way, can certainly help minimize waste, control cost, improve efficiency, and introduce equity into existing public systems.

So if medicine needs to up its innovation game, as many are suggesting, who’s it going to turn to? Where is the pipeline of leaders to fill the holy grail and how do you turn on the faucet of new and better ideas?

I’ve been thinking a lot about these questions over the past few weeks as I start my Fall semester at Harvard’s TH Chan School of Public Health. And no that wasn’t a name drop. It was a point of reference drop, to help place the problem I am about to describe, into context.

For the past 3 weeks I’ve been taking a pretty stand out course on quality improvement¬† taught by the incomparable Maureen Bisognano and her enviable squad of colleagues and friends. For a bit of background, Maureen is the President Emerita of the Institute for Healthcare Improvement, basically a healthcare innovation incubator based in Boston, and her friends include people like Don Berwick, Atul Gawande, Brent James, Ellen Goodman, and Derek Feeley, to name a few of the powerful speakers who inspired us. For 3 weeks, we reviewed international examples of ways to radically redesign the US healthcare system.

And then, I had fall registration.

Excited to push the boundaries of existing systems, I was eager to take classes across the University, and like Maureen showed us, find examples from other industries, sectors, and disciplines that could be applied to the great challenges facing medicine and build solutions that translate across public systems and private incentive structures. But to my surprise, that inter-sectional, open learning, not only wasn’t a requirement, but was incredibly difficult to find. And if it is hard to find at places branded on leadership, I worry it may be symptomatic of a larger issue.

Which got me thinking, just how are we going to train this next level of leaders when the educational pipeline through medicine looks remarkably similar to what was suggested in the landmark Flexnor Report in 1910, that established a system of medical education, that with few exceptions, continues today.

Courses continue to be divided by discipline, learners are isolated to their field of study, and for those who select to learn outside that box, they do so singularly, as a function of personal interest or a non-degree program rather than systematic integration of agents and ideas. Then is it any wonder why our systems remained silo’ed with divergent (and sometimes antagonistic) incentive structures despite overlapping public interests?

Don Berwick is often quoted as saying, “Every system is perfectly designed to get the results it gets.” In medicine, as we move upstream in our interventions for disease, to target root causes rather than downstream effects, we must do the same thing for the education pipeline. We have to challenge ourselves to teach future leaders how to think, reason, and execute rather than prescriptively guiding them, formally and informally, to reproduce the same system, with the same challenges we already have.

It has been more than 100 years since the last massive shift in professional medical education, perhaps parting with apprenticed dysfunction and practicing principled disruption is a good start.





Police Violence and Public Health: What We Know


What does it mean to understand police violence from a public health lens?

It starts with understanding how police behaviors can result in harm and who is most affected.

In the Cure Violence podcast link below, I introduce what I term adverse police exposures, or a conceptual framework to understand how harmful police behaviors can impact health and public safety. I then explore ways public health leaders, providers, clinicians, advocates, community activists, and students can advance our understanding and commitment to addressing adverse police exposures as important threats to public health and safety.

Cure Violence Podcast: Police Violence Through a Public Health Lens

For more resources on the topics and data discussed in the podcast, see the frequently asked questions below.

Have professional medical associations addressed police violence in the past?

Yes. Here are the American Public Health Association’s 1998 Impact of Police Violence on Public Health policy statement, the National Association of City and County Health Officials’ 2015 policy statement on Public Health, Racism, and Police Violence, the American Academy of Family Practice’s 2015 resolution declaring Discriminatory Policing is a Public Health Concern, and the American Academy of Pediatrics’ 2016 Initiative to Confront Violence in Children’s Lives.

Was Stop-and-Frisk only employed in NYC?

No. While the phrase “stop-and-frisk” is derived from a tactic utilized by New York police departments (and was ruled unconstitutional in 2013) similar tactics have been and are being used in many other cities. For example, in 2015 and 2016, the Department of Justice released scathing reports detailing similar discriminatory tactics utilized by both the Ferguson and Baltimore Police Department. Notably, these tactics are also ineffective, as noted here,

What does “ban-the-box” mean?

This is a national campaign to provide a fair opportunity for employment to those who are formerly incarcerated. In 2015, President Obama took an important step to do this for federal workers.

What do pediatricians know about how stress affects health?

While some stress can be good, too much stress can be toxic, particularly to the developing brain and body. For babies and young children aged 0-5, exposure to toxic levels of stress can have longstanding impacts on adult health. Having an incarcerated parent or caregiver is considered an adverse childhood experience that can contribute to toxic stress.

What’s problematic about police in schools?

For some children, their police contact is structured by their school’s disciplinary policies. According to the Department of Education, across public schools nationally, students of color are more likely to encounter police in this way. Specifically, black male and female students are disproportionately more likely to be referred to law enforcement and have school-related arrests, than all other students. These early exposures criminalize children of color in places where they should be safe to explore, learn, and grow and can contribute to barriers to higher education, employment, and successful participation in community.

What can doctors and health departments do?

We can collect data that captures the magnitude of police violence by counting injuries, morbidities, and deaths related to police encounters. Here is one way to start, authored by Nancy Krieger, a public health champion for this work, and colleagues at Harvard’s School of Public Health.

We can support community organizations that are seeking to redefine what safety means to communities of color. Here, the Ella Baker Center for Human Rights’ Justice Teams stand out as incredible leaders for their work to deploy community-led crisis response networks in California. Here is a list of other organizations working at the intersections of police accountability and racial justice from Funders For Justice, the member organizations representing The Movement for Black Lives, and Blackout for Human Rights, a collective of filmmakers, artists, activists, musicians, lawyers, tastemakers, religious leaders, and concerned citizens lifting the voices of the movement through media engagement.

And we can mobilize communities to go to the polls this November and speak up for public safety and health. Confused on the issues? Check out Campaign Zero, which lists comprehensive federal, state, and local policy agendas and a side-by-side comparison of where each presidential candidate stands on these important issues.