James K. Hildreth’s Presidential Investiture Speech
April 16, 2016
I start my tenure as Meharry’s president at a time of unprecedented change. Meharry is both a health care organization and an institution of higher education and dramatic changes are occurring in both of these domains. Furthermore, the students that we are training now are very different than students coming to us just a few years ago. The chief economist for Google has written that the world has entered into a phase of “combinatorial innovation”. Because of technology, innovators from different disciplines are collaborating and the results are nothing short of astonishing. I agree with the writer Henry Gibson who states that “the future is already here, it’s just not evenly distributed”. Unprecedented changes are being driven by linear factors that can be measured and predicted such as demographics and economics. They are also being driven by non-linear factors that cause disruptive advances such as rapid prototyping cycles.
Organizations such AAMC, Institute for the Future, NIH, the Congressional Budget Office, and the US Census Bureau have produced reports that paint the picture of what to expect ten years from now in the year 2026. By 2026 20% of the US population will be 65 years old or older and 90% will have a chronic condition. By 2026 millennials will be the largest living generation and all will be “digital natives”. If steps are not taken to avoid it, in 2026 spending from federal trusts (Social Security Old Age and Survivors Trust Fund and Medicare’s Hospital Insurance Trust Fund) will far exceed income to these trusts. By 2026 data accumulation will far exceed human cognition as big data becomes mega-data. Machine learning systems and visualization technologies will be the order of the day. By 2026 mobile technologies containing sensors for environmental, fitness, biological factors and geographical tracking will be widespread and have profound implications for health and wellness. The explosion of mobile devices related to health and innovative care models will “flip the clinic” and allow access to health information in non-traditional settings. Activities now restricted to clinics will be distributed across new technologies and non-traditional locations.
These predictions seem highly credible in the context of 2016 and how different the world is now compared to just a few years ago. “We Are Social” is an organization that tracks all things digital around the world. Their data shows that in the last quarter of 2009 an average of about 100 petabytes of data were uploaded or downloaded every month globally. A petabyte is 1 million gigabytes – so 100 petabytes is a tremendous amount of information. Fast forward five years to the fourth quarter of 2014 and the average monthly data traffic had risen exponentially to 2,800 petabytes. This is an inconceivably large number (2.8 x 1018 ). There are 7.5 billion human beings on earth and nearly half of us are now on the internet. About 3.8 billion (half) of us now regularly use a mobile device and about 2.3 billion people are regular users of social media. The point is that in just a few short years, planet earth has become extremely small because most of the humans who occupy it are now interconnected.
When I did my medical training in the early eighties we learned to treat the average patient. We now fully appreciate that no two patients are the exactly the same and the course of the same disease can be very different in different patients. We have moved from symptom-based intuitive medicine to recognition of patterns and evidenced-based medicine. Scientific advances, including genomics, proteomics, powerful visualization technologies and others have brought medicine to the verge of something extraordinary: precision medicine. Extremely large databases encompassing genetics, epigenetics, lifestyle and environmental factors will be used to generate algorithms that identify highly specific and personalized treatments for individual patients. This is now a national priority as announced by President Obama in January of 2015. A cohort of 1 million Americans is being enrolled across races, ethnicities, gender and age to begin collecting the necessary data. Precision medicine has caught the attention of multibillion companies not known for their interest in health care. Intel, Google and Microsoft are all partnering with health care organizations. This is because data and data science are at the heart of precision medicine and these companies do data science exceptionally well. The size and resources of these companies will drive the precision medicine process forward rapidly. At present there are many disparate data types and data streams in health care including lab results, claims and transactions, genomics data and patient’s personal data. We are rapidly headed for a future in which everything will be centered on the patient and the integration of all data and information related to the patient and his or her health. The integration will encompass payers, providers, patients and life scientists in a system designed to facilitate accountability, control costs, achieve personalization of care and continuous improvement in outcomes.
Prior to 1910 patients in the United States going to see a physician were just a likely to be harmed by the encounter as to be helped or healed. In that year Abraham Flexner’s scathing report on the poor quality of medical education led to the closure of scores of medical schools. Notably, Meharry was not one of them and the Flexner report made special mention of Meharry as having desirable qualities. The Flexner report led to a remarkable transition in medical education with the establishment of a four-year medical curriculum consisting of two years of basic science and anatomy and two years of clinical apprenticeship. A century later it is clear that medicine is again undergoing a period of transition. In 2000 the Institute of Medicine published a report showing that almost 100,000 people died each year from errors in treatment during hospital stays. This report and in conjunction with the high portion of the US gross domestic product (17.5%) devoted to health care, have led to a new era of transformation in health care and the passage of the federal Patient Protection and Affordable Care Act. Policy makers, employers and provider organizations are all taking steps intended to reduce costs and improve the quality of health care and to increase access to care. The new model of health care, the patient centered medical home, first developed by pediatricians in the 1960s, has emerged as the model of care going forward. This model represents a major paradigm shift in medicine from the current model that is centered on the physician, care is reactive and fragmented and patients are responsible for coordinating their own care. In the new model, care is proactive, centered on the patient and all necessary care is coordinated within an integrated team.
One of the main goals of the patient centered medical home is to keep patients out of the emergency department and out of the hospital. This has profound implications for training physicians since traditionally a substantial portion of their training has occurred in the inpatient hospital setting. This change demands that medical schools begin to think about curriculum revisions that adequately prepare students interested in primary care for this new medical model. The patient centered medical home and the large increase in the number of people with health insurance will result in a substantial need for more primary care physicians. Medical schools are trying to respond to this need but there will have to be a substantial increase in the number of federally funded residency slots in order to further increase the number of medical students being trained.
There are changes and challenges occurring in the world of dentistry and oral medicine as well. The traditional private practice model is increasingly giving way to corporate dental organizations. These are often money mills focused on high volumes and not high quality continuous care. As in medicine, technological advances are reshaping dentistry such that it is now possible to produce crowns and dentures onsite in dental offices using digital devices and 3D printing. These developments represent potentially disruptive forces in the dentistry with profound implications for academic dentistry and training new generations of oral health providers.
In parallel to changes happening in dentistry and medicine, changes are also taking place in the domain of higher education. It has been pointed out that if you want to see what higher education was like 1000 years ago, walk into a lecture hall of almost any university and change the language to Greek. As astounding as it may seem, it is true that pedagogy in 2016 is really not that different than in 1016 A.D.. We now understand that the sage on a stage model of teaching, a professor lecturing to large numbers of students, might be a great way to teach but for many students it is a terrible way to learn. Education experts have demonstrated in study after study that there are several different learning styles and new approaches are needed to maximize results for each individual learner. Like health care, the cost of attending both undergraduate and professional schools has increased dramatically over the last decade. So like medicine, higher education is also undergoing a transformation and as in medicine, technology is a major factor driving the transformation. Technology is being used both to transform teaching and learning but also to bring down the cost of education.
Academic health centers have a long history of innovation and discovery and Meharry like all other academic health centers is feeling the effects of changes in the research domain. For many years the National Institutes of Health has been the major funder of research conducted at medical schools and to a large extent at dental schools as well. Graduate programs that train future scientists at medical schools have also been largely funded by NIH; usually through a combination of institutional training grants and major grants (R01 grants) to individual scientists. The economic downturn of a few years ago resulted in a near crisis when NIH funding for research at academic health centers fell sharply. This problem was amplified by the burgeoning number of newly minted PhD scientists being trained around the country. These factors and others increased the average age for a scientist to obtain their first R01 grant from 38 to 42. Furthermore, training programs are also under pressure since fewer funded investigators mean fewer funds available to support graduate students. Major academic health centers with large endowments and profitable clinical enterprises have been able to weather the research financial pressures much better than small private medical schools such as Meharry with limited endowments and no support from public funds. At a time when technological advances and opportunities for major breakthroughs cry out for more public support of research the trend for less public funding of research, especially basic science research, seems likely to continue in the near future. These factors are driving academic health centers to partner with each other and with private sector companies to sustain and grow research programs. As a result, highly collaborative, networked research programs are becoming more and more common. Another major factor impacting the research enterprise is the emergence of data science as a preeminent discipline cutting across virtually all medical disciplines. Extremely large datasets are the norm as individual scientists can now generate several terabytes of data in a single day. Whether scientists are sequencing genes, collecting images or working with medical records, all of these activities involve enormous amounts of data. The accumulation of data has accelerated so much so that some experts estimate that 90% of all data generated by human beings in our history were generated in the last two years. Clearly data science and bioinformatics are now essential to having a robust research enterprise in an academic health science center.
These extraordinary changes and challenges frame the context in which I assumed the role of President of Meharry Medical College. I noted earlier that the future is already here but not evenly distributed. So I have no notion of our institution trying to catch up but rather the plan is to position the college to adapt to change and take a proactive posture rather than being trapped in a reactive mode where creativity and innovation are stifled. Furthermore, the college has the advantage of being relatively small and therefore we can be nimble and more easily adapt to changes and challenges. But being small does not guarantee nimbleness—our processes must be efficient and take full advantage of technology—which has emerged as the great equalizer. Small groups of individuals and small organizations can now thrive by having novel ideas and putting the power of technology to work for them. I also fully realize that in the current context a short-term perspective will not serve the college well and therefore we are framing a 10-year vision that we call Meharry 2026. The aspiration is to make the next decade, the sesquicentennial decade leading up to our 150th birthday in 2026, a transformative decade for the college. It will be characterized by Evolution and Transformation.
We will evolve the Meharry culture. I use the term evolution to mean the process by which an organism changes and adapts to its environment usually to have a higher fitness to ensure its continued existence or to outcompete other organisms. Meharry must have a culture that is not intimidated by change, one in which silos are minimized and communication across units is efficient; where the best ideas are accepted no matter who espouses them; and where everyone on the campus is valued for their role in the enterprise. In our evolution our core values and the mission of the college, serving the underserved, training superb professionals and serving our community will be preserved. And as the Meharry family has heard me say many times, the one thing we need when everything around us is changing, when we are navigating choppy waters, is a fixed point of reference – and for Meharrians it is our mission summed up by the college motto, “Worship of God Through Service to Mankind”.
We will transform our programs and infrastructure. As I have noted above, we are now training students who are millenials, digital natives. They engage the world and each other in ways that are very different from previous generations of students. And they will leave Meharry and practice their craft in a world that’s very different from previous generations. Therefore we must transform our curricula to account for the new realities. Our pedagogy must be transformed to employ active and engaged learning strategies. We must embrace and use existing and emerging technologies to best effect such as social media, virtual reality and on-demand content and programs. The century-old Flexner model of two years of basic science and followed by two years of clinical apprenticeship may well have run its course. Clinical experiences should start much sooner in the process perhaps as soon as day one of year one. And to the greatest extent possible, integration of basic science and clinical science should run throughout the course of medical school. These same principles should apply to our dental students as well. Part of my vision for the college is to build a state of the art learning center that includes flexible teaching spaces, virtual reality programs, simulation centers and innovation suites.
There are more than 900,000 licensed physicians in the U.S. and less than 6% of them are African American. All minority groups (Black, Hispanic, Native American) combined account for only about 12% of physicians. There is wide acceptance that diversity in physician ranks is highly desirable, especially given the demographic models showing that by 2050, current minority groups in aggregate will constitute the majority of people in the U.S. Furthermore, according national organizations, there will be shortage of 90,000 physicians or more by 2025 if steps are not taken to prevent it. I believe that if such a large number of new physicians are to be trained, a disproportionate number of the new physicians should be minorities as a way to address the lack of diversity in medicine. Among the population groups in the U.S., African Americans are the only group for which females outnumber males among physicians. Furthermore the number African American men enrolled in medical school has been in decline for the last several years. This is a pipeline issue as reflected by the declining number of black men who apply to medical school. It is important to point out that this is also an issue for dental schools as well as only 4% of applicants to dental schools are African American. Meharry is well-positioned to play a role in addressing this issue. We are particularly excited about the opportunity to partner with our sister medical schools, Morehouse, Drew and Howard and the AAMC to develop a coordinated national strategy. Our approach will lean heavily on our strong belief that role models for children are critical for developing a more robust pipeline. To that end we have begun working with principals of local middle schools on developing partnerships to engage children and foster interest in science and medicine. In addition to working on the pipeline issue, we would like to grow enrollments in our MD and DDS programs over the next ten years as resources grow. We will focus on recruitment of outstanding black males in expanding our programs but will continue to admit outstanding students of all races, genders and backgrounds as we have always done. One of our greatest enrollment challenges currently and going forward will be the cost of attending medical school and dental school and the high debt burden students have when they graduate. We take great pride in the fact that most of our graduates, both dental and medical, practice in underserved areas as primary care practitioners. The high debt burden, sometimes more than $300,000, can have a profound impact on the choice of specialty for medical students since primary care physicians are not nearly as well compensated as physicians in subspecialty fields. This same problem exists in dentistry as well as more and more graduates, because of higher salaries, are choosing to work for corporate dentistry companies focused on the bottom line. For these reasons raising scholarship funds to lower the debt burden for our students is one of my top priorities. Indeed proceeds from all of the ticketed activities that occurred during inauguration week at Meharry will be devoted to student scholarships. And to all of you who participated in these activities and who bought tickets to the gala tonight, thank you on behalf of our students. I am happy to report that the inauguration activities have generated close to $500,000 for scholarships and since I arrived last July we have raised more than $1.5 million for scholarships. Before my arrival the Board of Trustees authorized a $75 million scholarship fundraising campaign. To date about $9.5 million have been committed to this initiative. I would like to acknowledge two donors in particular who have committed $1 million each, Board Chair Dr. Frank Royal Sr. and Dr. Henry Moses, Executive Director of Meharry Alumni Association. Other major commitments will be acknowledged tonight at the scholarship gala.
I have noted earlier the paradigm shift happening in how medical care is delivered and paid for. Meharry as a health care provider must adapt to these changes in order to continue to provide the best care to patients and to have a sustainable clinical enterprise. In many ways the paradigm shift to a patient-centered clinical model focused on primary care works in Meharry’s favor since primary care has long been one of our strengths. We have already begun the process of establishing the patient-centered medical home model in our existing clinics. And although we will continue to serve as a safety net for uninsured patients as part of our core mission, we will establish outpatient clinics providing attractive services to insured and self-pay patients. This change in payer mix is an important element of establishing robust, sustainable clinical programs. I am very pleased to be executing this plan in partnership with Dr. Joe Webb, CEO of Nashville General Hospital, Meharry’s index teaching hospital. Dr. Webb and I are also exploring ways to work with primary care doctors in the community who could benefit from the structure and support that Nashville General and Meharry can provide as they transform their practices to conform to the medical home model. These are only two of a number of projects Meharry and Nashville General are working on together to provide a great work environment for providers and a great patient experience. Meharry will also explore other partnerships both local and outside of Nashville to provide clinical training opportunities for our students and residents. As of today Meharry has established 18 clinical affiliations locally and out of state that provide training sites for our students. Over the next decade, Meharry will also pursue global partnerships as well in places such as Africa, Brazil, Jamaica and Haiti. These global partnerships, that will build on existing and new collaborations, will provide exciting opportunities for our students and faculty and allow Meharry to assist populations who are dealing with some of the same major challenges that we deal with here at home such as HIV/AIDS.
We will also take steps to adapt the research enterprise at Meharry to the changes and challenges discussed previously. Meharry will establish a strong data science and bioinformatics team to enable scholarship utilizing large datasets generated by faculty but also to participate in research utilizing large public databases as well. Data science will be an important aspect of providing quality care to our patients under the new health care model. Data science will also enable us to better evaluate the effectiveness of our student programs and to make evidence-based decisions related to enhancing business processes. A key aspect of our strategy for research is to identify a few key areas on which to focus related to health disparities and to develop excellence in those areas. We will emphasize collaboration across departments and maintain strong technical cores that support the work of multiple investigators at lower costs. Novel infrastructure programs such as staff scientists who provide technical support to multiple principal investigators will be explored. Our clinical research program will be strengthened to enable our faculty to conduct translational research related to their clinical interests. Collaborative partnerships with biotech and pharmaceutical companies will be pursued aggressively to expand our research capacity and provide avenues for exploring the potential clinical utility of discoveries made by Meharry investigators. Incentive programs will be established that encourage innovation and entrepreneurial endeavors by our faculty. We will continue to build on the existing strong research ties between Meharry and Vanderbilt, such as the Tennessee Center for AIDS Research and the Meharry-Vanderbilt Alliance. Existing research ties with other institutions such as Johns Hopkins and University of California will be strengthened as well.
In support of all of these initiatives, we will strategically grow the Meharry faculty in order to fulfill our commitment to our students and patients and to sustain a stimulating and supportive environment for scholarship and service. We will work to ensure that administrative support is adequate in all programs and that it makes use of enabling technologies. Our business processes will be revamped and we will put the best tools and practices in the hands of our staff so that they can do their work efficiently. We will be very intentional about recognizing and rewarding excellence and as noted earlier, we will work to make sure that each and every member of the Meharry faculty and staff feel valued for their contributions.
Meharry’s connection to the community is long-standing and a very important part of its legacy. We will redouble our efforts to be connected to the community in ways that improve the health and wellness not just of the people of North Nashville but of Tennessee and beyond. We will work hard to listen and to provide the expertise and assistance needed to positively impact the lives of community members. Meharry will strive to show what my friend Reverend Sanders calls “cultural humility” and recognize that the community has as much to teach Meharry as we have to teach the community.
In closing, my Meharry family has come to know how much I love stories and so as not to disappoint them I will close with my version of a story well known to many of you. In the spring of 1826 a white teenager named Samuel Meharry was driving a salt wagon through the back woods of Kentucky trying to get to the Ohio River and a ferry that would take him home. It was raining, the road was a muddy mess and his wagon slipped off of the road and became stuck in the mud. It was late in the day and darkness was approaching. Despite his and his two horses best efforts, the wagon would not budge and he needed help. He set out to find help and his search led him to a simple cabin that was the home of an African American family. He stepped up to the door and knocked. I imagine that a black person free or not in 1826 in the south might have been very reluctant to engage this young white man. But at the risk of their freedom, they took young Samuel Meharry into their home, fed him and allowed him to spend the night with them. The next day they fed him breakfast and the man of the house and his young son went out and helped young Mr. Meharry free his wagon and get on his way. He told them that he was not able to repay them at the time but promised to do something to help the black race if he ever had the means to do so. Fifty years later in 1876 his promise was fulfilled when a medical department was established at Central Tennessee College with a gift of cash and property of about $20,000 from Samuel Meharry and his four brothers. This medical department was established specifically to serve the needs of African Americans or any persons of limited means. The founder, Dr. George Hubbard taught the first Meharry students in the basement of Clark Church. This is a wonderful story of grace and kindness that has defined the core mission of Meharry from its inception. When young Mr. Meharry saw the flickering light of the oil lamp in that cabin, he saw a beacon of hope. Some of our students saw the beacon; some for whom many other schools said no but Meharry said yes. Some of the same schools that said no, take the rejected students as medical residents. Thousands of patients have seen the beacon; when other hospitals turned them away, Meharry took them in and gave them excellent care. Excellent scientists and clinicians have seen the beacon. Drawn by the power of our mission and of having a profound impact on health, they came to Meharry instead of other better known institutions. I saw the beacon in 2005 and made my way to Meharry. The beacon has been shining now for 140 years. Over the next decade that beacon will shine brighter and brighter continuing to attract amazing students of all races and gender, grateful patients and outstanding, highly committed faculty and staff. I am proud to stand with all of the members of Meharry family as we hold up the beacon. To be sure, there are challenges ahead but the path forward even in the darkest hours will be well lit. Lit by the beacon.
Thank you all and God bless Meharry Medical College.