EP. 111: LEADING THE LEADERS OF MEDICAL EDUCATION

WITH DAVID SKORTON

May 7

WITH DAVID SKORTON, MD

The President of the Association of American Medical Colleges (AAMC) discusses how he went from struggling during his own medical school application process to now leading the organization that represents all medical schools and teaching hospitals in the United States.

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Episode Summary

The Association of American Medical Colleges (AAMC) plays a crucial role in health care. As the organization that oversees medical education and thus the pipeline of future medical professionals in the United States, its critical duties include administering the Medical College Admission Test (MCAT), managing the residency application service, drafting guidelines for faculty members and departments at medical schools and academic hospitals, disseminating data on medical education and workforce trends that shape policymaking at medical schools and government bodies, and promoting diversity in health care.

Leading this organization is David Skorton, MD, a cardiologist and pioneer of cardiac imaging and computer processing techniques, who also previously served as the 13th Secretary of the Smithsonian Institution and as President of Cornell University and of the University of Iowa. In this episode, Dr. Skorton shares with us how his family's immigrant past has shaped him, how he went from struggling during his own medical school application process more than 50 years ago to now leading an organization that represents all medical schools and teaching hospitals, why the arts and humanities matter to him, how he thinks about medical education given the emergence of generative artificial intelligence, what great mentors look like, how effective leadership often means learning from everyone around you, and more.

David J. Skorton, MD, is President and CEO of the Association of American Medical Colleges (AAMC), which represents the nation’s medical schools, teaching hospitals and health systems, and academic societies.
Dr. Skorton began his leadership of the AAMC in July 2019 after a distinguished career in government, higher education, and medicine. In his first year at the AAMC, he addressed social issues that affect health, guided the AAMC through a pandemic, and built a multiyear strategic plan to tackle the nation’s most intractable challenges in health and health care, working to make academic medicine more diverse, equitable, and inclusive.
Previously, Dr. Skorton served as the 13th secretary of the Smithsonian Institution, where he oversaw 19 museums, 21 libraries, the National Zoo, numerous research centers, and education programs. Before that, he served as president of two universities: Cornell University (2006 to 2015) and the University of Iowa (2003 to 2006), where he also served on the faculty for 26 years and specialized in the treatment of adolescents and adults with congenital heart disease. A pioneer of cardiac imaging and computer processing techniques, he also was co- director and co-founder of the University of Iowa Adolescent and Adult Congenital Heart Disease Clinic.
Throughout his career, Dr. Skorton has focused on issues of diversity and inclusion. A nationally recognized supporter of the arts and humanities, as well as an accomplished jazz musician and composer, Dr. Skorton believes that many of society’s thorniest problems can only be solved by combining the sciences, social sciences, and the arts and humanities. Dr. Skorton earned his BA and MD degrees from Northwestern University. He completed his medical residency and fellowship in cardiology and was chief medical resident at the University of California, Los Angeles.
In this episode, you will hear about:
• 2:42 - Dr. Skorton’s unexpected path from jazz musician to President of the AAMC
• 7:42 - Why current medical admissions aim to be “holistic”
• 12:09 - The lessons Dr. Skorton learned through mentorship and why the arts and humanities can create better doctors
• 17:32 - How Dr. Skorton has been able to “see past himself” enough to receive challenging criticism from mentors
• 28:01 - The core tenets of Dr. Skorton’s leadership philosophy
• 31:35 - How the AAMC views the future of medical education especially in light of advances in artificial intelligence
• 38:47 - The importance of diverse healthcare teams
• 46:32 - Issues that Dr. Skorton addresses through his role at the AAMC
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] The Association of American Medical Colleges, or AAMC, plays a greater role in health care than most people realize as the organization that oversees medical education, and thus the pipeline of future medical professionals in the United States. Its critical duties include administrating the Medical College Admission Test or MCAT, managing the residency application service, drafting guidelines for faculty members and departments at medical schools and academic hospitals, disseminating data on medical education and workforce trends that shape policy making at medical schools and government bodies. Promoting diversity in health care and more. Leading this organization is Dr. David Skorton, a cardiologist and pioneer of cardiac imaging and computer processing techniques, who has previously served as the 13th Secretary of the Smithsonian Institution and as president of Cornell University and of the University of Iowa. In this episode, Doctor Skorton shares with us how his family's immigrant past have shaped him, how he went from struggling during his own medical school application process more than 50 years ago, to now leading an organization that represents all medical schools and teaching hospitals. Why the arts and humanities matter to him, how he thinks about medical education. Given the emergence of generative artificial intelligence, what great mentors look like, how effective leadership often means learning from everyone around you, and more.
Henry Bair: [00:02:29] David, thank you for taking the time to join us and welcome to the show.
Dr. David Skorton: [00:02:33] Thank you, Henry and Tyler, it's great to be here. Congratulations on your show. As a fellow podcaster, I'm in awe of what you all are doing.
Henry Bair: [00:02:42] That means a lot to us. Well, as our introduction reveals, given how much you've done, there's so much we can discuss. But let's start as we normally do at the beginning. Can you tell us what brought you to medicine in the first place?
Dr. David Skorton: [00:02:57] So I did not start off with ambitions to go to college, let alone med school. My dad came over from Eastern Europe actually, during the influenza pandemic 100 years ago, left Eastern Europe during a pogroms in the in the Jewish Pale of Settlement. His ship ended up being diverted to Cuba, lived in Cuba for some years, and then entered the US through Key West. From Havana went to Milwaukee and we had some financial reverses as soon as we got going and we moved to Los Angeles, which we viewed as the promised land in those days. And I fell in love with the music scene. I was an aspiring saxophone player, and I was just positive that I could make it as a studio musician. I'm not sure why you're laughing, Henry, but anyway...
Henry Bair: [00:03:50] I'm laughing because I love this story so much. I started college as a musician, so I'm feeling a lot of resonance with what you're saying.
Dr. David Skorton: [00:03:57] Oh, amazing. What was your instrument?
Henry Bair: [00:03:59] I was a cellist.
Dr. David Skorton: [00:04:00] Oh, well, that's a whole different deal. That's much harder instrument. Anything that doesn't have frets or keys is much harder to play. And so the only thing that stopped me from a fabulously successful career in Los Angeles was that most of the people in the city were better musicians than I was. I just couldn't make it. And my dad, who just got to his last year of high school and finished, he convinced me that it would be a better bet, given my my skills to go to college. And so if it wasn't for my dad, rest in peace, I, I would still be playing in bars till they turn the chairs upside down. I did that all through college in Chicago, but it's a long winded way of saying that when I was in college, I was an undecided major for a couple of years, then a psych major, and then thought about medicine because I was always interested in the arts and also in social sciences, and I thought that psych was a sort of a major. Psychology was sort of a major where you, you know, you touch those different things. It was science, yes, but it was also humanities and social sciences. And I found it very, very interesting and took pre-med courses and applied to med school. And I had a background that was, um, not real impressive because I really was putting a lot of my effort into the music scene. But one of the schools put me on the waiting list. And for any aspirants out there thinking about med school, everybody turned me down except one northwestern, which was my alma mater. They put me on a waiting list and I was interviewed, and I got accepted at the very last moment. And so my message is believe that things can happen for you. I got into med school, you can get into med school as well. And so that was how it actually happened.
Henry Bair: [00:05:54] And now you lead the Association of American Medical Colleges. What a story.
Dr. David Skorton: [00:05:59] Yeah, very ironic, very ironic. And once I get into med school, I was not one of those people who scored super high on the medical college admission test. But one of the benefits of having that score was that my alma mater realized that they might have to keep an eye on me for support. I failed a test very early in my first year in a histology course, and the professor took me under his wing and he said, I know you can do this, and tutored me with his own slides, microscope slides, and helped me to retake that test and get through. And so I left that experience. And then the farther I got into med school, the more comfortable I was when I got into clinical rotations, I sort of came into my own. But I learned a couple of things. Lessons that I take to this day to the double AMC, one that the Medical College Admission test has things that can help people. Who are not at the very top of the pyramid in terms of application credentials. Secondly, that it's important to be patient with yourself. And thirdly, that a good teacher. And don't we all strive to be good teachers? Maybe one of the best attributes of teachers is to understand that there may be times where the teacher will need to go the extra mile with someone. And those experiences not only will help. The person you know. Get over an obstacle. But really, if that person turns into a teacher, I always remembered what it was like to get that extra help.
Tyler Johnson: [00:07:42] I want to come back. I actually am really interested to talk to you about some of the medical school admissions process, and some of your thoughts as a leader in that area. But before we get to that, I want to talk a little bit more about your journey. One thing that I just I noticed that you said very, very briefly, but it still really caught my attention. And I'm interested to hear you talk a little bit more about it, is that you said almost in passing, as if of course, everybody would understand this. You said when Henry asked you why you wanted to go into medicine, you said, well, I when I was in college, I had these disparate interests. I was interested in the arts and in the humanities and in science and. Et cetera, et cetera. And all of that was part of what led me into medicine. But, you know, although Henry and I, by intention or not, have ended up selecting a lot of people to come on to the show who became doctors and also have an interest in humanities and the arts and whatever. That's maybe not the stereotype, right? The stereotype is the person who majors in chemistry or biology or whatever, and does a lot of so-called hard science research in college and whatever. Can you talk us a little bit more through why to you, it seemed and seems intuitive that someone with an interest in the arts, in the humanities, that that that would be a because of and not an in spite of in terms of your desire to go into medicine.
Dr. David Skorton: [00:09:02] Yeah. And I want to I want to tell you that I've learned even though I was a medical educator and still am, but a medical educator for decades. In fact, in a couple of months, I'm going to my if you can imagine this, my 50th med school reunion. I have not been to any reunions in med school so far, but the 50th. I'm now a proud member of the so-called Half Century Club. So I've had a lot of experience teaching and I never forgot that experience I had. And two aspects of my experience one, I've shared with you the willingness to go the extra mile and realize that that extra effort on the part of an educator can make all the difference to a learner. But the second is that as I've come to the AAMC and learned a lot about the world of medical education. I want to make a shameless plug for one of my colleagues, Doctor Allison Whalen, who's our chief academic officer and has been my constant tutor and mentor in more up to date medical education issues. And also those who work in our services cluster. Gabrielle Campbell and Jivaro Russell have made me understand that up to date medical admissions processes aim to be holistic. And if we believe in that word. Then we're going to imagine that holistic means not just biological sciences. But a broad, broad view of knowledge and a broad, broad view of what it means to care and to care for.
Dr. David Skorton: [00:10:43] And so it may be. I wouldn't say in spite of Tyler, but I would say that as time has gone on the double, AMC and medical schools have developed a broader and broader idea of the many, many attributes that can make a really fine physician. And I can't let this part of the conversation go without saying that even though I struggled and we had financial challenges, my lived experience was nothing like many of the lived experiences of folks who are currently underrepresented in medicine and have been underrepresented for many decades. And so I want to say that for two reasons. One, I don't compare myself to those lived experiences, but also our holistic thinking has to include advantages and disadvantages that people have before they come to that preparatory point and before they come to that point of taking a test, making a decision, deciding where to apply. And one of the things that I've learned from Doctor Whalen and from others and from those who are leading those accredited MD granting medical schools, 158 of them, is that the more we think about the broad, broad talents and the broad, broad attributes of a successful physician, the more we're going to think broadly and holistically about those aspiring to that career.
Henry Bair: [00:12:09] So I'm curious to dig more into your own personal experiences, right? You mentioned how in college you weren't at first quite sure if medicine was right for you, or perhaps medicine as a career path wasn't even on the radar until you realized that this was actually an appropriate calling, given your diverse interests in the social sciences and the arts and the humanities, and that this was a way for you to channel those interests into developing a practical skill set that you could use to actually help people. Right. But this wasn't all in college. This was before medical school came along. And so I'm wondering, as you made your way through medical training, through medical school and residency and beyond, in what concrete ways have your own interests and explorations in the arts and humanities shaped the way that you approach patient care?
Dr. David Skorton: [00:12:53] It's a great, great question I give, and this is no false modesty. This is right from the heart. I give credit to a series of mentors who I was very fortunate to have. My dad was the first one. Well, actually the first one was an actual studio musician saxophonist in LA whom my folks scraped some money together and got to give me a couple of lessons. At the end of the second lesson, he said in the nicest possible way, better listen to your dad and do something else. Um. Which is okay. It's hard to hear at the time, but in retrospect, I thank that person for being honest. And so I had a series of mentors beginning with him and my dad. People in college, not just faculty, but other students and then, of course, in medical school. And so I somehow had the openness to see mentors in many places and to be willing to, relatively speaking, turn down my ego enough to take advice from people who walked a path before me, even if it's not the same path that I walked. And that had a big impact on me when I was in medical school. The histology professor was a very, very important mentor, but also a role model for me to this day. I think about that.
Dr. David Skorton: [00:14:18] Northwestern University had in those days, many physicians in private practice who also did clinical teaching, and the physician who taught me bedside physical examination was one of those physicians in private practice who had a clinical appointment at Northwestern and helped me to understand a little different take on the patient encounter. And he said to me, I don't remember the exact words after all these years, but the sense of it was that your patient is not just a collection of biological processes. Your patient is a human being who has had experiences, who is probably scared at the time they're coming to you, who's uncertain about the path forward, and any skills that you can bring to that encounter that have you seeing that individual as a fellow human being, a fellow person on this planet seeking answers, seeking meaning, and someone who is looking for more than a scientific assessment? The better physician you will be.
Dr. David Skorton: [00:15:33] And I didn't get that at first at all. Because I was thinking as a college student, how am I going to get through this organic chemistry test? I mean, that was a challenging course for me. And now someone was telling me, you know, you got through that course. You're in medical school now. Now you got to think about the overall encounter as being something different. You have to understand chemistry and physiology and biology and anatomy and many other sciences. But you have to understand that that encounter has an enormous impact. And when I had finished my residency later at UCLA and started my fellowship today, I started my fellowship, was the day that another very important mentor started his professorship at UCLA the very same day. His name was Joseph Perloff. You may not have heard of him. He was a cardiologist who was one of the people who developed the field of caring for congenital heart disease patients as they transitioned into adolescence and adulthood. And he had been an English major and was an incredibly erudite person. His wife was a famous, is a famous humanities professor, and he gave me the honor of having me review a chapter in one of the editions of his book, and I found some word that I thought I had to look up in a dictionary. And I went to him and I said, Doctor Perloff, this is so great that your wife taught you that word. It says a lot about your marriage. And that was like the wrong thing to say. And he said, I will let you know that I was an English major and I taught my wife that word. Now I don't have any idea which way it went. It was none of my business to bring it up. But he was proud of the fact that he came from a background in the humanities. And so I had a series of these mentors who had a view of medicine that included the sciences, make no mistake about it, but it went beyond them.
Tyler Johnson: [00:17:32] You know, I'm listening to you. I'm brought to one observation and one question. The observation that I think is really important for medical trainees is the fact that. So I, I do a lot of actual educating. That's a lot of my job. So I work a lot with the medical students, some with the residents and a lot with our oncology fellows, and especially for residents to some degree with older medical students, but especially with residents. I find that what I'm asking them to do is to, in effect, unlearn the reflexes that I spent the first two years of medical school teaching them, right? So I teach them to break a patient down into constituent organ systems, and then to think about each of the organ systems rigorously, and then to treat it like a logic problem, where you add up all the different pieces of information and come to a conclusion about what's going wrong and what to do about it, which, as you say, to be clear, is absolutely fundamental to being at least an internist. You have to do that, right you. But then at the same time, now when they get to be residents, I spend a whole bunch of time saying, now, you can't just think of this person as a constitution of multiple different organ systems and a logic problem, even though I just taught you or your colleagues to do that two years ago now, I need you to unlearn all of those things. Right?
Tyler Johnson: [00:18:51] But that also brings me to the question, which might sound like a funny one, but I actually think it's really important. Let me just tell a super brief story. I mentored a guy one time I was attending on the internal medicine wards, and he was this supervising resident on the team that I was overseeing, and he is maybe the smartest trainee I have ever trained in any setting. He was putting patients. He was in the first months of his second year, so just barely done with internship, and yet was putting together patients and coming up with super nuanced, complexly reasoned plans. Better than a lot of attendings that I knew just a few months out of internship. And I remember sitting down with him when we finished our month together and saying, look, in terms of your clinical reasoning and your, you know, acumen and your logic and all the rest of it, I have no feedback because it's probably better than mine is. The only piece of feedback that I can give you is just make sure that your life, your professional life, your life as a doctor doesn't amount only to you being the smartest person in the room. Make sure that there is more to it than that. And I have loosely kept track of him, but haven't really seen him in practice. That was many years ago.
Tyler Johnson: [00:20:13] I've always wondered, though, you know, that's a little bit of a could be a little bit of a hard piece of feedback to get in a sense, because there's sort of a suggestion that, you know, maybe you could be a jerk if you're not careful. I've never really known in the long run how he responded to that. But what I'm so struck by is that when you tell your story, not only do you tell about these various mentors you had, but you specifically identify the fact that you were able to see past yourself enough to take their feedback, even when the feedback was potentially challenging, or was the kind of feedback that might make some people bristle, or that might might make some people pull away from it rather than leaning into it? And I'm curious, since I think almost all of us are going to receive that kind of feedback, which can be the richest feedback at some point in our professional or, if we're really lucky, maybe professional careers or if we're really lucky, maybe even our lives. How have you cultivated a sense of selflessness or humility or whatever you want to call it, that allows you to respond positively to that kind of feedback, rather than bristling at it and turning away?
Dr. David Skorton: [00:21:28] Oh, you're giving me too much credit. I always thought that I had a lot to be humble about. I mean, I came into med school, you know, didn't get in any other school that I applied to. I did get into one which which is wonderful. It's all you need. But I did not go in with a big ego about that. I had an ego about other things, no matter what that saxophone session musician told me. I was positive that with a little more effort, I could have blown him away. But you know, whatever, here I am, and the fact that you're doing a podcast with me, as opposed to, I don't know, buying an album or seeing me in a stadium probably proves that he was right. But I really did not have the biggest opinion of myself. I had, you know, enough courage to apply and to try, but I, um, I've had other experiences in my life that have reinforced that, and I want to tell you about them, because people look at my resume and either they say, here's a guy who couldn't keep a job, couldn't hold on to a job, or they say, you know, how have you had these, you know, these big time leadership opportunities. You probably have realized this already, that the higher you get in some hierarchy, whatever the hierarchy is, the more it's important to understand that you are not going to understand everything going on within that hierarchy that you're supervising.
Dr. David Skorton: [00:22:54] So the biggest experience for me was when I first became a university president at the University of Iowa. You know, for a few days I thought, this is it. You know, I'm the man. I'm the man. Then I realized that this was a school, big public research university that was doing everything from the original writers workshop where the MFA degree was actually invented, all the way to, uh, award winning biomedical research, all under the same, you know, roof, if you will. And there is no chance whatsoever that I was going to be able to grasp all that. Then I was at Cornell University and it was the same deal. First, uh, and finest, a college of veterinary medicine. Amazing. Uh, agriculture school. Fabulous. Arts and sciences. No way. And then I got really humbled by being secretary of the Smithsonian. Where I walked in, and they were doing everything from the largest astrophysics group in the country is affiliated with the Smithsonian. It's at Harvard. They have on their campus an astrophysics group. A few years ago, if you recall, there was the first picture of a black hole that was developed from observations made from around the globe. The Smithsonian organized that whole effort, and also all the history and all the culture and so on.
Dr. David Skorton: [00:24:27] And so I felt unbelievably humbled to be leader of that, not just that it was an honor to do it, which was true, but that the best thing I could do would be to listen to the people working there who were experts in these various areas. And every encounter I had was a learning encounter for me. And that's that's not just a throwaway line. Every encounter with a curator or a historian was a learning experience for me. So I don't know exactly how it happened, but that hasn't been a big issue for me. And right now at the WAMC, I have no fantasy that I understand all the different things that all of our med schools and teaching hospitals are doing. No way. So I think that in an ironic way, the higher opportunities you have for leadership, if you really spend some time looking in the mirror, you will realize that you're depending more on mentors who theoretically work for you. Or are these horrible words like subordinate to you? But in fact are the experts in their areas?
Henry Bair: [00:25:31] Yeah, one of the best pieces of advice I received in, um, medical school, actually, was that, um, you know, with all your interactions in the hospital, this was in the setting of working in the hospital. It's like, it doesn't matter if you're talking to the the pharmacist, the technician, the resident, whoever doesn't matter, always assume that the other person knows something that you don't, and you can learn from them.
Dr. David Skorton: [00:25:53] Can I give you a great example? A vignette?
Henry Bair: [00:25:56] Please. Please do.
Dr. David Skorton: [00:25:57] So on my first day as an intern, they called them interns then at UCLA, we were on as a team and we went for orientation and they gave us a list and they said, if there's some symbol, an asterisk or something next to your name, you're on call. So, you know, go under patients probably waiting for you. And so I went upstairs and there were two patients for me to admit. One was someone having a gastrointestinal bleed. And this was before the days of Intensivists. And we were taking care of that patient in the ICU. And the other one was someone with a hyperosmolar nonketotic coma, as we refer to it in those days. And the GI bleed I had my head on right? I knew the different things that had to be done. I heard this other phrase and I, I clutched. And I said to the charge nurse on the floor who I just met. I said, do you have an internal medicine text? And she said, yeah, we do. But in the meantime, let me make a suggestion. And she handed me an order sheet. This is something you write on with a pen. And she said, here's some things you might want to think about doing for this patient. And she dictated the admitting orders, how much insulin, how much fluid and so on. And she said, put the date, put the time. Here's where you sign. She saved that person's life. And at the end of the year, I was declared a co intern of the year. And I thought that if it wasn't for the people I learned from starting with that charge nurse on the very first hours of my internship, I wouldn't have gotten through the year, let alone had some recognition. So it's possible to learn from almost everybody you meet. I'm learning from you all. I learned from you already, Tyler, this business about teaching him the different disciplines and then going back and sort of reversing the course. What a fascinating, you know, pedagogical device. It's cool.
Tyler Johnson: [00:27:59] Thank you.
Henry Bair: [00:28:01] Yeah. One thing I wanted to ask next was this question kind of follows from what you've just the path you've outlined for us through all of your leadership experiences in very diverse capacities and very diverse areas of it's not really not just academia, but, you know, I mean, the Smithsonian, it's hard to really describe what that network of museums does. Public education, civic education, all of it. You know, I'm wondering, as you go from position to position, leading all these institutions, is there an underlying thread? Is there a philosophy or an approach to leadership that you carry with you, regardless of which position you're in?
Dr. David Skorton: [00:28:43] Well, there's one I've tried to do. You'd have to ask somebody else whether it was successful. I don't think you can judge that on your own. But one is I, I believe in sort of flat or flat ish organizational structures because I think hierarchies are are hard on people. Sometimes you need them just to get by a chain of command or whatever you want to call it. But I think given my very strong belief, I think it is a belief actually, that you just can't understand all these things that are happening. You need a lot of input, including people saying, maybe you ought to reconsider that. Which is a nice way of saying no, I don't think that's the smartest thing to do. Maybe in different language, in their own heads. I think it's important to, for example, at the at the AMC, we have 15 divisions. We call them clusters. And each of the people who run those clusters have the title chief, you know, chief learning officer or chief academic officer and so on. And it's a flat organization. They all report to me and we meet twice a week, all of us together and argue through things. And so that's that's one I'm not sure if it's a philosophy, Henry, but it's one sort of approach that I've learned by understanding that I might as well have those folks close to me, because I need to learn from them if possible. It's got its disadvantages having a lot of people reporting to you. But but that's one.
Dr. David Skorton: [00:30:09] Another one I've already mentioned, and that is realizing the wisdom that people carry, whatever their title is or isn't, give you a great example of that. Smithsonian has a fabulous group of security officers. Who watch these treasures and guard these treasures every day. And that place is open every day. This museums are open every day except Christmas. And, um, when I was walking around, sometimes I would just talk with one of the security professionals and ask, you know, him or her what? You know what? What's your favorite piece in this particular gallery or whatever it is? Or what have you noticed about the public as they walk through here? And I, I learned stuff from listening to them because they were there all the time. You know, I was in some office in the so-called castle or, uh, you know, doing something else. But they were there all shift long watching the public interact with those treasures. And so, of course, they're going to know more about those transactions than I'm ever going to know. Right? And so, um, those are just some examples of, I don't know if they qualify as philosophies, Henry, but just things, ways of doing that I developed just by making mistakes and realizing maybe I would have made fewer mistakes if I would have, you know, listened more to people who are actually on the front line.
Tyler Johnson: [00:31:35] So there is one aspect of what you do now that we haven't really talked about yet, that I would just feel remiss if we had you on the show and didn't get to it. And there are at least two really sort of big picture philosophical questions that I'd like to ask at least two with regards to medical school admissions and how we think about who gets to train to be a doctor. So the first one is that I think the argument is pretty convincing, that if you draw a line arbitrarily and let's say the year. I don't know, 2000, and then you draw another line in the year 2030 or 2035. So when the people who are just applying to medical school right now will be getting ready to go out into fully independent practice after having finished residency and fellowship and whatever they're going to do for their training. I think you can make an argument that in that 30 or 40 year period, the very definition of at least what a doctor does and maybe even what a doctor is, will have almost wholly changed, right? You bet.
Tyler Johnson: [00:32:41] There was a sort of a famous scene. The movie is questionable in some ways, but there's a there was a movie at Robin Williams was in called Patch Adams about that was interesting because it was about training to be a doctor. And there's a scene in that. Robin Williams is this kind of gadfly iconoclast, and he has a roommate who's this very sort of by the book, you know, super studious. What we would have at my med school called a gunner medical student. And there's this scene where the gunner medical student is saying to Robin Williams, who never seems to study very much, while the gunner is always buried in some huge medical tome. He says, what you don't understand is that I might have a patient who presents in extremis ten years from now, and me, knowing the last fact that I studied from this textbook could be the difference between that patient living or dying. And if the fact is not in my brain, it will be my fault if the patient dies. Something to that. You know, that's sort of the the thrust of it that almost makes no sense anymore. You bet. And it will make even less sense once generative AI and neural maps and the whole nine yards are fully integrated into medicine. And so all of that is to say that if we're in the middle of this absolute sea change where having facts residing in your physiologic neurons, it's not quite superfluous, but it's much less central to being a doctor than what it used to be when that was much of what it was.
Tyler Johnson: [00:34:14] How does the AAMC even think about what they're supposed to be fostering in medical schools, in terms of how medical schools prepare doctors to be doctors? If I'm not even sure we exactly know what a doctor is or does now compared to 20 years ago, let alone what they're going to be doing or being 20 years from now, when the people who are just getting ready to start their training are going to be in practice. How do you think about that?
Dr. David Skorton: [00:34:42] Well, I'm a huge believer that local faculty in every institution and local learners in every institution. That interaction between those groups and among those people is the factor that has to be taken into account. I'm not trying to dodge the question, but I don't think coming from on high at the AMC and saying, here is how you should teach people to be a physician, and you have to do it exactly this way. I don't think that makes sense. And people who came long before me to the AMC and people I highly respect, like Doctor Whalen, they are sparing in publishing, for example, competencies. They do publish competencies, but you don't see them coming out every three weeks. They take a long time. They listen to a lot of faculty opinions, a lot of expert opinions and come out with them when it makes sense. And that whole orientation increasing orientation toward competency based education. If you look at the competencies, they're not just a list of you have to understand all aspects of the Krebs cycle and the details of the muscles and the feet and so on. There are those kinds of competencies in there, but there are very, very broad competencies. And I would say that, again, not to dodge the question, those on the oncology services that you supervise are going to have the advantage.
Dr. David Skorton: [00:36:10] I'm not trying to butter you up. I'm just saying it the way I believe it is the advantage of the interaction among you, your learners and your patients in that setting in a given day with a given clinical challenge. And it's hard to make very broad generalizations about that anyway, except to say that humility is important. That a work ethic is important, not the kind of work ethic that requires sleepless nights all the time and 90 hours and so on. But a work ethic that one wants to get better, and consideration for the stresses on everybody in that triad, the stresses on the patient, the stresses on the teacher. And the stresses on the learner. And so I think a combination of well thought out competencies taken in the context of local situations and with great helpings of input from all three of those aspects, the patient and that person's lived experience, the learner and that person's lived experience, the teacher and that person's lived experience. I think that's what we should be striving for. And long before we were talking about AI as we are now, you know, AI and some form has been around for decades.
Dr. David Skorton: [00:37:38] But long before we were talking about generative AI and who knows what number GPT will be up to by the time you're talking about it. I think that we realize that technology does make a difference, even without that kind of what seems like enormously jarring change, meaning that we have to be humble, we have to be willing to learn. And not just from books. Although books are always going to be helpful to some extent, whether it's in a physical form or some other form, and being willing to learn from that triad. All of us learn from each other, because that triad is what's going to make the difference right? For the patient. The things the teacher will learn from that experience will help the next person taught the thing. The learner learns from that triad will help the next that that person's trying to learn, and hopefully the positive feelings, the trust that might be inculcated in that patient will make it possible to accept the more difficult parts of that encounter. So I think it's I think it cannot come from on high, and I hope it doesn't sound like I'm dodging the question, but that's actually how I see it.
Tyler Johnson: [00:38:47] No, I appreciate that perspective. Let me ask my one other question on sort of in this same vein. You mentioned this a little bit earlier, but I feel like in the last, let's say five years especially, I mean, really in the last 50 years, but especially with special concentration of focus in the last five years, I feel like there has been this national reckoning about admissions to all kinds of things, but especially to schools. And, you know, it's interesting because there's been a lot of discussion, for instance, about admissions to Ivy League schools, even though that process will only ever touch a vanishingly small percentage of people who actually, you know, grow up. And the same thing is true about admission to medical school, right? The vast majority of people, of course, have no interest of going into medicine and don't go into medicine. And yet these are things that, for, I think, complicated historical and sociological reasons, get a lot of press, a lot of play. Right? People care about them a lot, even if they have no interest in going into medicine. And I feel like on the one hand, in, you know, at the beginning of the pandemic and in the in the wake of the murder of George Floyd and, and the national reckoning on race that came in the wake of that, I feel like there was a very concentrated focus on trying to strive for equity in admissions.
Tyler Johnson: [00:40:10] And then, of course, more recently there was the depending on who you talk to, famous or infamous Supreme Court decision striking down most forms of at least per se, race conscious admissions for schools in the United States. And then in parallel with all of those things, there have also been, for example, many schools in partly in response to all of that, who made their school, their admissions processes standardized, test optional, and then more recently, schools who have been going back to requiring tests, and then other people who have been questioning the value of meritocracy writ large and wondering if that's even helpful to our society in general. And so, I guess, as the person who is the leader of, you know, I think one of the world's leading organizations that helps to administer and certify and lead very exclusive organizations which whether they want to be or not, that's just what medical schools are by virtue of the numbers. How do you think about integrating all of those many threads that I was just talking about, and a dozen more that I haven't even mentioned into sort of counseling or trying to. I know you don't run an admissions process yourself, but trying to sort of lead by example in guiding medical schools in how to think about how to approach the philosophy of admissions.
Dr. David Skorton: [00:41:36] So great and very, very hard question. My approach to difficult questions is to try to go back to principles, to basic principles. So first of all, the year that I had my first faculty appointment, which was January of 1980, 3.1% of medical school matriculants were black men. And in 2022, when I looked at the data, it was 3.1%. So, number one, shame on us for having to wait for George Floyd to be murdered, to have a, quote, reckoning when we've been failing to find a way to have representation of black men in medicine for decades. Now. Why do it? Not for a political reason. Not because it's seen politically correct before or after George Floyd's horrible murder, but because a lot of information. Initially in the for profit sector and then increasingly in the nonprofit sector, shows that diverse teams just make better decisions. That the more diverse a team is when you're trying to solve a complex problem, the more different perspectives that are brought into that problem, the better the decisions are made. I think eventually the data will be convincing. That diverse health care teams save lives, and there's already quite a bit of data to suggest that diverse health care teams improve adherence, improve people's trust, and do other things that I believe will lead to better health outcomes. There was a study last year, in April of last year, that showed that in roughly half the counties in the US that have at least one black or African American primary care physician, that every 10% increase in the number in that county increase the life span of black residents in the county.
Dr. David Skorton: [00:43:36] And they didn't even try to figure out, did they actually see those physicians? So I think going back to principles, we know from a lot of literature outside of medicine and increasing literature in medicine, that diverse teams. Make better decisions. And I believe that there's accumulating evidence that diverse health care teams also make better decisions and do a better job. And so therefore, I believe that it's very important for us to find the right mechanisms to diversify. The health care workforce and nothing in the Supreme Court decision. Nothing said we could not diversify the health care workforce. What the decision said was we cannot take race into account as a specific factor. And so I say let's go forward. Let's find ways, as schools have done in states where that decision was made years ago, like California and Michigan, to find ways like UC Davis has to diversify its medical school classes when they already had the decision that they couldn't use classic affirmative action approaches. And so I spoke out in dismay about the decision in public at the time. But the point is, nothing in that decision said we couldn't seek to have diversification and people from different lived experiences in the health care workforce. So that's how I think about it.
Dr. David Skorton: [00:45:07] And in terms of standardized tests and and the more detailed specific areas, I think there's a place for all of those things to happen. I'm a great example. 50 years ago. Of someone who did not do great in a standardized test, and my medical school was able to utilize that information to give me more support. And so, of course, I have an interest in this. We we do a standardized test, the MCAT, and I want to state that publicly. There's no question about it. But I believe from my own life experience, long before I knew what the WMC was, I mean, the first year Amcas was in business was the year I applied to med school. And so I think it takes a whole bunch of different factors to do this. Right. And again, it's not a political point of view. It's a point of view that if we want to solve complex problems. We want to have a team that looks at those problems from many different perspectives. And given that we know now that the biggest single factor that affects one's health is not the number of people around them in white coats. But are the social determinants of health and the upstream factors that affect that along, of course, with genetics and behavior. Then we're going to want to understand more about those lived experiences and bring to the transaction people who will understand those lived experiences.
Henry Bair: [00:46:32] So now we've in the two preceding questions, we've talked about AI and healthcare, and we've talked about trying to diversify the health care workforce by changing the way that we select people coming up the pipeline. I'd like to open up more of the way that you think about the challenges we have in medical education today. So aside from those two topics, are there other issues in American healthcare education that you are particularly interested in addressing through the AAMC?
Dr. David Skorton: [00:47:02] Yeah. You bet. And Tyler, you brought it up when you used the word meritocracy. I think that we can go too far one way or the other in that discussion. If we have a system that's based entirely on what we believe at a given time is the meritocracy, we're just not going to be right all the time because we don't have all the answers at any given time, and things change. On the other hand, if we abandon it completely and say that the only factor is people's comfort with the experience, then that's not going to work either. We have to find some middle ground. And I will tell you from the horrendous experience of being president of Cornell University in a year where multiple suicides occurred, student suicides. Shame on me for having to go through that experience to think about it more as a university president, but I thought more about the learner experience and what it meant. And I made a little video explaining to student Body that I had had counseling. It helped me, and I could admit that that I had mental health issues and required counseling. And somehow I ended up with a pretty good job. I'm your president, you know, I told them and I said, if you learn one thing at Cornell, learn to ask for help.
Dr. David Skorton: [00:48:19] We need to remember that, that people will ask for help in different ways. Some may enunciate clearly, but others may not. They may show the need for help by other indications of stress. And so we have to find a way to take that into account while being sure, as educators, that we're preparing people sufficiently rigorously to do the complicated and ever changing job of being a physician. And I believe that the best way to find that, I don't know if it's a middle ground. Exactly. It may be more toward one side than the other. I think leaning a little bit more toward learner well-being is very important, but nonetheless, there has to be a certain degree of rigor. I think we will we will eventually find our way. And I think as artificial intelligence and many, many other technologies, maybe some we're not even thinking about right now, come to the fore. All of these assumptions will have to be reconsidered in that new context, but I think we can't go too far one way or the other. It can't be a rigid meritocracy, and we can't give up all rigor because it will be somewhat stressful. We have to remember that a learner under stress, like a faculty member under stress, needs to be cared about and cared for because whatever it is that they're trying to do, including living a reasonable life, will not happen. If we don't think about each other's stresses and each other's each other's areas of of vulnerability, we all have them.
Tyler Johnson: [00:49:58] You know, I this is going to sound maybe a little bit strange, but Henry and I, as we recounted, we recently recorded an episode looking back on all of the episodes that we've recorded, and we sort of look at each other and laugh because we never knew anybody would listen, and we certainly never knew that we would get all of these accomplished famous people to come on the podcast and talk to us. But they have, which has given us this funny window into talking into some of the most accomplished and renowned physicians and scientists and authors and what have you in the medical field. And sometimes we have gotten done with interviews and said, in effect, to each other, boy, that was a person who really knows how to talk about things like caring about other people or being humble or whatever. But it's another thing entirely to talk to someone where you can just tell that the North Star of their leadership and ethical and medical philosophy genuinely seems to be caring for all of the other people, whether that's the wellness of your students at Cornell, or whether that's the insights of everybody in any different capacity who worked with you at the Smithsonian, whether that's the thoughts and welfare of the doctors and the trainees and the patients and the educators. And I just it strikes me in listening to you, that that concern for the welfare of people shines like this golden thread through almost every answer that you've given about everything from broad leadership philosophies to solving the conundrums of medical school admissions, to why you wanted to be a doctor in the first place. Which I guess I just say, because as a teacher at heart, I feel like it's worth pointing out to those who are listening to the interview that it's worth going back and trying to trace that thread gleaming through the conversation that we've had.
Dr. David Skorton: [00:52:07] That's awful nice of you. I would credit much of it to my dad. When I was a kid, I was just sure I had all the answers to everything, just positive, no doubt about it. And I was a very active anti-war protester during the Vietnam era, which he was not thrilled about. One time we were watching television, sitting in our home in LA, and I was talking about something and I said, listen to that idiot. What does he know? You know? And my dad said, well, that idiot actually turns out has the same vote that you do. And took me a while to, like, fully absorb that. But I take very little credit for how things turned out. I mean, a lot of amazing experiences, starting with my dad telling me. That person on TV you're calling an idiot has the same vote that you do. Better try to understand where they're coming from because you know you're just another guy.
Henry Bair: [00:53:03] On that piece of advice. We want to thank you again, David, for taking the time to come on the show, for sharing your remarkable journey and your insights on leadership learned along the way. Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:53:35] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor or patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:53:49] I'm Henry Bair
Tyler Johnson: [00:53:50] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.