“Learning from Yellowstone”: Commencement Address to Philadelphia University Physician Assistants Graduating Class

October 2016 Vol 9, No 7 - Editorial
David B. Nash, MD, MBA
Editor-in-Chief
American Health & Drug Benefits
Founding Dean
Jefferson College of Population Health
Philadelphia, PA
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As a parent and a faculty member at Thomas Jefferson University for the past 26 years (including 8 as Dean of our College of Population Health), I have been to more than my share of commencement exercises. Fortunately, I really like going to commencement. As a result, I was honored to be invited to address the 2016 graduating class of physician assistants from Philadelphia University, especially now that our 2 great centers of learning will be merging over the next 3 years.

A good commencement address should be pithy and contain an element of humor. There should be some take-home messages, one hopes memorable ones, and an inspiring challenge to the graduates, peppered with some sage advice for the future. Of course, telling a compelling story makes it more likely that those in the audience will grasp and retain the essential components of the message. Presented here is the speech I gave.

My physician wife and I celebrated our 36th wedding anniversary this summer with a first-time trip together to the magical place known as Yellowstone. Yellowstone is truly a gigantic ecosystem embracing more than 22 million acres across Wyoming, Montana, and Idaho. It is the nation’s first official national park, signed into law in 1872 by then-President Ulysses S. Grant: 2016 marks the 100th anniversary of the National Park Service, with Yellowstone as its oldest, and arguably most important, national treasure.

I believe that there are many key parallels with this enchanted and transformative place and our ailing healthcare system, and that several key take-home messages lie within a deeper exploration of Yellowstone.

First, allow me to provide some context about Yellowstone National Park. Thirty years ago, 3.6 million visitors came to Yellowstone. Today, that number has doubled to 7.2 million. During this time frame, the thinking about what Yellowstone means as an ecosystem has dramatically changed and is exemplified by the May 2016 issue of National Geographic,1 which is devoted entirely to this change in our thinking. Yellowstone sits atop a supervolcano that, over the past 2.1 million years, has cratered approximately 3 times, creating the largest caldera in the world on top of the most active thermodynamic site in the world.

Half of the world’s known geysers are in this caldera section of Yellowstone Park. As a result, the ground is characterized by 4 amazing geologic findings, including mud pots, which is actually boiling mud; fumaroles, which occur when water gets in one of these pots and steam is vented; hot springs, which are visible boiling mini lakes of water; and iconic geysers, which are created when water becomes superheated steam under pressure and, due to geographic restrictions, periodically erupts in a mixture of superheated water and steam. But enough about the magic of Yellowstone: how does all of this connect to our healthcare industry?

First, the ecosystems of Yellowstone and the 21 million acres that include the park and its surrounding environment are all about the interconnectedness of Mother Nature. For example, restored bison herds now routinely leave the confines of the park every winter in search of more grazing land. As the herd grows larger, its need for land also increases; however, human activity in the area surrounding the park has also increased dramatically in recent years. The result is an unexpected overlap between nature and man: bison herds crossing roadways and turning up in suburban shopping centers in their search for grazing land.

Our healthcare system is also incredibly interconnected, albeit not always in an organized fashion. As an industry, healthcare represents nearly 18% of the US gross national product. As the world’s largest economic engine, when we change one component of this ecosystem, it naturally leads to other changes. Just witness the incredible consolidation in our industry, including in Philadelphia.

Change is the only constant. The caldera that is the center of Yellowstone National Park is changing daily. The mud pots, fumaroles, hot springs, and geysers are eroding and changing the geography on a daily basis. The tectonic plates are still moving, fueled by the heat blazing through from the supervolcano below. Well, the industry you are about to enter is in constant change as well. As graduates, you will be facing a world moving rapidly from a focus on the volume of the services we deliver, to a focus on how to maximize the value of those services to the patient and to others who pay for them. You will not only witness the transformation of our industry, you will be part of it. In 4 words, the best way to describe the theme of this transformation is—“no outcome, no income.” You will be assessed and held accountable for the clinical outcomes you achieve. This represents a massive change in the ecosystem and will continue to erode the current geography as we now know it.

Diversity and change are other important themes in this story. The diversity of the flora and fauna within Yellowstone and the adjacent national park known as Grand Teton is truly amazing. This diversity is also mirrored in the influx of new visitors to the park. Rather than only Americans on vacation, the largest change is in the number of middle-class guests from countries abroad, especially China. My wife and I saw literally busloads of non–English-speaking Chinese vacationers, dressed in American name–brand clothes, clamoring for pictures at each of the key tourist stops within the park. We marveled at how far China has come economically to be able to support a middle class that is wealthy enough to make the trip from China to Yellowstone.

Switching to healthcare, the workforce in our emerging system is also very different from when I was beginning my career. My medical school class of 1981 had 10 women, which, at the time, represented the largest single number of women in any class at the University of Rochester Medical Center’s history. Today, women comprise more than 50% of the current class at Sidney Kimmel Medical College of Thomas Jefferson University, and it has been this way for the past 10 years. One of my twin daughters is a senior resident in medicine at Jefferson in a large and very prestigious internal medicine residency training program. Her training is very different from the training process my wife and I endured nearly 35 years ago. Physicians who trained when we did never met a physician’s assistant until they became a senior teaching attending. Instead of practicing on your own, you will be expected to be an integral part of a clinical care team. That is perhaps the most important change, and one that has been long overdue.

Another component of transformative change involves rescuing people from their own bad behavior. Historically in Yellowstone, feeding bears human trash was encouraged; in the 1930s and 1940s, this was a highly anticipated part of a park visit. Fast forward to 2016, and the park service has evolved in its thinking about keeping people and bears separated and allowing bears to roam, but minimizing contact with the millions of visitors. One can see the challenge inherent in this juxtaposition of people and large animals. The park has figured out, at least for now, how to maintain a healthy balance between wildlife and human visitors. The healthcare system needs to maintain a balance between encouraging health and treating acute illnesses. You will be asked to focus on health as we move to a model where maintaining good health is the goal. The challenge in our industry is that we don’t have a 30-year time horizon like the park service did for this evolution in thinking.

Recovery and reinvention are possible and necessary, in the park and in our business. During the Yellowstone fires of 1988, a large part of the park was consumed in an inferno that lasted weeks during the late part of that year’s summer. More than 25,000 firefighters from many states were engaged in what looked like an unwinnable battle against Mother Nature. Then one brief parkwide thunderstorm with good rainfall essentially extinguished the blaze.

The lodgepole pine, the most common tree in Yellowstone, was devastated. But wait! The lodgepole pine has 2 types of cones in which its seeds for the future lie. One cone opens on its own, and most of those were consumed by the fire of 1988. The other cone, known as a serotinous cone, only opens in an ambient temperature of 113˚F. These cones, opened by the near fatal and destructive fire of 1988, sowed the seeds for the future resurgence and reinvention of the lodgepole pine. Our industry, although not consumed by fire, is going to have to reinvent itself for the future. You will be part of that reinvention as you engage with patients in a way that your predecessors never thought possible.

You will communicate with patients by e-mail, text, and video conferencing. You will be available 24 hours a day, 7 days a week. You will be engaged in the continuous conversation as to how we might maintain health, rather than only exclusively respond to the episodic call to fix what is broken. You will be the serotinous cone under fire, ready to reinvent the system for the future.

Finally, the human aspect of Yellowstone and some of its dramatic challenges are best exemplified by Teton County, WY, home of Jackson Hole, one of the state’s busiest cities, especially in the summertime. Teton County is the wealthiest in the country, with the highest per-capita income. But, below this glossy veneer lies an economy dependent on minimum-wage workers who cannot afford housing in the immediate town itself or in many parts of the surrounding suburbs. We heard multiple stories during our visit to Jackson Hole about 1-room rentals for $1000 a month. I do not mean a studio apartment, but 1 room in a single home renting for $1000 a month! It is impossible for teachers, policemen, firemen, and hotel desk staff to afford a home in Teton County itself.

Here, there are many parallels with the great city of Philadelphia. As I hope you may appreciate, 25% of our population lives in poverty. Half of that group lives in what the government euphemistically refers to as deep poverty, which is defined as income that is <50% of the federal poverty level, which leads to food and housing insecurity, especially for children in single-parent households. You will be challenged by these social forces, which are like tectonic plates grinding on each other, making income disparity a key predictor of health in our society. In our city, from a zip code in Center City to a zip code in North Philadelphia—a distance of only 2 miles—may predict a difference of a decade in one’s life span. For me, this is unsustainable, and you will be part of the leadership of the future that will need to tackle these disparities.

Let me leave you then with some advice from a waterfall. I know this may ring hollow, but we saw many waterfalls during our 7-day visit to Yellowstone, such as Lewis Falls on Lake Lewis and the falls at the Grand Canyon of the Yellowstone, which were made famous by the 19th-century painter Thomas Moran. I have some advice from an unknown author that you can get from a waterfall, and it’s germane to our conclusion here today.

First, go with the flow. There will be bad days and good days, so-called bad patients and good patients, and patients who will test your patience.

Roar with excitement. Here, I would challenge you to celebrate the gains, and find a way to get solace from every clinical advance you and your teammates are able to achieve. Improving the quality of life for individual patients and offering solace wherever possible are core components of your mission.

Let your cares fall away, and focus on what really matters. That means taking appropriate time to appreciate the blessings and gifts that every individual possesses.

Create your own music. To me this means don’t always follow the herd. Do something different. Engage with your patients in ways that perhaps your colleagues have not yet embraced. Measure your outcomes and promote the best outcomes by benchmarking against national best practices.

Immerse yourself in nature. I would urge you all to visit Yellowstone. Stay active. Be a role model to your patients by remaining active, staying in shape, watching calories, and helping patients to see what a healthy lifestyle really means.

Finally, make a splash. To me, this “advice from a waterfall” is the most important. Be a mentor to a junior colleague, and in doing so, create your legacy. I hope you find your own Yellowstone.

As always, if you would like to share your views about engaging with the patients we serve, you can reach me at david.nash@jefferson.edu.

Reference
1. Quammen D. America’s wild idea. Natl Geographic. 2016;229(5).

Last modified: October 28, 2016
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