Acceptance Speech, Yale Wilbur Cross Medal for Alumni Achievement Ceremony
October 2, 2023
Many thanks for this recognition, which means a great deal to me and reflects accomplishments that would never have been possible without the support of Yale, its Graduate School of Arts and Sciences, and so many mentors, colleagues, and friends who have inspired me, lifted me up when I lacked confidence, promoted me, comforted me in hard times, and added tremendous joy and ample laughter to my life. I find myself full of gratitude for so many of you in the room, and of course beyond, who have supported me. Most especially, I want to shout out my husband of 38 years, a Yale College graduate and the best partner anyone could have. When you are with John, you feel like you can do anything because of his abiding faith in the good of humanity.
Because we have students in the room (and hopefully all of us remain students our whole lives, always learning), I thought it might be helpful and interesting to talk about my experience in terms of transitions.
I love transitions (as much as they are unsettling too) because they allow a time of disengagement and reengagement, and in that moment when one has disengaged from the previous work but not yet reengaged fully in the new work, all things are free, unencumbered, full of potential, open to what may be new. Think of shifting gears (when the clutch is in before accelerating); think about shifting weight (for instance, during skiing or skating to turn, or dancing before a reconfiguration of the body). It is a time of promise. Transitions, for me, are at the heart of learning.
I have had the benefit of several key transitions in my career—and an academic career allows for that. I guess because at the core of the academy is the pursuit of truth, with emphasis on the pursuit, not the attainment, of truth. Transitions play a special and fundamental role in this pursuit—a role best understood in retrospect because, when one is in the dance, it is difficult to perceive the pattern of the dance.
Preparing for this talk gave me an opportunity to “get on the balcony” (a phrase coined by Professor Ronald Heifetz at Harvard), meaning to step back and see the recurrent patterns that emerge from the daily flail of work. I hope our balcony tour in the time we have together will be helpful, as you may be approaching, in the middle of, or just recovering from a transition.
My first graduate school experience was at the University of Chicago, where I received an MBA in health care administration. I chose this career after taking a course in college from Professor of Sociology Paul Starr as he was drafting his now seminal book, The Transformation of American Medicine. Health care was changing from cost-plus reimbursement to capitated payments. DRGs and HMOs were cutting edge, and the career promised to be meaningful. After school, I pursued hospital administration at Mass General Hospital (MGH) and fully enjoyed the pace, challenge, and impact on patients and families. I worked with Don Berwick, then an assistant professor in medicine, and quality improvement was so exciting. It was a taste of inclusive leadership and the use of management engineering techniques for improving patients’ experience. It also was a great equalizer in the hierarchical system of medical care.
Life was good at MGH, but two forces led me to make a transition. First, I was 30 and wanted to have children (I knew no women in the senior administration of MGH in 1992 with children, and the “mommy track” did not appeal) and on a more career-defining level, I knew I was improving patients’ experience inside the hospital but every day I would walk to the Red Line to go home and see the same massive health issues: drug use, homelessness, chronic illnesses. I felt: while I am working so hard to improve hospital care, Boston is not getting any healthier. And I had questions about health and health care I could not answer with my existing toolkit.
So I went through a sizable transition (with the attendant emotional uncertainty and worries) and ultimately decided to pursue a PhD to attain more tools—theory and methods—to pursue the truth of how we could improve the health care system, already by then recognized as wildly expensive, replete with medical errors, and losing the public’s trust.
Thank you, Yale, for accepting me! My bosses at MGH were baffled that I would throw away my budding career there, and my father, sure I was making a big mistake, said, “Why would you ever want to get a PhD? That is such a waste of time, and you have a good career!” He was not an academic.
I adored my doctoral training—often in this very room, with the wonderful faculty in YSPH. My first class was with Professor David Williams, and he taught me about the social determinants of health. When he showed the chart that only 10% of premature mortality averted is due to medical care, I actually raised my hand and objected, incredulous that that could be true. And through that semester, public health, as distinct from medical care, sunk in.
My learning curve was steep and I was a philomath…not polymath (one who knows everything) but philomath (one who likes to study everything), and took classes in history, political science, economics, sociology, and tons and tons of biostatistics, epidemiology, and health policy.
When I finished, many faculty helped me transition to an instructor and then an assistant professor in YSPH. I am grateful to the then-Dean, Mike Merson, who helped me get my first research grant; to Sam Chauncey, who opened the door to teach in health management; to Mark Schlesinger, Sally Horwitz, and Jody Sindelar, who supported my application to be an assistant professor in health management. And off I went—gears fully switched—from hospital administrator to academic.
I was inspired—I thought: I get to teach and study, and people will pay me to do this? And I get to set my own schedule. Like so many academics with young children, I worked part-time for a few years and then full-time, but my hours were 5 a.m.–7 a.m., 9 a.m.–2 p.m., and 9 p.m.–midnight. It worked! And I felt my family gave me grounding and perspective, and of course enormous love and support, which helps any career along.
During review and promotion time, life became stressful—particularly as Yale would ask us to “frame” our work and to “boil it down to a few punchy sentences.” I was hounded by the question, “but what’s your focus? What population, what disease are you an expert in?” Remember, philomath? This was tough for me. By my tenure review in 2006, I had 115 peer-reviewed papers, 15 book chapters, and strong external funding—but I was all over the board! Thirty papers in end-of-life care, 20 in long-term care, 20 in quality improvement in cardiovascular care, a few in involuntary job loss, a few on utilization review and insurance, even some on competency-based education in health management…the list goes on. I was shameless. Have a question? Let’s try to answer it!
And then a transition—brought about by one of my former students, Kristin Mattocks, who was working with Dr. Harlan Krumholz here at Yale, a creative, generous, and outstanding mentor to me. The student, who was a teaching assistant in my methods class, introduced me to Harlan as a qualitative researcher—something he was interested in but not experienced with, and we started to collaborate to solve a problem.
In 2003, only about a third of patients with lethal heart attacks received the angioplasty (or similar procedure for opening a blocked coronary artery) within 90 minutes of arriving at the hospital. And opening that artery saves lives. We noted, however, that a set of hospitals were consistently getting it right—they were faster and more successful. And amazingly to us from our privileged perch, these were “no name” hospitals.
But what did they know? We sought to study them intensively, extract the recurrent patterns of their behaviors (e.g., practices, equipment, space, culture, leadership), hypothesize how they did it, and then test those hypotheses through a series of quantitative studies. We found a handful of “tricks” they had—from getting EKG results from paramedics before the patient arrived at the hospital to tackling the politics of allowing Emergency Medicine physicians rather than cardiologists to activate the cath lab. Together, these made all the difference. Harlan then led our strategy to work through payment and physician re-licensure systems to incentivize the adoption of these evidence-based techniques, and six years later, 95% of patients were receiving the life-saving procedure within 90 minutes of hospital arrival. It was a transition—from one way of practice to fully another. And it took questioning the accepted practices, taking time out to study and think, and then fearlessly making the changes to be on a new path.
I am proud of that work, and so very thankful when, since that time, I have had friends and family, and many I do not know, survive such heart attack events due to prompt treatment.
We used the method known as “positive deviance,” which means looking for the outlier institutions that are achieving amazing results despite being in the same environment as others, study them qualitatively and intensively, generate hypotheses to test quantitatively, and then spread the evidence to make change happen on a large scale.
Our work was getting lots of press—it felt exciting to be in the New England Journal of Medicine, JAMA, and Archives of Internal Medicine all in the same year, and of course, tenure felt good too; plus, in 2005, I had a sabbatical!
Sabbaticals are great times for transitions, and although I was very happy in my role, a transition was on the horizon, this time to leave my focus on hospitals in the US and begin a decade of work in global health, largely in low-income settings.
In November 2005, I was very happily enjoying sabbatical when the Clinton Foundation reached out to me to discuss Ethiopia with them. Again, it was all due to a former student, KP Yelpaala, who had an internship with Ira Magaziner, then the head of the Clinton Foundation, as he and President Clinton met with Ethiopian officials to help their rebuilding efforts. Dr. Tedros, now the General Director of the World Health Organization and then the new Minister of Health in Ethiopia, wanted help from President Clinton on elevating hospital quality. Ira was hunting for academics who knew about hospital administration, and KP mentioned me.
I had no association with Ethiopia except the famines in the 1960s. So, when the Clinton Foundation contacted me, I immediately convened the others at YSPH who did work on AIDS or Africa, and I assumed I would facilitate the meeting, like a catalyst. I would be in the early stage of the reaction and then I would depart, leaving this work to others. But as the Clinton Foundation people started to talk about what they were looking for, which was hospital administration experience and research, I realized—oh my goodness, I think I can help. We created a team, wrote a grant, and off we went to work in Ethiopia on what is now known as “health system strengthening.” This work was profoundly fulfilling and led to a decade of expanding global health at Yale, including the creation with, Mike Skonieczny, of the Global Health Leadership Institute—still alive and well today with the leadership of Professor Leslie Curry and Erika Linnander.
Research was the bedrock of our work, as we were teaching from an evidence base developed in the country, and eventually across many low-income settings in Africa and Asia. We evaluated countless interventions largely in the area of leadership development, management systems, and data monitoring—with the goal of equipping and empowering communities with the tools and practices to meet their health and health care goals.
Consistent with the conceptual underpinning of global health (versus international health), the US is part of the globe, and although I was largely funded to do global health work, I did continue to tussle with the issues Professor David Williams first taught me at YSPH about the social determinants of health. Again with a sabbatical in 2012, I was asked to write a book with another former student, now Professor Lauren Taylor, on our findings that the investments in social services (e.g., housing, education, nutrition) are far more predictive of population health outcomes than are medical care investments—perhaps explaining why in the US we spend so much (on medical care) and yet have relatively poor health outcomes, the core learning of the American Health Care Paradox: Why Spending More is Getting Us Less.
Between publishing this, which became widely cited, and becoming the Head of College of Branford College, I began to realize that translating research into practice and speaking publicly was meaningful for me. More and more, I felt drawn to the most basic questions of creating and sustaining learning communities that are free to question the status quo, open to new ideas, and that empower voices that have important contributions to make but are, for any number of reasons, marginalized.
Another transition was still in my future at this point, although I did not know it. I had begun to teach in and direct the Grand Strategy program at Yale, and Professor Tim Snyder’s work Black Earth influenced me greatly. In it, he argued that during World War II, the areas that were able to save more Jews were those where there was local leadership, where local efforts—mutual aid societies, community centers, local schools, clinics—were robust and people knew each other as communities.
President Trump was elected in November 2016 just as Vassar had reached out to me about their presidency. In the context of increasing authoritarianism in the US and abroad, I was drawn to the importance of leading an institution to be trusted, inclusive, responsive, and accountable in the community and by the public. Like all my other transitions, I took time to think, to imagine a new focus, to consult with mentors, and to feel what it might be like to lead a college. And not all at once but over time, I realized—I wanted to try. So, I left Yale and moved to Vassar.
Ironically, the more I changed, the more I stayed the same. And many of the methods I worked on, including positive deviance and capacity building in low-income settings, I am now applying to liberal arts education. We have an ongoing study of positive deviance of colleges in the US. Do you know that on average, colleges graduate only 50% of the students who matriculate? We have models to create a predicted graduation rate based on the college’s resources and their student populations and now are examining, with the help of the Lumina Foundation, those institutions that consistently achieve an actual graduation rate that is more than two standard deviations above their predicted graduation rates.
What are they doing differently? That’s our research question, and of course, we want to learn and ideally spread whatever evidence emerges. Vassar is also working closely with the University of Global Health Equity, the late Paul Farmer’s project in Rwanda, to develop its capacity to teach using a multidisciplinary, liberal arts approach to medical education. We are working with faculty on pedagogy and with the institution on sustaining a culture of inclusion, questioning the status quo, and critical thinking. And, of course, every day on campus, we are working to sustain an inclusive and responsive culture and an institution that can be trusted by its constituents and the broader public.
What to make of this bundle of experiences? I am not wholly sure, but a few patterns emerge for me. First, students have often been at the center of change for me. They often do not know it, but they have opened many doors in unexpected ways. Listening to those voices, if we are to be scholars and educators, is so very fulfilling—as learning goes both ways.
Second, the pursuit, rather than the attainment, of truth seems crucial. It is so easy to get lulled into the false sense of security and superiority by a good P-value, a New England Journal of Medicine publication, or, dare I say, tenure. I prefer to keep my eyes open for questions I still have, problems that persist that I think I may be able to contribute to addressing, and new contexts that challenge my extant way of thinking. It is a tough approach because one goes from being expert in some areas to being completely new and unfamiliar, and I have felt that many times. At the height of accomplishment, I have moved to open a new area of inquiry. It is not for everyone, but it has made for a meaningful journey for me.
And last, if change is the throughline of this talk and my career, I must end in paradox—as all this change has been possible due to the tremendous stability that has come from my love-filled marriage to John, the stability of our health—which we all know is so important—and the many institutional and personal supports that Yale and the academy at large have provided me. I am, again, so grateful to be here with you all. Thank you.