Jada Bussey-Jones, MD (Host): Hello. This is Jada Bussey-Jones, the current President of the Society of General Internal Medicine and the host of SGIM's President's Podcast. We engage SGIM's former presidents who are leaders across healthcare, public health, policy, and academia. As we lead up to the organization's 50th anniversary, we aim to capture insights from our national thought leaders so that our organization, our members, and healthcare broadly are in a stronger position to grow, innovate, and meet the challenges of our time.

To our listeners, I say thank you so much for joining us. Today, I am so excited to have Dr. Thomas Inui. Dr. Inui is a retired academic physician. His last academic position was as the Joe and Sarah Ellen Mamlin Professor of Global Health Research at Indiana University School of Medicine and as co-director of research for the AMPATH HIV program in Kenya.

A primary care physician, educator, and researcher, he previously held positions as the head of General Internal Medicine at the University of Washington School of Medicine, and as the Paul C. Cabot Professor and Founding Chair of the Department of Population Medicine at Harvard Medical School. In addition to being the past president of SGIM, he has had numerous honors, including elected membership in Alpha Omega Alpha, the Institute of Medicine, and the National Academy of Medicine, just to name a few. He is a serving member of the Council of the President's Society of General Internal Medicine and the recipient of SGIM's Robert Glazer Award. He has published more than 340 manuscripts and 8 books on a broad variety of topics including patient communication, health promotion and disease prevention, and the social context of medicine and medical humanities.

He is an expert in mixed and multi method qualitative and quantitative program evaluation. I'm so delighted to have you here with us today, Tom, and I want to thank you so much for agreeing to spend time with me. Um, and I know that, uh, your words of wisdom will, will be helpful to us all. I have been incredibly inspired by really your introduction, as well as all the introductions that I read through, and I'm looking forward to hearing your insights today.

Thomas Inui, ScM, MD, FACP: Thank you.

Host: Yes, absolutely. I'd love for you to start maybe by just telling me a little bit about yourself, your background. I heard a lot about your personal background, but how you got started on this path. And so I'd love to hear just a little bit about your story, if you will.

Thomas Inui, ScM, MD, FACP: Well, I'm the son of a German English mom, who was a farm girl from Illinois and a Japanese American young man who met at Hopkins. She was a nurse and he was a surgical resident. They met in the emergency room on a weekend when she made a mistake and put a chicken that she had gotten from the Northeast market in the refrigerator and got paged to talk to Dr. Inui who wanted to know what in the world she meant by putting a chicken behind the vaccine vials in the refrigerator and what she was going to do with it, and when she said she would cook it, that night he said, I like chicken, and got an invitation to the row house where she lived. So I'm a Hopkins kid.

Born of nurse and a surgical resident. I mostly grew up in the Midwest and college in Philadelphia, medical school at Hopkins. Medical school residency, early faculty work, chief residency there. I, along the way, became engaged, I think, in what I would call real leadership, if that's the question you would, you're asking about, how does one find oneself in a leadership track in life? Probably when I was a chief resident in medicine at Hopkins. There were about 70 plus residents, interns, and JARs and SARs in the, in the medicine residency. There were two chief residents, we split the house staff, we split the floors. We rounded every day on new admissions, every day except every other week on Sunday, on new admissions and took care of that house staff.

We taught two or three times a week, stand up sessions on subjects of relevance to the current inpatient experience, and we tried to make sure that the house staff each were pursuing their work with success and enthusiasm. We met with the chair of medicine every day to provide a snapshot of how the resident service was doing. 

We did each half the consults for internal medicine from all of the resident services in the hospital. Personally, all of the problem patients on the resident service. In those days, Hopkins was a segregated hospital, racially segregated. The Osler wards were all black, the Marburg wards were all white, and the chief residents were the pinnacle doctors on the Osler wards.

We had attending physicians, but they were really teachers. They would see a case or two and profess on that case. The chief residents were the senior most, built in physicians. So we were appointed as junior faculty. It was a faculty job. So I felt like a leader in those days and had as not just a schedule making responsibility for the residents, but a mental, emotional health responsibility, a medical learning responsibility, a future careers responsibility.

I took all of that seriously. Dr. A. McGee Harvey, who invited me to be a chief resident, said that, about Steve Acuff, my co-chief resident, and myself, that he had chosen us because we were good with change. Which I thought, okay, that's okay. I would accept that as a real compliment.

He meant by that, I'm going to retire and Victor McKusick is going to be my successor before you guys step on the floor. So, he meant, that kind of change, but everything was changing. And, I could you know, eyes on the prize, try to stay focused on my responsibilities, and accept change, because I wanted it.

Truth be told, that German English mother of mine was the individual who desegregated the Ys, YMCA, YWCA in Youngstown, Ohio, and, was an exchange student program manager for Northeastern Ohio for the AFS, working on global perspectives and bringing peace. So she was a social activist.

And there I was in a setting in which, we were taking care of all black patients from the neighborhood and on the Osler wards, no air conditioning for patients in each room. No real attending faculty level responsibilities except the chief residents. With the question hanging in the air whether we should be doing this at all, let alone conducting medicine that was racially segregated in that way

in East Baltimore.

I wanted change. So, I felt that Dr. Harvey had somehow been astute in his choice making. And I took that position with real enthusiasm, which was good because we didn't get a day of rest, except every two weeks, we got a Sunday off. Otherwise, we went to work at 8, and we finished at about 2: 30 in the morning and then went home for a brief night's sleep, if you can call it that, and then back at 8. That was a very long year.

So, I think, with all seriousness, would have considered myself to have entered a leadership track in my career. Every position thereafter in the Indian Health Service, in the VA, in the University of Washington and the other universities in which I work, would have worked, was taken with the understanding that I had leadership responsibilities of different types as I went.

Host: Thank you so much, first of all, for telling me about yourself and your story, your family, and, sort of your leadership journey, including the ability to lead through change and especially in a system where change was needed, right, a segregated hospital. So, I just want to acknowledge, first of all, a meeting, a wonderful interaction that you and I had at a national meeting where you talked about this idea of narratives in which you just displayed so eloquently, and that, that has meaning as a leader.

And so I wonder if you have any, any thoughts about how leaders might use their stories or other narratives to affect change or how you've used storytelling, which is what you encouraged me to do. So I wonder if you have any thoughts that you'd like to share about that?

Thomas Inui, ScM, MD, FACP: I did encourage you to do that. Thanks for remembering that and you've done it wonderfully in your columns. I appreciate it. I have believed that all meaningful change, as Margaret Mead said, is the result of the actions of a few people in history, you take long view of it. That if curves of various types move, they move because of the actions of a few.

I've never considered myself to be a paragon of any kind, but I have considered the life I understand the best to be my own. I don't really imagine that I understand other people's lives and decisions and values fully. So I have tended to lead by action, but also, in my description of my actions in stories.

In fact, in my SGIM presidency, which I look back because I remembered, oh, that was sometime last century, turns out it really was in the last century, it was like 19, let me check my notes here, 19, oh my gosh 86. That was back a ways. If I look at it and say, what did I do during that year that might've been instrumental in some longer term way for the society; I would say there might be three things that I did.

One was to recognize that committees had become the work groups of our society. And I began with counsel to outline for each committee chair or co-chair what we hoped they would do in the year coming, and to ask them for reports. Warn them we're going to ask for reports at the end of their year of chairmanship of these work groups, the committees of the society. So, started to use the infrastructure and organization of the society as a way in which the society does work, that's one.

Two, I didn't really spend any time on the name change. The name change from Shrepsum to SGIM was a big topic of discussion the year before, and I just said, a rose by any other name, smells so sweet and just went on from there. That was my total statement on the name change.

Three, was we expanded, thanks to Bob Centaur, who was a hero and was the ringmaster not only of our meeting in that year, but the meeting of the Society of Medical Decision Making as well. He doubled up in his responsibilities as the director of professional meetings and increased the meeting from two days to three, without knowing whether we could afford to do that from expenses for occupancy at a hotel, in the double-sided ledger vis-a-vis the revenues we would get from increasing attendance for the day, for that extra day without increasing the registration fee. So it was all about getting more people to come.

Well, so we went to three days. And that made all the difference to people wanting to run workshops. Finally, I wrote President's Columns that were stories, rooted in my own life, the life I understood best. And asked some core questions like, what kind of research is it that we do? In those days, it's hard to remember, but, health services research was a newly born field.

People didn't really even know what health services research was. Anyhow, one column was about, learning how to do research that was meaningful to me, as somebody who wanted to be a primary care doctor and be evidence-based in my work and guided by evidence in the way in which I organized my work and that of others.

So, I wrote very personal columns. They were stories about how I had come to perspectives in my life. And that's the way I introduced myself to the membership. And then continued into the presidential address, which is the last thing we do in the SGIM president's office. And that was stories.

It was actually, as I look back and think about it, a story about the source of meaning in medical care and about determinants of health, which that's the subject matter of the address. And, about the broadening of the scientific lens beyond biomedical science to the social sciences and cultural anthropology.

I gave the address as a series of stories about patients I had known. I won't retell it. So, there are the things I did as president, and they include shifting to storytelling because I felt that stories carry meaning and have power, and because I felt that there was nothing I could do to really mobilize the society to action better than just deciding why I might have chosen to do something in my life and use examples not to show why I was a pillar, but instead because I understood the examples.

They were my own. They were somewhat self-revealing. The presidential address was attended by my wife, Nancy, and by our son, Tazo, who was about 10 years old. And he had never seen me at work before. He sat in the audience of about a thousand people in those days. And that was the image he had then thereafter, of what dad does when he goes to work. There are a thousand people sitting in the auditorium, and he's telling stories. So, it created a bit of a misunderstanding on his part, but he's recovered from that by now.

Host: That is so great. I love the narratives and you clearly had a transformative impact on the organization. All the things that you mentioned from the name, to the three day meeting, you know, really all of those things are still in play today. So thanks so much for that. I realized that you were the first ever Chief of General Medicine, Division Director for General Medicine at University of Washington.

And so, this idea of career development and organizational change for divisions and organizations or units, maybe just talk briefly about that. So we talked a little bit about your leadership role within SGIM, but kind of your leadership role within a unit of GIM or whether you are supporting research faculty across the world, but, maybe you'd share a little bit about your contributions and thoughts there.

Thomas Inui, ScM, MD, FACP: Well, you're right, I was the first, general internal medicine, at first, section leader. The section was the so called GIM group. We had a different title organizationally. We were called the Medical Comprehensive Care Unit actually, at the Seattle VA Hospital in those days, now Puget Sound VA.

And, it is hard to think of how different a time it was. I had been recruited to this position that was described as a general internal medicine unit, only to arrive and realize that the five faculty I had, I was, one of the five faculty. Then there were two endocrinologists, one gastroenterologist, and one infectious disease specialist in my unit, as well as eight nurse practitioners. And together we were the Medical Comprehensive Care Unit. So it was a bit odd to think about it as a general internal medicine unit, but back in the day, the idea that there was an organizational element, like a division in a department or a section in a hospital, that was specifically made up of general internists was a bit odd.

Instead, it was made up of subspecialists who were interested in practicing general medicine. Infectious disease and endocrinology are two good examples of such folks. Nephrologists are another, and this particular gastroenterologist was another. We saw the undifferentiated patients, not taken up by the specialty clinics for care.

Another historical odd fact is in those days, primary care in the VA was illegal. What do I mean by that? I mean that VA hospitals ran on appropriations that allocated budget to each hospital in proportion to and in response to their number of bed days. They were given revenues because they had had a certain number of hospitalizations in the prior year.

And the budget that was available in the overall capitated budget was allocated according to the number of bed days. So, primary care in the outpatient department was a waste of time. It was certainly a waste of money. But the hospital director that I had and my chair of medicine or chief of medicine at the VA hospital thought it was the future of the VA.

They both were convinced that that policy would move in the direction of primary care on an outpatient basis. So I carefully negotiated a job in which I yes, was general medicine section head with all subspecialists and was explicitly given in my first contract at my request, understanding that to the extent that we practice prevention and good primary care in the outpatient department for people with chronic diseases, I would be costing the hospital instead of generating revenue, and that was okay with them.

They would not hold it against me. That was part of my understanding coming in. So, it wan Necessary then for us to grow. We wanted to add other people to our unit. The demand was infinite, basically. Even in our area, it was, even at a time in which many of the new veterans were scared of anything that smacked of the Armed Services because they were early returnees from Vietnam.

They were afraid to come into the VA. It felt like the military to them. They had had horrible experiences. But we wanted to grow because demand was there. The waiting list, which we monitored for our general medicine clinic, was about two months, which we thought was too long. So we added general internists as we went.

We had the idea that we should be willing to structure our clinic in new ways. So we added a psychiatrist as well. There we were really copying the Boston model prevailed in the BI, if I remember right, the Beth Israel Hospital. We had so much mental health inside that patient population, we added a psychiatrist.

We negotiated with the hospital and actually had a modular building built, which accommodated us and our clinic. My thesis was, if we lived, that is to say, had our offices in our clinic, we would care more about the daily operations of the clinic. So the clinic space was divided into offices of the faculty and the clinical rooms, examination and procedure rooms.

We decided that we would do research together that focused on our daily work. So, we could identify problems and challenges that we were experiencing in our daily work and then turn them into research opportunities. I published an article with my colleagues that was in, in medical care, which in those days was an odd place to put clinical research, but we did it, called the Best Laid Plans and, it was an article that got in because we said, we have an example of a clinical care improvement initiative that actually damaged the outcomes we were trying to achieve measurably.

And this is the first time we think looking back over the last 10 years that anyone has published a quality improvement damage article. It was one in which we decided I'll tell the story and then stop, that we could together look at the impact of posting instructional signs in the bathrooms on how to do clean catch urine specimen collections.

And after we posted them in a quasi experimental manner, we were able to show against controls that we had more contaminated urine specimens when we were collecting urine specimens for culture than we did before the signs. In other words, the signs had damaged us in trying to get clean catch urine cultures done in a clean way.

And, we did a little of observational research with human studies approval, that showed that the reason that we damaged it was people were trying to read the signs at the same time as they were collecting the urine specimen and handling the cups, they were putting their fingers inside the cups.

So we did that kind of research, in those days. It wasn't funded. It was research that was problem solving, or in that case, problem creating. So we had to cease and desist and others of that type. So we formed a combine of the general medicine faculty to start doing clinical research of that nature and mentored one another.

We didn't really have a senior mentor. We just held hands and went forward. And I became the advocate for the faculty in the promotional review process, as well as the source of feedback and support for them. I wasn't allocating much money, but ideas, and assistance and collaboratorship. 

That was how we began, and yes, that was the general medicine section at the VA at the beginning, all subspecialists.

Host: Well, I think first of all, to know where primary care has come, right? So the recognition that, that there is value in primary care practices and an expansion of the role of general internists in that. So, thank you for your leadership there as well. I'd like to end our conversation first with more general question about now that you have retired formally, how you are spending your time, hobbies, self-care, what are you enjoying these days?

And then I might ask just if there are any parting comments, last comments that you'd like to share with our listeners, as we wrap up our time together today.

Thomas Inui, ScM, MD, FACP: Well, thank you, Jada, for the chance to chat. In retirement, I gave myself about six months to be in a time of not knowing what I was going to do. That was a phrase that Tony Schuchman uses. My good friend. And then I went to, this was in Indianapolis. I went to the Habitat for Humanity office and said, you know, the last decade or so, I appear to have worked almost exclusively doing my primary care in homeless clinics. 

And indeed that was the case. And I, I've come to feel passionate about housing as a prerequisite for health. Getting people up off the street where they cannot be healthy. So, for the first six years, I was working, of retirement, I was working as a, first as an apprentice in house construction, and then as a kind of a junior supervisor, helping the people who came to building sites, as a part of their community service time from large organizations, but who needed to know how to do what needed to be done that day and with the tools and so on. That continued when I came to Olympia, where I now live, Olympia, Washington, and was physically demanding. So it was good for my body, until I spent so much time erecting scaffolding that it wasn't good for my body anymore.

And I shifted to less demanding forms of community service. I joined choruses and began to sing in community choruses. Two years ago, I was in two big ones and two little audition only parts of those big ones. So I was in four all together and we were singing in community performances and in nursing homes and other place, markets and in other places.

One was called the Peace Chorus because the core belief is that singing into the world builds peace and understanding. And the other one is Masterworks because we love doing classical music as well as other forms of music. So making music is part of what I do now. When I stopped being active as an academic faculty member, I actually reduced the number of journals I read to one.

I kept the New England Journal, because I have a lifetime subscription to the New England Journal. They got into financial trouble a long time ago and they offered a $300 lifetime subscription, which my wife and I took at the time because our annual income was $6,500. That seemed like a lot of money, but then we just did calculations about how much it was going to cost them to let us have this for the rest of our, we hope, long lifetime. And we took it. The New England Journal checks from time to time to see if I'm still alive because they don't wanna be sending it out to a dead letter box. And now it's an e-journal and instead of a printed journal. But I read that one.

Then I gave myself permission to read books, whole books. I really, had been so busy reading medical and public health and health services journals, technical journals, that I hadn't had time to read books, novels and historical books. And I've greatly valued that. So I have a Kindle and I keep going.

I'm currently reading Zadie Smith's White Teeth. If you know that book, you know it's all about diversity. It may be set in England and Jamaica, but it's all about diversity. And I've been so stressed out by the intolerance in recent political affairs that I like a book with some tough mindedness to it, but that has humor about, how we make our way as the homonyms across our differences.

So, reading is part of what I do. That's not really community service, it's just my anti dimensiona.

Host: Yeah, I really appreciate you sharing what has brought you joy and, and really even after leaving, formally leaving the field of medicine, what you have done to support health and well being for others. So thank you so much for that. I want to share my extreme gratitude for you joining us today, again.

I want to thank our SGIM staff and particularly Roz Boggle, who is the executive producer, as well as the entire production team. And I want to thank our listeners. You have been listening to SGIM President's Podcast. If you like what you've heard, please rate us and leave a comment wherever you listen to podcasts as it helps others to find us.

Also, look for us on the SGIM website, sgim.org, and follow us on X.