Jada Bussey-Jones, MD (Host): Hello, This is Jada Bussey-Jones, the past 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 hope to capture insights from our national thought leaders so that our organization, our membership, and healthcare broadly are in a stronger position to grow, innovate, and meet the challenges of our time.

So to our listeners, thank you so much for joining us. Today, I'm so delighted to talk with Dr. Thomas Gallagher, who is a journal internist and a Professor in the Department of Medicine at the University of Washington, where he's the Associate Chair for Patient Care Quality, safety, and Value. Dr. Gallagher is also a professor in the Department of Bioethics and Humanities. His research addresses the interfaces between healthcare quality, communication, and transparency. He has published over a hundred articles and book chapters, which have appeared in leading journals and including JAMA, New England Journal of Medicine, Health Affairs, and many more. He is also the executive Director of the Collaborative for Accountability and Improvement, an organization dedicated to advancing the spread of communication and resolution programs. In 2017, his work was recognized with the receipt of the John M. Eisenberg Patient Safety and Quality Award for individual achievement presented by the National Quality Forum and the Joint Commission.

Of course, he served also as the President of Society of General Internal Medicine, and he has been recognized as a Master of the American College of Physicians in 2019. Tom, thank you so much again for joining us. I would love-- after that fabulous introduction that talks a lot about your history, but I really want to hear it from your perspective. Tell me about yourself, how did you get started on this pathway in medicine? And in particular, why did you choose general internal medicine as your career?

Thomas Gallagher, MD, MACP: Well, it's so great to see you and have a chance to chat together today. And when I look back on sort of my career, I think a couple of things are important. One, both my father and my grandfather were private practice generalist physicians in Southern California. This was way back in the day where when you were in practice, you owned an office and employed a staff. And my grandfather was a solo practice pediatrician in downtown Los Angeles. And that's really old school. I think people have trouble imagining what it would be like to start out a career as a physician today versus back when my grandfather was starting. But my grandfather was actually my pediatrician for a little while until my mom thought maybe it's not such a great idea to have your grandfather as your pediatrician.

But as I would watch my dad in the town where we grew up, we'd be in the grocery store and he'd run into one of his patients, and I could tell there was something really special going on in the relationship between the doctor and the patient. And I thought I'd really like to be a part of that sort of specialness. So, I went into college knowing that I wanted to go to medical school, but feeling like there would be plenty of time for science classes. And so, I took the minimum science classes required for medical school, but I was a religion major. And that's where I really became interested in ethics and philosophy and human values as they relate to medicine.

That was also the time, incidentally, I think, I became interested in leadership, although it wasn't through a traditional route. I've always been interested in music and did a lot of piano and voice growing up and, in college, became interested in conducting. I went to a small liberal arts college where someone who has some but not extensive musical skills can participate in things like conducting. And so, I ended up taking several classes in conducting and conducting the pit orchestra for a couple of musicals in college and really became interested in how do you get groups of people to essentially play in harmony together and in time, and realize there that you need a different set of skills to sort of help groups perform optimally. And that's when I became interested, I think, in leadership. Having a father and a grandfather who were both generalist physicians, I think, that was a natural path for me to follow. And I've really been pleased that I've taken that route.

Host: I love it. First of all, I have loved hearing these stories, sort of the origin stories for all of our colleagues in general internal medicine, and they're so varied, right? So, you are one who had came by it earnestly having generations of physicians in your family, but still the interest in religion and ethics and values and how that's been integrated into your career as well as the pathway to leadership through music. I just love hearing the different pathways. So, thanks so much for sharing about your career broadly.

I wanted to hear, because as I was looking at your bio and, of course, much of the work that you've done, I wonder if you might share a little bit about your interest in communication, particularly communication around medical errors, how we share with our patients and families these kinds of things. And just based on your years of work, are there things that you think we should know either as clinicians or as patients and communities?

Thomas Gallagher, MD, MACP: I think, as I was watching my father in action. As I said, I could tell that there was something special about the doctor patient relationship. And so, as I was in medical school, I really became interested in what happens when that relationship is under stress. And as I started my medical training, I sort of thought there aren't many things that put that relationship under stress as much as when something goes wrong in healthcare. Patients come into the healthcare environment vulnerable, scared. There is a knowledge and power differential between the patient and the provider. Patients and clinicians hope that healthcare will go well, but it's a human enterprise. And so, patients will be harmed either because of errors or system failures, or because medicine even delivered properly is inherently risky.

And then, as I'm sure everyone in medicine does, I had a variety of experiences as a medical student and a resident where I saw significant things go wrong in care, and I saw how strong that impulse was on the part of healthcare providers to look the other way, to want to put our heads down and hope everything would blow over to minimize or rationalize. And I could just see how that approach of sort of looking the other way, not being willing to step forward and have some of those difficult conversations, how it made things so much worse for patients and families and how it made things so much worse for the healthcare team.

So, my academic career really has focused both on research, but then later on driving implementation around programs that are known as communication and resolution programs that try to provide a structure and a process given these human reflexes that we all experience and doctors are not immune to sort of not be interested in looking at problems squarely in the face; having structures and processes so that each and every time something goes wrong, the organization can support physicians and other healthcare professionals in responding appropriately is really important.

Although, Jada, I will tell you, as I started on this research career, I thought I might have been making a mistake because I thought, "Well, maybe people will get the hang of this very quickly, and I'll need to move on to another research topic." And, you know, four or five years later, it turns out it's super hard to do this well. And it also turns out that as a research area, it has many of the benefits of being something that really can support a long-term career lending itself to empiric research, health policy research, advocacy work with all sorts of different stakeholders, and a funding source largely, but not solely through the agency for Healthcare research and quality. So, I sort of stumbled onto a topic that turned out to be both personally really meaningful, but also a good one to build an academic career around.

Host: Well, I mean, it's such important work. And so, you kind of leaned into this question, but have we made progress? I mean, it's certainly been enough to sustain your career. Have we moved at all? I know that there's still work to do, obviously, but any movement in this space that you can sort of point to?

Thomas Gallagher, MD, MACP: I have really been pleased by the progress. And just as evidence of that, the CMS released about six months ago what they called their patient safety structural measure, which is a series of attestation statements that hospitals have to say yes or no, do we have these different elements related to a strong culture and climate of safety in place at our organization?

And communication and resolution programs got not only one, but two attestation statements. Organizations now have to attest whether they have a highly reliable communication and resolution program in place, and whether they use metrics. Shout out to all of our general internal medicine measurement colleagues. Are you using metrics to track the progress of your communication and resolution program and report that data quarterly to your board? So when the field progressed to the point where CMS included it in an attestation requirement, I thought we're making significant progress here. But one of the reasons CMS did that, because they recognize that having something like a communication and resolution program is super important, but many organizations are implementing these programs really inconsistently. And so, CMS hopes that the patient safety structural measure will encourage more reliable CRP implementation.

Like, just as an example, we were working with one organization that had two patients virtually identical. They both were middle-aged patients who experienced a delayed cancer diagnosis. in this case, both experienced a delayed cancer diagnosis because of a critical finding on a CT scan from about a year prior had been overlooked. Both were diagnosed with stage IV cancer. One patient was an affluent businessman. The other was an undocumented non-English speaking landscape worker. And to watch how differently the organizations handled these two very similar patients that experienced their harm events almost at the same time. It was really disturbing and disappointing and pointed out how much progress the field has to make. The wealthy businessman got a prompt explanation, an apology, an offer of compensation. And the claims folks working with him described him as very easy to work with.

The patient who was not documented and unhoused non-English speaking, initially they balked at providing him an offer of compensation, because they said he didn't have a social security number and that was necessary to provide compensation, which it turns out it's not. And then, they decided, "Okay, well, I guess we can provide some compensation, but he's going to have to sign this five-page form written in English," had to get that translated. And all the while this gentleman was literally asking for Dr. Kevorkian. He was just so upset, he wanted to kind of crawl into a hole and die.

And these types of efforts not only are a good way of seeing how well organizations are committed to a culture of accountability and transparency. But it turns out they're an important stress test as well for our commitment to treating patients with equity and dignity and respect no matter what their background is.

Host: First of all, again, I'm just so inspired by this work and I know it's one thing to have a career in academic general internal medicine, but to really see the impact of your work in these structural changes. Even when there's still a long way to go, I think, this is a great example of that.

So, I appreciate you sharing about your specific career interest and your expertise and all this great work that you've done. I want to sort of zoom out a bit to talk about GIM, general internal medicine more broadly. And when you think about the trajectory of general internal medicine as a career path, even as you're thinking about your prior leadership as the president of Society of General Internal Medicine. What have you seen as some important changes over time within academic general internal medicine, or what challenges do we still need to kind of address to support the careers of those of us in academic general Internal medicine?

Thomas Gallagher, MD, MACP: Becoming engaged with SGIM was sort of a no-brainer for me because my early career mentors--  Also, one of my most important early mentors was Wendy Levinson who was a prior SGIM President. When I came to UW from WashU in St. Louis twenty-three and a half years ago, I dropped into an organization and a division with several past presidents, Steve Finn, Eric Larson, David Dale. And I was highly influenced by those mentors to really recognize, well, if SGIM was the place for them, if it was the place they wanted to sort of call their professional home, I wanted to do that as well.

As a physician scientist, I think it's such a challenging time right now. And I really feel for our younger colleagues. I think one of SGIM's real strengths has been all of the career development programs that it has for folks in a variety of tracks and interests. But at least at this moment in time, the funding landscape is so uncertain that I can imagine if I were contemplating a career as a physician scientist at this moment, I might feel like this is just far too much uncertainty to tolerate and look at doing something different.

So, I know the society is really leaning in hard, both on its own and with partners, to try to address some of the challenges that physician scientists currently face. I think primary care and academic general internal medicine remain under threat. Although, if you look back over the history of the society, there are periodic reports, trying to completely re-envision what primary care looks like. And it's been a difficult needle to move. There are others who are much more expert than I am in what does the future of primary care look like. I've benefited greatly from really developing a very specific area of focus and then doing a deep dive in that area, which I think is something that if you're a physician scientist or a clinician educator or a full-time clinician, you can also really do. But that's taken me into all sorts of places I would never have imagined going.

I was in December at a week-long conference. And then, now this sounds like a boondoggle, but it was not a boondoggle, but it was in the Cayman Islands, a conference of captive healthcare insurance companies. So with our work on responding to harm, liability insurers are intensely interested in it. And I've had to raise money for our work, not only through grants and contracts from traditional sources, but from non-traditional sources like liability insurers and philanthropy. And we have a corporate sponsor program and all of these sorts of things.

So, I would never have guessed that I would be spending time talking about our work with liability insurers, brokers, attorneys and other stakeholders at a conference in the Cayman Islands. But it's by diving deeply into one specific area, and then getting immersed in all of the stakeholders who are important in that area, that it has been possible to make the work go forward.

And so, in some respects, the term generalist is a little bit of a misnomer for me because I've developed this very specific area of expertise, and then been able to really work with a variety of aligned individuals and organizations in that very specific space. But I don't think that's all that unusual when you look at the careers of academic general internists. At least physician scientists often develop a very specific area of focus and expertise, and then build on that. Whether that means going to heart association meetings or cancer meetings or informatics meetings or public health meetings. So, being an effective generalist means having broad interests, but also the ability to really go deep in one specific area.

Host: I love that. And what we've been talking about with a lot of our other past presidents is generalists, they're allow to see the entire person to have this sort of whole person focus. But then, the academic part of our mission oftentimes allows us to drill down and dive deeply into certain areas of interest and impact. So, it's the opportunity to do both, which I love.

One question that I want to ask, I've been asking everybody, as we lead up to our 50th anniversary, if you have any reflections or thoughts or advice that you would like to share to SGIM as an organization or future leaders, as we're thinking about the next 50 years of the organization, any thoughts about that that you'd like to share?

Thomas Gallagher, MD, MACP: We've been fortunate to have such a great group of not only member leaders, but also staff leaders. One of the things I'm most proud of during my time as president is working with colleagues to recruit Eric Bass as our CEO. And Eric has just been a godsend to the organization. I think as our first physician CEO, he has just done a masterful job of leading the organization forward, together with the rest of the dedicated staff. But it's been so fun to see Eric flourish in this role and for the society to thrive.

I don't know whether being generalists makes us a little bit risk averse. But I hope SGIM can continue to be bold and to take chances. And I think at times the organization has been a little bit not politically conservative, but conservative in terms of the types of ideas and pathways and strategies that they've been willing to embrace. And I think this is a time for boldness. I think it's a challenge, because our membership is diverse. And anytime that you embrace bold ideas, you risk alienating some of the members. And that's always a very, very tricky trade off. But SGIM, as people say, punches far above its weight. It's a small but mighty organization. I think there's the potential for us to be even mightier through being a little bit bolder or in the words of one of my mentors, Tom Delbanco, who was one of our past presidents to embrace a little bit more the role of troublemaker. And there's good trouble, and there's bad trouble. And I think SGIM could chart that path to embracing being a good troublemaker in ways that chart a path through this really turbulent time.

Host: So, those are great words of wisdom and advice. And also, I have to echo your comments about Eric Bass and the phenomenal role that he has played within the organization. As we're beginning to wrap up, I know you've done such incredible things, some of which you've highlighted over the course of your career. I'm curious about what keeps you well. Do you have things that bring you joy, hobbies, or other things that you do for self-care outside of work that you'd love to share with the audience?

Thomas Gallagher, MD, MACP: Well, I think that's an area of improvement for me. Work has been, over the last, you know, my wife would say forever, you know, been intense. And I think it's a little bit how I'm wired. I remember at the beginning of my career really being frustrated about why I hadn't had a paper in JAMA or the New England Journal yet. And that was a source of a lot of frustration for me.

And I remember when I had my first piece in JAMA, one that, by the way, Wendy Levinson was instrumental in helping to move forward, my brain was like, "Oh, yay. How come I don't have two papers in JAMA?" I was like, "Wait a minute. Shouldn't you like take a little bit of time to celebrate?" And apparently, that's just not how my brain is wired. And it's helpful in some respects. But it really makes it hard to get the balance right between work and family and other parts of wellbeing.

And so, I think if I could give myself some advice to sort of from current me to prior me, I think I would tell myself to not worry so much about whether you've had the paper in JAMA or the New England Journal. If you're doing good work, it will work itself out. But I find that much more difficult to put into practice. It's sort of easy to say. We've been doing some work with Bill Sage and other colleagues down at Texas A&M on some of the challenges and opportunities of having an intergenerational workforce. And this is an area where I actually think our younger SGIM colleagues have way more to teach the older generation than vice versa. Because I think the younger generation of SGIM members have come through medicine at a time when there is a whole vocabulary around wellness and wellbeing and burnout and stress that-- I don't know about your experience, Jada, but I certainly didn't have any sort of awareness. And my daughter is wrapping up her third year of a family medicine residency. And I see how differently she and her colleagues think about wellbeing and stress. Us older generations sometimes makes the mistake of thinking that this is somehow lack of a commitment to work as hard as prior generations, which I think is not the case at all. But they have a vocabulary and sort of thoughts around wellbeing and stress that seem a little bit foreign to many of us. But I think we can learn an enormous amount about. And so, I hope we're empowering the younger generations of our membership to sort of lead us older folks in embracing some of these concepts.

Host: I agree completely. I was just telling one of my medical students how we did not even have parental leave essentially when I was in training because it was just frowned upon. No one-- even though we had several women, residents-- got pregnant during residency because it was thought of as something that was done to colleagues, and there weren't, you know... So, things have come a long way. We can learn a lot from our younger generation.

Thomas Gallagher, MD, MACP: You and your female colleagues had to endure that. That's unfair and unnecessary. And I do think there's been progress in some of those dimensions.

Host: Absolutely. So, maybe, I will just offer a last opportunity to offer any final words or reflections as we're wrapping up our time together today. Any last thing that you want our listeners know or to think about as we wrap up?

Thomas Gallagher, MD, MACP: Well, I've been so fortunate to engage with SGIM over the course of my career. And I think it's like any relationship. The more you put in, the more that you get out. I know I've received far more from SGIM than I ever gave. But, you know, when I see younger physicians or trainees who are interested in societies like SGIM, I just remind them to throw themselves in and immerse themselves in all the opportunities, it was by putting my hand up and volunteering for things kind of over and over and over again, that one opportunity led to another.

And so, SGIM is an amazing organization, and I hope everyone who's listening is sort of thinking about what can they put their hand up for to help the organization, because it's that immersion and engagement that not only provides the fuel. You know, SGIM is so much more of a member-driven organization than any organization I belonged to. And that's both a blessing and, at times, a little bit of a curse. But I hope everyone who's listening to the podcast really comes away and thinks, "What can I do to help the organization move forward?"

Host: Well, I want to thank you, Tom, for all of your expertise and your wisdom and your insights that you've shared with us today. I want to thank the listeners for joining. I also want to thank the SGIM staff and Roz Bogle, our executive producer and our entire production team. Also, again, thank you to our listeners. You have been listening to SGIM's President's podcast. If you like what you've heard, please rate us and leave a comment wherever you listen to podcasts. It helps others to find us. You can also look for us on the SGIM website, sgim.org, and follow us on X.