Jada Bussey-Jones (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 members, and healthcare broadly are in a stronger position to grow, innovate, and meet the challenges of our time.

So to our listeners, I say thank you so much for joining us. And today, I also want to thank Dr. Stephan Fihn, who I'm so excited to talk with. He is a Professor of Medicine University of Washington. Dr. Fihn earned his MD St. Louis University and his MPH at University of Washington, and he has countless transformational leadership roles across academic institutions, the VA health system, and societies like Society of General Internal Medicine.

For all of his work, he's been recognized with several awards. Just a few include the Association of Chiefs and Leaders in General Internal Medicine's Chief's Recognition Award; the Robert Glaser Award for Outstanding Contributions in Research, Education, and Generalism in Medicine; the Society of General Internal Medicine's Eleanor Rhodes Service Award; VA Exemplary Service Award; and the Undersecretary Award for outstanding Achievement in Health Services Research. That research addresses strategies for improving efficiency and quality of primary and specialty medical care, and understanding the epidemiology of common medical problems. He has published over 300 scientific articles and book chapters and co-edited two editions of Outpatient Medicine. And he's the deputy editor of the JAMA Network Open.

So, Steve, thank you so much for agreeing to spend some time with me today. I think that introduction—I'm always impressed when I read the intros for my colleagues, but it epitomizes a career of leadership, it epitomizes a career of impact. And so, with so many roles and experiences, I just want to start at the beginning. How did you start on this journey, and particularly on your leadership journey? Did you always know you wanted to be a leader?

Stephan Fihn, MD: No, I didn't. I've always been a person who wants to try and make things improve, and have a great deal of difficulty saying no to requests. And along the way, you know, opportunities arose. And over time, I began to be able to try and evaluate opportunities for leadership. As you do more, as you well know, you often get asked to do other things. And I'm sure you get asked all the time. And again, part of this is the ability to determine which opportunities are best suited my particular interests and abilities.

 In terms of specific opportunities, it's kind of odd to say, but I've never actually applied for a job except for one in my later career, which get. So, one thing sort of led to another. Over time, I've kind of developed a rubric, if you will, for deciding what opportunities to take. It's unfortunately all too apropos at the moment with current events. It's actually Colin Powell's doctrine for going to war. And there are four criteria.

One is have clear strategic objectives. So if an opportunity comes up, is this something where I can actually make a difference, there's something to be accomplished? Two, he said popular support, overwhelming popular support. And in that, I interpret that as something, is this an institution or an organization that's going to provide the environment and support to be able to accomplish those objectives? He also said you should have overwhelming force, which I sort of meant, "Do you have the qualifications? Do you have the resources? Is this a good fit for you?" And the last was, you have an exit strategy?" And by that, I think, "Do you move on?" You know, is this sort of a dead end or is this something that's going to lead to some gain in knowledge and skills that you'll be able to take on to the next opportunity?

So as opportunities have arisen, I sort of look at them that lens and say, "Is this something that's going to be well-suited for me?"

Host: I love that, sort of considering opportunities as if you are going to war. I had not thought about that, but I think that's a fascinating sort of rubric to use. Tell me a little bit about yourself, if you don't mind, about background before you started medicine, your road to medicine more broadly.

Stephan Fihn, MD: I grew up in the Midwest, a family that had no academics or medical folks. And that I think was a major factor in my ultimately ending up in medicine was my mother had fairly severe and longstanding mental health issues that got me interested in psychiatry and psychology. I went to college, became a psych major. And then, actually, after that, did a chemistry major, and went off to medical school thinking I would go into psychiatry. fell in love with internal medicine and that was a love affair that persists till today, and did not do psychiatry.

And When I was a fourth year medical student on an externship at Barnes Hospital in St. Louis, where I actually also met my wife. I had a senior resident who had been at the NIH and had returned to finish his residency and do a cardiology fellowship. He was at NHLBI. We became quite close. And he actually invited me to come do a fellowship when I was done with my residency at NHLBI. And I agreed.

So, I went off to my internship already having arranged my fellowship in cardiology. And I got on a cardiology rotation early in my internship and realized that I didn't like it. I envisioned it to be listening with stethoscopes and figuring out physiology. And in those days, it was more becoming echocardiograms and cardiac tests and procedures.And I realized it was going to become a procedural specialty.

And so, I went to my chairman, who was mentor for me, Bob Petersdorf, and told him wanted to change course. And he said, "Well, what do you want to do? And I said, "I want something general, something more cognitive, not procedural." And I was thinking about infectious He was a very gruff and brisk guy. And he said, "Nah, don't do that." He said, "There are too many ID guys around, do something else." And I said, "Well, should I do?" And he said, "Well, there's this new program, the Clinical Scholars Program, you should go do that."

So, in those days, we listened to our mentors and I applied to the program. And a few weeks later, I was on service at the VA and I got a message from the Chief of Medicine, who at that time, Phil Fiacco was the Chief of Medicine at the VA, subsequently the chair of the department and the dean. And he called me into his office and said, "I hear you don't know what you want to do with your career." And I said, "Yeah, I think I have a plan." And he said, "Well, you're attending, Jim Ritchie, who's a cardiologist, said that you abandoned this NIH fellowship and we're going to go do something else, primary care or something." And I said, "Well, that's my plan." And he said, "That's a terrible decision and you're going to ruin your career." And I sort of shrugged and went off and it turns out to have been the best decision I've ever made. And I was very, very happy as a clinical scholar and that led into GIM.

Host: love that story. And sort of symbolizes a story that I've heard a lot, especially during that time where there weren't many models and wasn't much respect for general medicine or generalism as a career choice, especially in the academic space. So, I'm so glad that you stuck with it.

So, you mentioned sort of getting introduced to SGIM. Tell me a little bit about that. How did you get started in the organization? Was it a part of the fellowship? What started you and sort of what kept you coming back?

Stephan Fihn, MD: Well, I think Lee Goldman in his discussion that you mentioned that, in those days, there was something called the Tri-Societies, the AFCR, and everybody went to those. That's where you presented your research. You got to know colleagues. Your chairman was always there. And as first-year fellow, I went to AFCR to present my research. And my mentor and fellowship director, Tom Nguyen, had mentioned it at the hotel down the hill, across the street at the shore, there was this meeting of Trepson, and that I should go check it out. And I went down there, and I was immediately enamored with what was going on, phenomenal people, really interesting discussions, and was very different in those days. But I immediately decided these are my peeps. And from then on, I have not missed a meeting except for one in, I think, something like 46 years.

Host: Amazing. Yeah. These are definitely our peeps. But that's amazing that you've only missed one meeting in all that time. That is awesome. So, tell me during your tenure president, if there's anything, any experiences that you want to reflect on, something that you're particularly proud of, if you think back, it could be as president or really any time during your membership.

Stephan Fihn, MD: I've witnessed the transition of SGIM from what was basically a mom and pop organization, you know, Elnora Rhodes, who was our revered administrator for many, many years, sort of ran the organization with a part-time high school student. And during I think the tenure of several consecutive presidents, Bill Tierney, Nikki I think we undertook to professionalize the society. When Elnora retired from the society, we hired a professional administrator, Dave Carlson. We organized finances of the organization, which were really hand to mouth and established the rainy day fund and a good financial base.

And then, I think, you know, the evolution has been to professionalize the society today where, you know, it's a remarkable organization and supports so many people and so many activities in a tremendous way. So, you know, I think I and some of the other people played our small parts in sort of maturing the organization, so that it's been durable.

I think a funny thing was when we recommended that—I was secretary treasurer at the time—that there be a reserve account, a rainy day fund, if you will. And we suggested that, you know, it be equivalent to one year's budget and people were appalled. How can you keep all that money from, you know, our members in the bank? And we said, well, most of our money comes from the annual meeting. And what happens if the annual meeting gets canceled for some reason? And people said, "Oh, that could never happen." So, I sort of smiled knowingyou the pandemic happened and we couldn't have a meeting, you know, I was just pleased that we had a society that was resilient enough to be able to survive that.

Host: Yeah. Well, that's amazing. And personally appreciate the foundational work that you and others did to kind of really bring our organization forward. As we're looking forward to our organization's 50th anniversary, you were kind enough to share with me your presidential address. I'm wondering if there are any recommendations or thoughts that you want to share for the next generation of leaders or the organization 50 years from now, what you hope.

Stephan Fihn, MD: Oh, my goodness, I have trouble thinking about two, much less 50. But I think to emphasize what the society's done extremely well to maintain that, for me, it's been the collegiality, the relationships, the long-term associations throughout my association with SGIM. I think unwavering commitment to equity, diversity, and fairness and justice, that's been part of the society from its get-go. And I've learned a lot over the years from society members. I've been taught much about that and the best possible ways.

There are two areas where I think the society could really invest more and, if you will, do better. One has been the practice model. I think people fail to understand that, you know, the primary care model, which we championed 40, 50 years ago, was really designed to address specific problem. And that problem was fragmented care. or were getting their care from all these different places. The quality was quite low and spotty. And the idea was that, you know, you could coordinate that, you know, general physician who could coordinate that. And I think it's been somewhat successful, but I think not near so successful as any of us had hoped. Care was still fragmented. And worse, I think, patients aren't terribly satisfied in general with medical care. They may be satisfied with physician if they can find one and see one.

But in general, I think there's not a very high morale among practitioners. It's an expensive model. And so, you know, I think we really need how to make that practice model much more functional, much more affordable, much more effective. It may mean abandoning some of the sort of long-held tenets about how we practice being much more adventuresome and innovative and flexible. I don't know what those changes necessarily will be, but I think, you know, it's important, particularly for our younger members not to cling to something which was a model. It needs to be updated. It needs to grow and adapt to the rapidly changing society. And I think we need to support that.

 I think the other area when I joined SGIM, it was a research organization. That's what attracted me. there's still certainly research. And the organizations evolved, I think, properly and beneficially to encompass a much broader base of members, clinicians, teachers, all sorts of policy-oriented folks, and I think that's wonderful. But I do feel that we've not maintained our commitment to research. I think a lot of our research members are presenting their work in other venues.

And this is going to sound a little harsh, but I think that sort of quality of research has not kept up. I think we're engaging in a lot of opportunistic research using databases and statistical techniques, which don't involve going out and really asking the harder questions and getting primary data. And I think that's unfortunate, because I think we're in a tremendous position to really capitalize on the assets, particularly the electronic health record. That not only is vehicle for improving care, but it's a tremendous vehicle for conducting research, not just passively by analyzing the data, which are absorbed. But by using it, you know, as an instrument to intervene and change care. I hope that, you know, members will really take advantage of the HR and other opportunities to sort of be much more creative much more productive in terms of the kinds of research that are being conducted.

Host: Wow, you've given me so much to think about, and our organization a lot to think about. So, I really appreciate that. am wondering if we could just take a step back to maybe a little less serious topic and talk about, you know, you have clearly sustained a successful career. So, I'd love to hear about your sources of inspiration. I'd also love to hear about your sources of joy. It's got to be busy to be a leader and to have multiple irons in the fire. So, what inspires you and what keeps you well?

Stephan Fihn, MD: My inspiration have been the people that I work with. I've always said that you better like the people you work with, because you'll spend more time with them than you will probably with your family or anybody else. And I've been so fortunate. I've always worked for people. I admire and respect the colleagues I've had in SGIM. I still work closely with many of them. I think that's been my inspiration. My wife is an inspiration too. has always encouraged me to be a much better person than I otherwise would be, I think.

And in terms of joy, have so many sources of joy. I mean, my career has been, you know, very satisfying particularly, again, the people I've had a good fortune work with. In my personal life, I've got three wonderful kids and now three grandsons. And spend as much time with them as possible. My wife and I now have more time together. We've just become stewards for an organization called Sound Water Stewards, which does citizen science on our island and the island adjacent to us. We raised service dogs. towing them around at the annual meeting.

Host: Oh, that's right. Yes, I remember.

Stephan Fihn, MD: Our 11th one, and Cambria will be able to come to the meeting this year. I try to ride my bike 80 to a hundred miles a week and swim 8,000 to 10,000 yards and stay active and occasionally try to get to my woodworking shop. So, I've got lots to do. And I'm still active. As you said, I'm the executive deputy editor at JAMA Network Open, which is big job. We get 20 plus thousand submissions a year. And I have to deal with about a third of those. we publish eight articles a day, and I'm still engaged in research at the university.

So, you know, I've stopped being division head and I've shed most of my administrative—in fact, all of my administrative responsibilities. But I'm still busy and going to keep going for a while, I think.

Host: That is so awesome, and I feel incredibly blessed too, as it sounds like you do as well to have jobs that I love, right? I was just talking to a family member. And she has worked for 30 years in a job that she does not like. I feel incredibly grateful to have careers—even though they're not perfect—but over and above, you know, things that I love.

And to your point, now you're able to explore and spend more time on all those other things as well. So, thank you for giving me that inspiration. So, as we are wrapping up here, I'm just going to give you one last opportunity for any final comments that you want to share or any final thoughts that you want to share with the audience.

Stephan Fihn, MD: Yeah. And I will say this, I'll say this to the junior members of our society, that times seem very challenging and discouraging right now. And think that there's every reason to be optimistic, to look forward to a future. I told that story of me and medicine, just to sort of let you know that for many of us, life was uncertain. There weren't funding agencies. My university didn't even have a division of general internal medicine. We've weathered Nixon, we've weathered Reagan, we've been through some really tough political times and as well as financial times. And this is a great career. And, you know, I think there's every reason to be optimistic. The people around you will support you and help you. And just think this is not a time to sort of be too depressed and we all need to stick together and wait till things improve and do all we can to get them to improve.

Host: I love that. Thank you so much, Steve, for that final message of optimism and resilience. I'm going to say I want to thank you again for joining us today. And also thank the SGIM staff and my producer, Roz Bogle, and the entire production team. I also want to say thank you to our listeners.

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