Assessing Our Department: Looking Ahead to 2023

Transcript

• 00:00Um, so just again just to welcome you all
• 00:02to the first of our Grand Ramsey routes
• 00:04or 2023 and please do look out for emails
• 00:07from Krista about our upcoming events.
• 00:09Please reach out to Rosemary for them if
• 00:11you want to meet with any of our speakers.
• 00:14We're welcoming Dr.
• 00:15Fred Schick next week and we'll
• 00:17be visiting us from UW.
• 00:18And of course we have doctor Stephanie
• 00:21Gilson and Doctor Asad Omar and
• 00:24rounding off our January series.
• 00:26And so please do also send us any
• 00:28suggestions that you have for grand rounds.
• 00:30Our committee will be meeting
• 00:32in around 2 weeks,
• 00:32so if you do have any names or suggestions,
• 00:34send them to me or send them to Rosemary and
• 00:37we'd be delighted to add them to the program.
• 00:39So without any further ado,
• 00:40please welcome Doctor Linda Mays.
• 00:44Right. Instead of the quick.
• 00:49Welcome everyone. Microphone.
• 00:54Now it's the microphone working.
• 00:55It is great. Well, welcome everybody.
• 00:58I'm so glad it's so good to see you.
• 01:01Turn this on too.
• 01:02There's too many buttons to turn on here.
• 01:06So very good to see you, everyone.
• 01:08I'm really welcome you
• 01:09back from the holidays.
• 01:11I hope you had an incredibly restful time.
• 01:14The holidays are very much
• 01:16for rest and relaxation.
• 01:18I hope you weren't caught in
• 01:20those terrible travel snarls.
• 01:21I have to admit that I thought about
• 01:23so many of you and hoping that you
• 01:25weren't in those Southwest lines
• 01:27that I was seeing on the news or
• 01:29looking for your luggage somewhere,
• 01:30but that you also had a time for
• 01:33reunion with family and friends.
• 01:35That's truly what the holidays are about.
• 01:37And really much about reflection.
• 01:40I wanted actually this we we have
• 01:42actually if you haven't noticed we
• 01:43actually have two opening department
• 01:45talks we have one at the opening
• 01:47of the academic year and one at
• 01:49the opening of the calendar year.
• 01:50But this particular one I think
• 01:53is very much about reflection and
• 01:55wanting to think with you about
• 01:58whether you observe the holidays,
• 02:00whatever you observe,
• 02:01to actually think about this
• 02:03metaphor of the winter solstice
• 02:05because on December 21st was the
• 02:07longest day of the year.
• 02:09And you may not have been counting,
• 02:10but I hope you've been noticing
• 02:12that since December 21st,
• 02:13we've gained a minute every day of light.
• 02:17So it is the interface of light and darkness,
• 02:20and there are many ways that people celebrate
• 02:23the winter solstice about exactly that.
• 02:25But the balance of light and darkness,
• 02:28there's a lot going on as a
• 02:31backdrop for our department,
• 02:33a backdrop in our society and culture.
• 02:36But I do hope we actually will also take the.
• 02:39Embedded metaphor of Steinbeck's
• 02:41quote that what good is the worth
• 02:43of summer or spring or of light?
• 02:45Let us say that without the
• 02:48sweet cold of winter.
• 02:50So there is a lot that's going
• 02:51on and a lot of good things and
• 02:54a lot of challenging things.
• 02:56It's worth really looking back
• 02:58or looking a bit back at 2022.
• 03:01And so many of the things that are still
• 03:03going on that are out of context for us,
• 03:06the tremendous,
• 03:07we could call it political drama,
• 03:10political theater that even
• 03:12was going on last week.
• 03:14The inflation that is stressing so many
• 03:17families that we serve and whether
• 03:19we serve and research or clinical,
• 03:21the increase.
• 03:22Continued war in Ukraine.
• 03:25And the dramatic,
• 03:26dramatic increase in gun violence
• 03:30impacting so many children and families.
• 03:33I don't want to begin this talk
• 03:35and that kind of dark way.
• 03:37I really want you to hold the
• 03:40dark lightness metaphor in mind.
• 03:41But it is important that this
• 03:43is a context for all the change
• 03:45going on in our department,
• 03:47in the school and in our society.
• 03:49And I would ask the question of
• 03:52when we really stopped counting.
• 03:55It has been.
• 03:56It has been 1035 days,
• 03:59March the 12th 2020 when the pandemic began.
• 04:04And our world's changed and yet
• 04:06New Haven is still a hot spot.
• 04:09There were 771 cases last week
• 04:13in the state of Connecticut.
• 04:15It's not quite the same as it was,
• 04:17but COVID is still with us and there's
• 04:20140 something patients still in
• 04:22young New Haven Hospital with COVID.
• 04:24So COVID is still a part of the metaphor.
• 04:28Of our changed and changing world.
• 04:31And our world has changed,
• 04:32not just because we're
• 04:34working now in a hybrid way.
• 04:35We have people back here
• 04:37that I keep looking back to.
• 04:39We have people back here as well
• 04:41as all of you here in the room.
• 04:43It's not that we're paying attention
• 04:45to the new variants and whether
• 04:47we wear masks or don't mask.
• 04:49And what environment do we wear mask in?
• 04:52But we're also coping,
• 04:53as I've said now on several occasions,
• 04:55with a tremendous amount of uncertainty,
• 04:58and we're learning how to cope
• 04:59with that in a culture that hasn't
• 05:02always had so much uncertainty.
• 05:04And a theme that I'm going to
• 05:06come back to is we're actually,
• 05:08there's a tremendous amount of change
• 05:10going on in academic health centers,
• 05:12which I will come back to this because
• 05:14this is the context in which we're working.
• 05:17So it is a changed and changing world.
• 05:21And it is the continued backdrop as we
• 05:24take this moment on January the 10th,
• 05:272023 to look ahead and we try to find
• 05:30the needle that will navigate ourselves
• 05:32through this thread of uncertainty.
• 05:35So what would you say the
• 05:37state of the department is?
• 05:39I would say we're actually
• 05:41doing quite well though.
• 05:42We actually are stressed and we
• 05:44have some challenges that I will
• 05:46talk about and we're in the midst
• 05:48of tremendous amount of change.
• 05:50And I picked the graphic of change
• 05:53versus chance quite intentionally.
• 05:55Because it was on March 12th,
• 05:572020 that we were presented with a
• 05:59chance that we didn't anticipate,
• 06:02but we have adapted to it and
• 06:03we are adapting to it.
• 06:04But it has brought a tremendous amount of
• 06:07change that we are still in the middle of.
• 06:09And as usual,
• 06:10I will talk about a lot of some of the
• 06:13watts of what's happened in the department,
• 06:15but also a lot of the how,
• 06:18how are we going to get forward?
• 06:20What are the changes we're
• 06:21going to continue to be making?
• 06:23How are we thinking about?
• 06:25Just as one caveat.
• 06:27I intend the slides that you will see.
• 06:30I actually also intend them
• 06:32as a reference point for you.
• 06:34So some of them will have more
• 06:36information than I will go over.
• 06:38I want you to be able to go back to
• 06:40them and ask a question what about X
• 06:42and go back and look at the slides.
• 06:45So they've been created some of
• 06:47them with that purpose in mind.
• 06:49I also want to remind you again
• 06:51that we actually did an opening
• 06:53talk in September 2022 and set a
• 06:55number of goals for these areas.
• 06:58And I'm going to go back to some of
• 07:00those goals and ask the question,
• 07:02have we met them or where are we in those
• 07:05goals? Because we're also in a climate
• 07:07and I and A priority of holding ourselves
• 07:10accountable to the goals that we set.
• 07:14And then to remind you of our we also set
• 07:16a theme for this academic year in 2022,
• 07:19which was generativity and grace.
• 07:21And I will come back to
• 07:23that theme throughout,
• 07:24but also at the very end with the quote.
• 07:27The world is not ours.
• 07:28The Earth is not ours.
• 07:30It's a treasure we hold and
• 07:32trust for future generations and
• 07:34maybe be worthy of that trust.
• 07:36So that is a theme that will come back to us.
• 07:39With that in mind,
• 07:40here are the areas that I want to cover.
• 07:43I want to do a few departments snapshots,
• 07:46kind of traditional,
• 07:47a few things that I think it's worth
• 07:50covering every year so that you get
• 07:53a sense of the kind of fundamentally
• 07:56basic data about the department.
• 07:58I want to offer you a strategic
• 08:00reframe about how we present ourselves
• 08:02and how we present the work we do.
• 08:05We're a tremendously complex department,
• 08:08and there's multiple ways of presenting,
• 08:10so I'm going to offer you an idea.
• 08:13The second,
• 08:13the third is to follow up on some of
• 08:16those goals we set in September 22 and 22.
• 08:19And then for the last part of the talk
• 08:22I'm going to talk about working with
• 08:24systems and thinking systemically.
• 08:27We tend to think departmentally.
• 08:29But I want us to also be thinking where
• 08:32do we fit in the system and how does
• 08:34should that be changing our thinking?
• 08:37I want to bring you into the little
• 08:39graphic I showed you earlier about
• 08:41how medical centers are changing,
• 08:42then how that impacts our clinical mission,
• 08:45and then return to generativity and grace.
• 08:49Glad to see people coming in
• 08:51and people coming on.
• 08:53So.
• 08:55Importantly, this is one of those
• 08:56slides which I give you for information,
• 08:59not for reading.
• 09:00And I'm going to give you,
• 09:02I'm going to tell you what the
• 09:04three key points on this and
• 09:05then when we post the slides,
• 09:06when Christa points the post them online,
• 09:09you'll be able to go and
• 09:11look at the actual details.
• 09:13But the key points are.
• 09:15That as a community we're growing.
• 09:17We're now 531 people in this community.
• 09:21That does not include the secondary
• 09:23faculty appointed in other departments.
• 09:25Primarily we are 531.
• 09:27Our faculty has grown to 187,
• 09:31which is pretty dramatic.
• 09:34Our latter faculty up here at 70,
• 09:37we were just a few years ago, 43,
• 09:39so we have grown dramatically.
• 09:42And if you look down at the
• 09:44racial and gender distribution,
• 09:46we're getting better, we're getting better,
• 09:48but we still have a lot more work to do.
• 09:51This is a slide that you will
• 09:53want to go back to.
• 09:55But I want to actually take a little bit
• 09:57of a deeper look at the promotion progress,
• 10:00and this takes that 70 ladder
• 10:02faculty and splits them up.
• 10:04And as you see,
• 10:05we're still a little top heavy.
• 10:08You actually should be kind
• 10:09of decreasing as you go up.
• 10:12So we still have a few more professors,
• 10:14we should have more associate professors.
• 10:16And so we begin to attend.
• 10:18We need to attend to the
• 10:21developmental progression here.
• 10:22If we actually look at the
• 10:25associate research scientist ranks,
• 10:26once again we need to be attending
• 10:29to moving more ARS folks up and to
• 10:32this research scientist and the
• 10:33senior research scientist rank.
• 10:36It's work that's going going
• 10:37and we've been doing it,
• 10:38but we need to do more.
• 10:41And then finally,
• 10:42one that you've heard me talk
• 10:44about so many times with our
• 10:46masters level clinicians as we
• 10:47need to be able to attend to,
• 10:49how do our masters level clinician
• 10:52progress beyond assistance professors
• 10:54to give them a trajectory and a
• 10:57progression reflective of the clinical
• 11:00sophistication that they present.
• 11:02The other snapshot is to look
• 11:04at our department finances.
• 11:06And we've actually grown in that way too.
• 11:08We have a 52.1 million now
• 11:10revenue for the total department.
• 11:13You will also notice that our
• 11:15expenditures go a little bit
• 11:16more we spend beyond our means.
• 11:18That reflects actually the clinical practice,
• 11:21which I will talk in more detail about,
• 11:23but I want to call your attention
• 11:25to a few details.
• 11:27Our direct expenditures on grants and
• 11:29contracts not including the INDIRECTS
• 11:32is over half of our clinical revenue.
• 11:34This 28 little over 28 million.
• 11:37We have 161 active grants.
• 11:41That's in grants and contracts.
• 11:43That's actually quite extraordinary.
• 11:45We have 161 and this is the number of
• 11:49grants that went in actually just last year.
• 11:51So we have a lot of grants.
• 11:54I also want to call your attention
• 11:55to this is just fee for service
• 11:57billing that we bill 12.5 million,
• 12:01but look at the difference
• 12:03in what we collect.
• 12:05And that reflects the structural
• 12:08built in reissues around
• 12:10reimbursement for behavioral health.
• 12:13We bill what it is worth.
• 12:16We build what we should be getting.
• 12:18But this is what we collect and
• 12:20you can see that just small detail
• 12:22that our inpatient unit does a
• 12:24little bit better on collections
• 12:26a little bit but not much we bill,
• 12:28but we don't get what we should
• 12:32be getting structural issue.
• 12:34I want to dive just a little deeper in
• 12:36the sources of income for the department.
• 12:39And again,
• 12:40this shows you that grants
• 12:42and contracts are 50%.
• 12:43That's really our,
• 12:44that's our bread and butter.
• 12:46We are, we are really strongly
• 12:49at grants and contracts.
• 12:50But endowments plus gifts makes up
• 12:53nearly 20% of our total revenue.
• 12:56This is why we spend so much
• 12:58time in talking about linking
• 12:59to donors and associates,
• 13:01because this is a substantial
• 13:03portion of supporting the department.
• 13:06We are very different from other departments.
• 13:08We have great relationships with donors.
• 13:10We actually cultivate them.
• 13:12We look for a lot of resources in that way.
• 13:16I want to dive just a little bit
• 13:19deeper into the clinical revenue.
• 13:21Now what I showed you a moment
• 13:22ago was simply
• 13:23the fee for service revenue.
• 13:25We have a lot of clinical
• 13:27contracts for clinical services.
• 13:29So our total clinical revenue is here.
• 13:32Our personnel costs are here.
• 13:35We have 16.2 million and total clinical
• 13:38revenue we it cost us 15.5 and personnel.
• 13:42The non personnel cost include IT support,
• 13:46malpractice, etcetera.
• 13:48And then we pay assessments on clinical
• 13:50to back to Yale School of Medicine
• 13:53at 2.6 and we have space cost at 2.5.
• 13:58This leads to a shortfall of 6.5.
• 14:03Some points to make.
• 14:05I'm not showing you the rest of the budget,
• 14:08which is about research and education,
• 14:10but because we fully cover that line
• 14:13of business by department resources,
• 14:15fully cover it,
• 14:16that actually makes us in
• 14:18contrast to other departments.
• 14:20I refer to this as the Bay of
• 14:22Fundy phenomenon because usually
• 14:24in other departments the clinical
• 14:26revenue flows to support research.
• 14:29We like the Bay of Fundy flow backwards.
• 14:32Well,
• 14:32actually research doesn't support clinical,
• 14:34but our clinical doesn't support research.
• 14:38The other point to cover is that this
• 14:40number is 95% of our total clinical revenue.
• 14:44Personnel are our greatest expense.
• 14:47Makes sense.
• 14:48Doesn't it mean behavioral health
• 14:50is delivered by people?
• 14:52We're not using operating rooms,
• 14:54we're not using procedures.
• 14:56It's delivered by people.
• 14:58The second point,
• 14:59excuse me,
• 15:00second point to make is this delta is
• 15:02covered by our colleagues in your medicine.
• 15:06So when I talk about systems in a little bit,
• 15:08it's very important that we're
• 15:10a part of this system.
• 15:12Next point to make is that these are fixed
• 15:15costs by being members of the Yale system.
• 15:18The assessments and the space cost are
• 15:20fixed by being members of the Yale system.
• 15:23And even if you took out those fixed costs,
• 15:26there would still be a deficit.
• 15:29That reflects the structural issues
• 15:31that relate to the reimbursement
• 15:33for behavioral health.
• 15:34Why I keep hammering on that is because
• 15:37all of you have a chance when you vote.
• 15:40When you talk to your representatives,
• 15:42you all have a chance to make that point.
• 15:44It's actually really critical.
• 15:47And we'll come back to this in a moment.
• 15:51Remember, philanthropy is nearly 20%,
• 15:54nearly 1/5 of our annual revenue.
• 15:58And we had a,
• 15:59so we worked really hard with donors.
• 16:01We actually had a great virtual
• 16:04Associates event in November of 2022.
• 16:06We used a short Ted talk format so we
• 16:09could we could highlight more people.
• 16:11We did a research in clinical.
• 16:13Our associates really liked
• 16:14the blend of clinical,
• 16:16they really liked hearing
• 16:18from hearing the the clinical
• 16:20stories as well as the research.
• 16:22And then we supplemented that
• 16:23with posters and talks that we
• 16:25put online that gave us a whole
• 16:27library of things that we could.
• 16:29Continue to use for other events,
• 16:31so thanks to everyone for doing that.
• 16:34And we will have smaller and
• 16:36more focused and more frequent
• 16:37fireside chats that are focused on
• 16:40specific topics coming up in 2023.
• 16:45Just so you know, for 2022, we have
• 16:48gotten 2.4 million in current use funds.
• 16:50That means gifts that we can actually use
• 16:54now that come to all of you as either
• 16:57specific programs or more generally.
• 16:59And there's a number of pending gifts that
• 17:01are under active discussion, as listed here.
• 17:05We're really this little graphic up
• 17:07here is to make the point that it's not
• 17:11just money that we're looking from,
• 17:12from our associates.
• 17:13They give us their time,
• 17:15they give us a tremendous investment in time,
• 17:17but they also connect us to networks and
• 17:21to goods, as it shows in the graphic.
• 17:23Just this week alone,
• 17:25I've had two associates reach out to
• 17:27me and say you should contact this
• 17:29person because they're doing this and
• 17:32venture capital and behavioral health.
• 17:34Some of that comes about,
• 17:36some of it doesn't,
• 17:37but they actually make the networks for us,
• 17:39so it's more than just their donations.
• 17:43These are some of the areas that
• 17:45we're actually working around raising
• 17:47funds and stewarding the relationships
• 17:49with our donors around.
• 17:51Faculty recruits surround actually
• 17:53bridging funds,
• 17:54an innovation fund for those ideas
• 17:57that aren't ready NIH grant ready yet,
• 18:00but they just need a little funding
• 18:02to start it.
• 18:03We're working with Pediatrics around a
• 18:05child health, not child mental health,
• 18:07but child health more generally,
• 18:09a collaborative venture and also how
• 18:12to sustain our clinical practice.
• 18:15And while we always look for endowment
• 18:17funds that will go through perpetuity
• 18:19that you know well past any of us,
• 18:21those funds will still be yielding.
• 18:23We also always need gifts that are flexible,
• 18:26that we can use now to meet the
• 18:28need that there is that we have.
• 18:33So now let me go to this reframe
• 18:35that I want to thank with you about.
• 18:39And I'm going to present an idea,
• 18:41I hope that if the idea will be planted
• 18:44and then you can go and look at the slides
• 18:47again and and send thoughts or maybe
• 18:49volunteer because I will call for volunteers.
• 18:51But how in the world do we present ourselves?
• 18:55So how do we actually actually capture the
• 18:58complexity and synergy across our missions?
• 19:02We, like any other department
• 19:03in the School of Medicine,
• 19:05have the traditional missions.
• 19:07We have research, we have clinical,
• 19:09we have teaching,
• 19:10and we add policy to ours.
• 19:13In 2019, we rebranded ourselves with
• 19:16a new tagline of where Discovery
• 19:18inspires care as a way of presenting the
• 19:21relationship between research and clinical,
• 19:24between education.
• 19:25All of those things was intent intended
• 19:29to be captured in those four words.
• 19:32We think of ourselves as developmental
• 19:34science and child mental health,
• 19:35and we often present it where we have
• 19:39developmental research here at the
• 19:41core and things flowing out from it.
• 19:43Another way we present it is a Union.
• 19:46A union around the child and family,
• 19:48the kind of patient centered perspective.
• 19:51And putting these kind of the four
• 19:53missions around that and say that
• 19:56we're helping children and families
• 19:58thrive from generation to generation
• 20:00with a special focus on excellence,
• 20:03that's another one.
• 20:051/3 way we present ourselves is around
• 20:08these particular things that we value highly.
• 20:11We value being a developmental science hub,
• 20:14so we talk about developmental neuroscience,
• 20:16we talk about neuro epigenetics.
• 20:19We talk about translation,
• 20:20how our clinical work is informed
• 20:23by our research.
• 20:25We say that we're multidisciplinary,
• 20:26which we are indeed are.
• 20:27By the way, there's about 20 different
• 20:30disciplines represented in this department.
• 20:31Makes us probably the most
• 20:34diverse discipline.
• 20:35If the word Disciplinarity is a word,
• 20:37it makes us the most diverse.
• 20:40We talk about multiple generations
• 20:43that we actually work across
• 20:45generations clinically and research,
• 20:47and we talk about Community implementation.
• 20:50So those are all the ways that we frame.
• 20:53But I want to suggest another frame.
• 20:56And I want to suggest that maybe we
• 20:59strategically refrain thematically.
• 21:01So that we have work in neurodevelopment
• 21:05and neurodevelopmental disorders.
• 21:06We have work and movement
• 21:08regulation and disorders,
• 21:09mood and emotion regulation,
• 21:11HealthEquity, trauma and stress.
• 21:14And then if you frame it thematically,
• 21:16then these missions,
• 21:18and I'll show you an example.
• 21:20These missions are embedded in each theme.
• 21:24And then across that are the various other
• 21:26ways that we'd like to describe ourselves,
• 21:28which are indeed true the intragenerational,
• 21:31the normative development,
• 21:33community implementation,
• 21:34translational, multidisciplinary.
• 21:35So I'm just going to pick
• 21:38one because I I mean,
• 21:40I'm presenting this as an idea.
• 21:42I'm just going to pick one and
• 21:44show you how I think it works.
• 21:46So if you take just trauma and
• 21:48stress and you just think about it
• 21:50and I'm sure this is not complete.
• 21:53But you think about everything
• 21:55in the center that touches
• 21:57trauma and stress from
• 21:58across all the missions.
• 22:00So we have the Steven and colleagues Group
• 22:03Center for traumatic stress and recovery.
• 22:06We have kierans, health omics,
• 22:09the fathers for change with Carla
• 22:11before and after baby life, Helena,
• 22:13the eye caps and the family based recovery.
• 22:16You go over to education and you see
• 22:18how much of our educational efforts are
• 22:21indeed focused on this particular theme.
• 22:24And go to clinical and see how
• 22:26much evidence based work we're
• 22:28doing in this particular theme.
• 22:30And in policy, indeed,
• 22:31actually we have, even though we,
• 22:33if you were just to look
• 22:35at our policy as a group,
• 22:37you might not actually see how much
• 22:40policy work we're actually doing that is
• 22:43related thematically to this particular area.
• 22:46Excuse me.
• 22:47And then you can actually put these
• 22:50same kinds of community etcetera.
• 22:52Around this because there's
• 22:54examples of that all within it.
• 22:56Ioffer it as an example.
• 22:58I don't offer it as I we should do this.
• 23:00But ioffer it as an example and ask you
• 23:03the question is that does it have utility?
• 23:07Are there other ways to conceptualize
• 23:09our work that better reflects the
• 23:11integration across our mission areas?
• 23:13Rather than talking about
• 23:14our separate missions,
• 23:15are there other ways to represent
• 23:17us so that we actually show how
• 23:20synergistic our missions are?
• 23:22What are the gaps?
• 23:23I would suggest it's a way of
• 23:26actually identifying the gaps better.
• 23:29What does it not capture?
• 23:31Should there be other areas?
• 23:33And are there any volunteers?
• 23:34And you don't need to raise
• 23:35your hand right now,
• 23:36but are there any volunteers for
• 23:38wanting to think about either
• 23:40this way or other ways to better
• 23:43capture the complexity and the
• 23:45synergies of this department,
• 23:47which then allow us to
• 23:49better identify the gaps?
• 23:53So then I want to follow up on some
• 23:55goals that we set in September,
• 23:57because it's really important if you're
• 23:59going to set goals to say did we meet the
• 24:02goals or are we meeting the goals and
• 24:05that is this this theme of accountability.
• 24:09So to the first one, as you know,
• 24:12climate and culture is incredibly important.
• 24:14It is a high priority area.
• 24:17Our community has taken a we
• 24:19we've been stressed with COVID,
• 24:21we're coming back,
• 24:22but we've been stressed.
• 24:24And so we really want to have this be a
• 24:26community that everyone feels welcome,
• 24:29respected and that they have
• 24:31a contribution in.
• 24:33So some of the very concrete
• 24:35areas that Tara and the many,
• 24:37many people working with Tara have made
• 24:40as goals as one is about mentoring.
• 24:43And there is a survey underway or
• 24:45gone out that I hope everyone will
• 24:47respond to about not only what kind of
• 24:50mentoring would you like to receive,
• 24:52but what kind of mentoring would
• 24:53you like to give.
• 24:55And notice we put this under
• 24:56culture and climate.
• 24:57We'll come back to it and research.
• 25:00Onboarding is another how do we make
• 25:02people not only feel welcome in the
• 25:04department, but no know what to do?
• 25:07And also,
• 25:07when we're trying to search for people,
• 25:10how do we actually have those
• 25:12searches be very open and without
• 25:14as much as we can without bias?
• 25:17So we've done a great deal of
• 25:19refining the search process,
• 25:20have bias training now and we have
• 25:22onboarding that's ready for implementation.
• 25:25So great progress since September.
• 25:29Accountability, including annual assessments.
• 25:31We've done the annual faculty reviews a lot,
• 25:36but how can we make that more broad?
• 25:38We're doing it even now,
• 25:39as I'm showing you where we're
• 25:41meeting some of the goals,
• 25:42but that's in progress.
• 25:45Ongoing workshops.
• 25:45We have workshops now scheduled for
• 25:48about leadership that are scheduled
• 25:50now again for the winter and spring.
• 25:52And I hope you've seen some of
• 25:54the announcements,
• 25:55but we will continue to have
• 25:57workshops around building community,
• 25:59around leadership and around this theme
• 26:02on diversity, equity and inclusion.
• 26:05Building the pipeline is one
• 26:07that we will never end.
• 26:09But we need to be intentional about it.
• 26:11And so I print it as ongoing.
• 26:13But we need to be intentional about
• 26:15how do we create a diverse pipeline,
• 26:17fellows, trainees, faculty.
• 26:19And then the community engagement input,
• 26:23the Viola Bernard Award is
• 26:25a great example of this.
• 26:27And in September said that
• 26:29we would announce it soon.
• 26:31You probably saw the announcement,
• 26:33but just to remind you that we
• 26:35actually have two awardees.
• 26:37So the first inaugural Viola Bernard Award,
• 26:40Carla Marron doing work on a novel
• 26:43digital intervention for Latinx mothers,
• 26:45but using design justice principles.
• 26:48So that gets her in the community.
• 26:50And Dakota Becker doing work on
• 26:53grief sensitive consultation again,
• 26:55designing it with colleagues
• 26:57from the community.
• 26:59So this these are examples of the
• 27:01progress on the goals for DEI.
• 27:04For research.
• 27:05Very grateful to everyone
• 27:07helping Tom on this,
• 27:09but several of the goals we set
• 27:12were bringing researchers together
• 27:13to talk about shared goals.
• 27:15That's now actively happening.
• 27:17Tom's regular research
• 27:19internal communication.
• 27:21The regular research and progress sessions,
• 27:23I would encourage you to come to those,
• 27:25encourage your fellows to come.
• 27:26They're great.
• 27:27The cross talk sessions and faculty meetings,
• 27:30we just had a great one last week
• 27:33with Emily Olson will continue
• 27:35to have those really encouraging
• 27:38research and clinical interface
• 27:40and then sharing common resources.
• 27:42Tom and Young son are working now
• 27:44on how we can actually have a
• 27:47common resource for recruiting and
• 27:48to all clinical studies that is a
• 27:51common resource and share subjects
• 27:53and share that recruiting process.
• 27:55So that excuse me not each lab
• 27:57is not trying to recruit.
• 27:59For themselves, but we're actually sharing,
• 28:02so stay tuned.
• 28:03But Tom and Young son are
• 28:05are moving that forward.
• 28:06We've clarified some guidelines
• 28:08for space allocation.
• 28:10This is my way of driving
• 28:11you to the intranet.
• 28:12Those are on the intranet.
• 28:15And then we have in progress
• 28:18developing guidelines for OK awards
• 28:20and the survey that I mentioned
• 28:22earlier under Community and
• 28:24culture is also about research.
• 28:29Education and professional development.
• 28:31These are all in progress,
• 28:33but a point to actually really emphasize.
• 28:36Is that we need to actually develop
• 28:39and integrated child and family
• 28:41behavioral health professional
• 28:43training from multiple perspectives.
• 28:45We have implemented with
• 28:46our colleagues in Yale,
• 28:48New Haven and in Pediatrics
• 28:50of training for pediatricians
• 28:52and basic behavioral health.
• 28:54Trying to work on the pipeline
• 28:56that I'll talk about in a minute.
• 28:58Ongoing is a certificate program
• 29:01in child and family behavioral
• 29:03health policy in collaboration
• 29:05with other policy groups at Yale.
• 29:07And we need,
• 29:08as we as we are starting to do,
• 29:10to reinvigorate consultative relationships
• 29:12with schools and other community
• 29:15organizations because we do a lot of
• 29:17clinical work in relation to schools.
• 29:19But how do we make that then an education
• 29:21and professional development effort?
• 29:25I think the most important is them.
• 29:27Where we still need to make some progress is
• 29:30creating a professional development brand.
• 29:32So that when you come to the
• 29:33child Study Center for a training,
• 29:35whether it's an autism,
• 29:36whether it's anxiety,
• 29:37whatever the theme is that you
• 29:39know what you're getting,
• 29:41that we have a consistent brand across
• 29:43that we have a series of short courses,
• 29:45maybe their research updates,
• 29:47whatever they are, but we have a consistent
• 29:51professional development reach out.
• 29:53And this third one is really important
• 29:55to me is that we need to attend to
• 29:58and improve the educational climate
• 30:00for all of our training programs.
• 30:02As I will talk about in a minute,
• 30:04there's been tremendous clinical demand
• 30:07in our for all of us, for everyone.
• 30:09But I want to be really sure that in
• 30:13our training programs that that clinical
• 30:15demand doesn't swamp and over shadow
• 30:18the education and the educational purpose.
• 30:21So we need to attend to that is how even
• 30:24with all the clinical work before us,
• 30:27how do we ensure that all of the
• 30:29you here for training are getting
• 30:32that educational experience.
• 30:34And then rebuild.
• 30:35And I really do mean rebuild.
• 30:39A learning community because we've had the
• 30:41impact of the pandemic that has separated us.
• 30:44Even by virtue of the fact that we are,
• 30:46some of us are here,
• 30:48and I'm very grateful for the number
• 30:49of people sitting in the room,
• 30:51but equally grateful for
• 30:52the number of people online,
• 30:54we actually are still learning how
• 30:56to work in a hybrid way and how
• 31:00to rebuild a learning community.
• 31:02Our communication, Krista,
• 31:04continues to unite us just remarkably.
• 31:07And there's many things on here
• 31:09that I hope you all have noticed.
• 31:11I hope you are reading them.
• 31:12I hope they open rate keeps going up.
• 31:14But the one I really wanted to
• 31:17note is that just today,
• 31:18just literally this morning,
• 31:20Krista sent out the newest issue of
• 31:23why CSC Connections which you can think
• 31:25of is our new and updated annual report.
• 31:28It's beautiful. Go read it.
• 31:30It's far better than any state
• 31:32of the department. Trust me.
• 31:34Really. Really.
• 31:35So go read it and and you'll see.
• 31:37And then you see some of the other
• 31:39things that are ongoing.
• 31:42I want to spend actually.
• 31:45The rest of the time.
• 31:47Focusing on our clinical practice.
• 31:49Because it is a significant
• 31:51piece of work for us.
• 31:53It is what fuels so much of our efforts.
• 31:56And we actually have a ongoing,
• 31:59we actually have a continuum of care.
• 32:02We don't always talk about it that way.
• 32:04We talk about outpatient over here,
• 32:06hospital over here.
• 32:07We don't always talk about it.
• 32:09The continuum of care that we have
• 32:11that goes from our inpatient unit,
• 32:13our CL, we're embedding
• 32:15clinicians and Pediatrics now.
• 32:18We're embedding them in primary care.
• 32:20We have access mental health,
• 32:22which reaches out to pediatricians.
• 32:25We have our outpatient behavioral health.
• 32:27Services, icaps in home,
• 32:28our day hospital, emergency department.
• 32:31You can think of this as
• 32:32actually a continuum of care,
• 32:34multiple levels of care that we provide.
• 32:38How do we make this actually
• 32:40more clear to people,
• 32:41especially our legislatures?
• 32:42But that's another point.
• 32:44How do we make,
• 32:45but also how do we begin to think
• 32:48about the better integration
• 32:50across these levels of care?
• 32:52I've shown this slide a number
• 32:54of times and so I I hope that
• 32:56just just to remind us that in
• 32:58our outpatient service well and
• 33:00our overall clinical services,
• 33:01we have outpatient Youth Services
• 33:03as well as services for adults.
• 33:06Those divide between treatment
• 33:08and assessment.
• 33:09We have a whole host now of hospital
• 33:11based services from the Children's
• 33:12Day Hospital to the inpatient unit,
• 33:14the Ed CL and now increasingly
• 33:17more and more that are PD based
• 33:20in the pediatric department.
• 33:22Where we're really embedding the whole
• 33:25notion of this is improving access.
• 33:28I want to talk about some
• 33:30clinical highlights in 2022.
• 33:32So with our pediatric collaborations,
• 33:34just so you know the access
• 33:37mental health program which is
• 33:39allows pediatricians to call and
• 33:41get behavioral health consults,
• 33:42just look at the volume that should have
• 33:46been a 0 not that far in the future.
• 33:49But the volume of 11,000 consultations?
• 33:54And about 2200,
• 33:56more than 2200 unique youth served.
• 33:59Think about that as a possibility
• 34:01when you're doing that,
• 34:03that actually you're preventing some
• 34:04of those kids from coming to the Ed
• 34:07because you're giving the pediatrician
• 34:09some skills and some information.
• 34:11The reach training I've already mentioned,
• 34:13which is actually giving pediatrician
• 34:15skills for the frontline behavioral health
• 34:18assessment and intervention so that
• 34:21we build again this continuum of care.
• 34:25Some other clinical highlights to to cite.
• 34:28Is that in collaboration with our Yale New
• 34:31Haven colleagues just across the street,
• 34:33we now have a grant for
• 34:35an urgent care center,
• 34:36which hopefully will help with
• 34:38the emergency room challenges.
• 34:40And we also have a grant around zero suicide,
• 34:43that is to work on this increasing
• 34:46issue of suicidality and adolescence
• 34:48and to try to reduce the rate.
• 34:51We have program growth.
• 34:52The day hospital has now come to 350 George.
• 34:56So now truly we actually have a synergy
• 34:59driven by place, not just by theme.
• 35:02And we're continuing to embed pediatric
• 35:06psychologist and subspecialty science.
• 35:08Another highlight is we were able to
• 35:10address and December the salary equity
• 35:12issues for the Masters level clinicians.
• 35:15It was a long, long haul.
• 35:16I'm so glad we got there.
• 35:19It's really, really important to
• 35:21recognize people for the work they do by
• 35:24appropriate and equitable compensation.
• 35:26And that we are continuing to work
• 35:28very closely with our colleagues at
• 35:30the state around child behavioral
• 35:32health and collaborating with Yale's
• 35:35Office of State and Federal Relations.
• 35:37Just just actually 2 hours ago,
• 35:40we were meeting with the state
• 35:42representative who was a strong
• 35:44supporter of child behavioral health.
• 35:45Just in December,
• 35:47Senator Martin Looney,
• 35:48who is the leading Democrat of the state,
• 35:50visited the Child Study Center,
• 35:52the first time he had actually visited
• 35:54Yale and the School of Medicine in many,
• 35:57many years.
• 35:57And he has introduced a bill as much.
• 36:00There's much that has to happen,
• 36:02but he's introduced a bill before the
• 36:05state legislature about thinking about
• 36:07a continuum of care for behavioral
• 36:09health for children in Connecticut.
• 36:12And cites the Child Study Center
• 36:14as a resource for helping him
• 36:16build that and think about that.
• 36:18So we're doing a lot of that
• 36:20work I hope doing.
• 36:21I hope all of you will
• 36:23engage with us about it.
• 36:24And we actually will have an upcoming
• 36:27webinar next week that they ask for
• 36:29to inform our state colleagues.
• 36:31But most importantly on highlights would
• 36:33be not just this is important, yes,
• 36:36and these are just pictures of the day.
• 36:37Hospital just wanted you to have them.
• 36:39But most importantly on highlights is
• 36:42the dedication of the clinical team,
• 36:44the families who come for our care
• 36:46and all of you who give so much
• 36:49service and so much time that should
• 36:51be actually at the top of the list of
• 36:53highlights of our clinical practice.
• 37:03So now I want to ask the question.
• 37:05I've been talking and we've all been
• 37:08talking about a surge now since.
• 37:102021 late 2020.
• 37:11Is it really a surge or are we
• 37:14really now in a new normal?
• 37:16Have we really plateaued or not plateaued?
• 37:19Have we risen up and now we're at
• 37:21a a new higher level?
• 37:23I want to show you some data
• 37:25that suggests that the clinical
• 37:27demands are at a new normal.
• 37:29So the first is to look at our
• 37:32inpatient from the hospital data
• 37:34and to look at discharge trends.
• 37:36So the red line is length of stay.
• 37:40Average length of stay,
• 37:41the blue line or the blue bars or discharges.
• 37:45And if you were just to take a step back,
• 37:48you would look and say, Oh well, the volume.
• 37:50The volume seems to have gone down.
• 37:52But you have to look at length of
• 37:54stay and you see that the length
• 37:56of stay of kids has gone up.
• 37:59So two factors.
• 38:00One is that we are seeing
• 38:02increasingly ill children.
• 38:04With greater mental health needs,
• 38:06so they require longer service.
• 38:08And perhaps equally important,
• 38:10if not more important,
• 38:12for your advocacy efforts if
• 38:15they don't have anywhere to go.
• 38:17The continuum of care is broken.
• 38:19So they stay,
• 38:20they need to stay on our hospital
• 38:23based units longer than would even
• 38:26be clinically perhaps indicated,
• 38:27but they have to stay there.
• 38:30Because the continuum?
• 38:31There's nowhere for them to go.
• 38:33Same for eating disorders.
• 38:34There's no question there's been
• 38:35a dramatic increase in eating
• 38:37disorders in the last three years.
• 38:39Why is another is an important question,
• 38:42but an incredible increase
• 38:44on doubling and tripling,
• 38:45but also their length of stay because
• 38:48there is nowhere for them to go.
• 38:50So we're working with our new New
• 38:53Haven Hospital colleagues to try
• 38:54and stand up a unit in Bridgeport
• 38:56so that the kids can go there.
• 38:58But right now there's nowhere for them to go.
• 39:00A broken continuum of care.
• 39:03If you just look at the behavioral
• 39:05Ed volume across the various
• 39:07hospitals that are in the Yale
• 39:09New Haven Health system,
• 39:10but just focus here,
• 39:12you see that there's actually an
• 39:14increase in the volume of kids in the Ed.
• 39:17Surely there's an increase in number?
• 39:20But I want you to look at the yellow line.
• 39:23There's a tremendous increase,
• 39:25just a rise up and the number of hours
• 39:29reflecting the new mount of time that
• 39:32kids are staying in the Ed and this
• 39:35is true across the delivery network.
• 39:37But let me just show you in another
• 39:39way that I showed you in September,
• 39:41if you look at the borders here.
• 39:43This is literally the number of kids
• 39:46sitting in the Ed waiting for beds,
• 39:48a broken delivery,
• 39:50a broken continuum of care.
• 39:52And look at this tremendous increase
• 39:55in border hours between FY20 and FY21.
• 39:59This is the,
• 40:00this is the clinical issue or a
• 40:02clinical issue that we're dealing with.
• 40:05So you can just say the volume
• 40:07trend for our
• 40:08hospital based services is a 33%
• 40:10increase in the average daily census.
• 40:12So it's gone up.
• 40:14But 190% increase in emergency
• 40:18behavioral healthcare. And a 284%,
• 40:21I didn't actually show you that graph,
• 40:23but a 284% increase in kids coming to
• 40:26primary care needing behavioral health.
• 40:29But that is, I think, the new normal.
• 40:33Our own outpatient services,
• 40:35this actually goes from 2019
• 40:37now through the end of December
• 40:392022 and you can see that 2020,
• 40:422020 to 2021 was actually or 20.
• 40:45The year 2021 was actually where we
• 40:49had our biggest peak and now we've
• 40:52started slow down a bit on referrals,
• 40:54but we are nowhere back to where we were
• 40:57originally a new normal and these are total,
• 41:00the total increase.
• 41:01So it's about 102%.
• 41:04Doubling since 2019.
• 41:07These are just telehealth visits
• 41:09and actually telehealth visits
• 41:10going all the way through December.
• 41:12You see that we're doing on average
• 41:15about 1000 telehealth visits a month.
• 41:18Dramatic, actually we could do
• 41:20more if there were more people.
• 41:22And then just to give you the numbers,
• 41:24I said 102% increase,
• 41:2760,000 plus visits scheduled over
• 41:30the fiscal year, 82,000 visits,
• 41:33video visits total since 2020.
• 41:37And just last year alone or the last
• 41:40fiscal year 2500 or more kids served.
• 41:43So a tremendous increase in volume.
• 41:47I would say our referrals are
• 41:48at a higher baseline.
• 41:49We're seeing an increase in anxiety,
• 41:51depression, suicidal ideation,
• 41:53eating disorders.
• 41:55The greater severity requires
• 41:57longer treatment, thus they stay.
• 41:59There's less freedom, if you will,
• 42:01to move people in and out.
• 42:03There's fewer programs available in
• 42:05the continuum and a workforce shortage
• 42:08which just leads to a backlog system.
• 42:11And that's what we need to be thinking about.
• 42:13We're doing our best clinically
• 42:14to manage that,
• 42:15but we need to be thinking
• 42:17about our role in the system.
• 42:19And I want to come back
• 42:21to the financial reality.
• 42:23I've told you all this,
• 42:24but I just want to reemphasize
• 42:26the structural issue.
• 42:28And to show you that it's
• 42:29oftentimes an answer you here as
• 42:31well just change the payer mix.
• 42:33Changing the payer mix doesn't do
• 42:35it because commercial payers are
• 42:38just as poor on paying as Medicaid.
• 42:40So.
• 42:41What I would suggest is that
• 42:43we are at a pivotal point.
• 42:47We're at a pivotal moment.
• 42:49We're still in a tremendous change
• 42:51process that began in 2015 when Yale
• 42:54Medicine asked us to restructure
• 42:57our practice into one practice.
• 42:59Into one integrated practice.
• 43:02In 2019,
• 43:03we moved into the new clinical space.
• 43:06Sadly,
• 43:06in March 2020 the pandemic
• 43:08happened and all that change that
• 43:10we were doing of bringing people
• 43:13together and thinking together
• 43:15actually was temporarily halted.
• 43:17And now we need to work on finances,
• 43:20workflow, how we integrate,
• 43:21research and envision the
• 43:23practice for the future.
• 43:25We are in a tremendous change
• 43:27process and a pivotal moment.
• 43:30And so some questions that are
• 43:31before us is how do we manage
• 43:33our clinical need with the
• 43:35clinical resources we have.
• 43:38Are there alternative ways to
• 43:40generate more clinical revenue?
• 43:42Are we managing our cost effectively?
• 43:45But those are the transactional questions.
• 43:48The strategic questions are these.
• 43:51What kind of size of practice
• 43:53do we want to sustain and grow?
• 43:56What's our unique niche
• 43:58as a clinical service?
• 43:59What are our metrics of excellence?
• 44:01What do we call excellent care?
• 44:03And how do we maximize, I would say,
• 44:06the synergies between our clinical
• 44:08services and our ongoing clinical
• 44:11research programs and expertise.
• 44:13So when I want to spend the
• 44:15next few minutes though,
• 44:16all those questions in mind.
• 44:18Because I want to spend the next few minutes.
• 44:21With this, well, I'm sorry,
• 44:24an answer to those questions.
• 44:25We actually have already engaged a
• 44:28consultation about our practice with
• 44:30Doctor Ken craft and that practice was
• 44:33over August through through the early fall.
• 44:36Part of the recommendation was
• 44:37that we have four work groups.
• 44:39I'm very grateful to those of
• 44:41you who are working in the work
• 44:43groups here they are defined.
• 44:44We're on a very fast timeline
• 44:46because we really want to get
• 44:48ideas and start on this work and
• 44:50you can see that the timeline.
• 44:51Just to have a final report on these
• 44:53and a report then to your medicine and
• 44:56consulting with your medicine by April.
• 44:58This is good work.
• 45:00This is good important work that we're doing.
• 45:04But I want to spend the last
• 45:06bit of time on these questions.
• 45:09What does it mean to work within
• 45:11a system and think systemically?
• 45:13What's happening in the Academic Medical
• 45:16Center that's impacting us and then
• 45:19return to our theme for the academic year?
• 45:22So first,
• 45:23a systemic thinking.
• 45:25I've showed you this multiple times,
• 45:27but let me let me walk you through it again.
• 45:29That we work within an academic
• 45:31medical and an academic health system.
• 45:34Here we are.
• 45:35And we have clinical non clinical missions
• 45:38and our clinical mission sits within
• 45:40the group practice of this medical school,
• 45:42Yale Medicine and we overall sit
• 45:44within the Yale School of Medicine
• 45:46and the School of Medicine sits
• 45:48within Yale University.
• 45:49We also have collaborative relationships
• 45:52and funding relationships and service
• 45:55relationships with the Yale New Haven
• 45:57Health System and the Children's Hospital.
• 46:00So what does it mean to work within a system?
• 46:05The cost and benefits, there's some cost.
• 46:07The decision process is
• 46:10multilayered and slower.
• 46:11Inevitably.
• 46:12There's fewer degrees of decision making.
• 46:15We have, I showed you earlier,
• 46:17we have assessments on our revenue.
• 46:19We have shared space cost and the health of
• 46:22the system has impacts the health of us.
• 46:25It has local impact.
• 46:28But what are the benefits?
• 46:30Well, the benefits are we have shared
• 46:32learning from system expertise.
• 46:33We're not alone.
• 46:34We're in an we're in an academic
• 46:37Medical Center.
• 46:38We have shared infrastructure.
• 46:39If we had to pay for all of this,
• 46:42it would be a challenge,
• 46:44libraries, HR, legal support,
• 46:46etcetera.
• 46:47We have a much stronger negotiating
• 46:49platform for anything that
• 46:51we might need it from,
• 46:52from the indirect rates with
• 46:55the NIH to commercial payers.
• 46:57We have a shared brand.
• 46:58We have funding support that comes
• 47:00from Yale Medicine and the hospital.
• 47:02And we have the health of the system
• 47:04has a local impact, so when the
• 47:07health of the system is doing well.
• 47:09It has a benefit when it's not doing so well.
• 47:12It might have a cost.
• 47:14So what does it mean to think this way?
• 47:18So to think locally,
• 47:20departmentally versus thinking systemically,
• 47:22I would say that this is actually a
• 47:24pretty familiar medical metaphor.
• 47:26You can talk about a localized pneumonia or
• 47:29you can talk about a systemic infection.
• 47:32It's either local or it's systemic.
• 47:34And when it's systemic,
• 47:35everything, not just the lungs,
• 47:38there's impacted by that infection.
• 47:40And so we traditionally think
• 47:42this way a goes to B.
• 47:45Reduce cost.
• 47:46Practice does better.
• 47:48Doesn't work that way if you're
• 47:50in a systems world that multiple
• 47:52things impact each other and there
• 47:54are very complex interactions.
• 47:56So I would argue that while we often tend
• 47:59to think of ourselves as a department,
• 48:01and we are.
• 48:03The better we understand the systems
• 48:06we inhabit and the larger systemic
• 48:09challenges or opportunities.
• 48:10The better,
• 48:11more effective our problem solving
• 48:14and efforts to adapt will be.
• 48:16So I'm going to, in a minute,
• 48:17I'm going to show you how to
• 48:19shift that to systemic questions.
• 48:22But I also want to focus on
• 48:24the academic health system and
• 48:26the Academic Medical Center.
• 48:28Remember,
• 48:28early on I told you that there are major
• 48:32changes in the academic Medical Center.
• 48:35That not just Yale.
• 48:37All across this country,
• 48:39all across the world,
• 48:41the Academic Medical Center
• 48:42as an entity is changing.
• 48:45And so let me bring you into that just a bit.
• 48:48And there's a literature on this.
• 48:50Again, I'll give you the slides,
• 48:51you can look at the references.
• 48:54But this quote is from 2014,
• 48:56so it was starting to change
• 48:58well before the pandemic.
• 48:59The pandemic,
• 49:00like it did so many other things,
• 49:03just accelerated the change.
• 49:05But changing well before.
• 49:07So just take the first line.
• 49:10A revolution underway in Healthcare
• 49:12is fundamentally changing how every
• 49:14academic Medical Center operates.
• 49:16And notice that it is how the
• 49:19research enterprise is organized,
• 49:20how the missions come together
• 49:22in you and meaningful ways.
• 49:24Academic Medical Center is changing,
• 49:27so let's look at what that change looks like.
• 49:31Historically, academic medical
• 49:33centers have been sources of knowledge
• 49:37generation and centers of excellence.
• 49:39They've been based on this virtuous cycle.
• 49:42That research and forms clinical care.
• 49:45Clinical care reforms research.
• 49:46That they've been based on
• 49:49building the physician, clinician,
• 49:51scientist and we still are doing that.
• 49:53I'm not saying it's outmoded,
• 49:54but we're still doing that.
• 49:56Care was driven by research questions.
• 49:59The disease that had an unusual twist.
• 50:02The new treatment was driven by and
• 50:04is driven by research questions.
• 50:07Focused on training the best researchers,
• 50:09the best, the best teachers,
• 50:11the best clinicians,
• 50:13here's the important statement.
• 50:16Patients historically came
• 50:18to the Medical Center.
• 50:20Because they wanted the expertise.
• 50:24And they came because they would
• 50:26benefit from the expertise and they
• 50:28would both wait and pay for that care.
• 50:31I myself have sent my family to say no,
• 50:33no, no, no,
• 50:34you want to go to the academic Medical
• 50:36Center because that's where the expertise
• 50:38and the state-of-the-art care is,
• 50:40and it still is.
• 50:41But there are social changes pushing them.
• 50:45So here,
• 50:46here's an example of where the
• 50:49academic Medical Center actually
• 50:50really thrived in the pandemic.
• 50:53There is a tremendous literature on
• 50:55if you were a patient with COVID.
• 50:58In 2020 or 2021,
• 51:01you fared better when you went to the
• 51:04Academic Medical Center that actually
• 51:05includes in the state of Connecticut.
• 51:07Yale New Haven Hospital had the best
• 51:09outcomes of the state of Connecticut.
• 51:11You fared better because you
• 51:13came to a learning environment.
• 51:15So the academic Medical Center
• 51:17has such tremendous strength,
• 51:19tremendous, that we need to preserve.
• 51:21But we need also need to be
• 51:23aware of the changing forces,
• 51:25and here are the changing forces.
• 51:28Historically, there was a greater emphasis,
• 51:31as I suggested earlier,
• 51:33on the value of expertise to the patient.
• 51:36And on this relationship between research
• 51:39and clinical innovation then actually on
• 51:42enhancing access or attracting patients?
• 51:45And clinical revenue was used to
• 51:48supplement research and education,
• 51:49not in behavioral health,
• 51:51but but clinical revenue was
• 51:53used to supplement.
• 51:54But two things happened.
• 51:57Well, 111 consequence of that.
• 51:59Is that there was not clear
• 52:01accountability within academic
• 52:04medical Centers for clinical cost
• 52:06or efficient clinical practice.
• 52:09You are really driving it by the
• 52:11research needed by the developing new
• 52:13treatments etcetera and not paying a lot
• 52:16of attention to the cost or efficiency.
• 52:19But the other two things that happened is
• 52:22a greater competition for research costs,
• 52:25thus needing more supplementing of
• 52:27research by clinical funds and at the
• 52:30same time clinical cost going up.
• 52:32So less available clinical revenue
• 52:35to read to supplement research and
• 52:38greater competition in the outside
• 52:41the academic Medical Center world
• 52:44of clinical care,
• 52:45more people entering that arena.
• 52:48This is the perfect recipe for
• 52:51something called disruptive innovation.
• 52:54And I want to bring you into this
• 52:56idea of disruptive innovation
• 52:57and have us think together about
• 53:00what that means for us and how we
• 53:04can actually become disruptors.
• 53:05So here's what disruptive innovation is.
• 53:09You have a high quality service
• 53:11technology available to a select group.
• 53:13Think of academic medical centers.
• 53:15You have a great, great quality and some,
• 53:19some people can access it's great
• 53:21and you continue to sustain with
• 53:23steady quality improvement and you
• 53:25continue your service and technology
• 53:27for those people that can get it.
• 53:32But. There might be a new approach
• 53:35to the service or technology
• 53:36that's more widely available.
• 53:38That reaches people who
• 53:40can't access the blue.
• 53:42It's more widely available.
• 53:43And you continue to rapidly improve
• 53:46the quality of it you have and
• 53:47you can pay attention to cost and
• 53:50pretty soon you're actually up
• 53:51at the quality of the blue box.
• 53:55And you overtake, if you will, the market.
• 53:58You disrupt the market of the blue.
• 54:01And you overtake it with something more
• 54:04broadly available and more accessible.
• 54:06That's disruptive innovation and there
• 54:09are multiple examples surrounding us.
• 54:11So a very classic example of
• 54:13disruptive innovation is meant
• 54:15the mass produced automobile.
• 54:16It's all the myth.
• 54:17You know, it's not a myth,
• 54:19but it's kind of the historical
• 54:20story that Henry Ford that came
• 54:22rolling off of the assembly line.
• 54:24That's true.
• 54:25But before the assembly line,
• 54:27there were actually really,
• 54:28really high quality cars being made
• 54:31that were available to a select few.
• 54:34Henry Ford's innovation was not
• 54:36the Model T it was creating the
• 54:39mass produced automobile that was
• 54:41available to many people that then
• 54:44became of extraordinary high quality.
• 54:46And then if you just look on down,
• 54:48there's a number of other
• 54:49disruptive innovations,
• 54:50e-books or a disruptive innovation.
• 54:53You can get a book anywhere now.
• 54:55You can hold it on your computer.
• 54:56You don't have to go to a bookstore.
• 54:58It disrupted bookstores.
• 55:01Or actually desktop publishing ecommerce.
• 55:03Think of the dramatic impact of ecommerce.
• 55:06So being able to not you don't have
• 55:09to go to a brick and mortar store.
• 55:11You can actually now get almost
• 55:13the same quality material.
• 55:15Now I'm not comparing us to a store or a.
• 55:19But I am saying that this process
• 55:22of disruptive innovation has
• 55:23impacted academic medicine.
• 55:27Because now you can actually get
• 55:30your infusion. Or your cancer.
• 55:33Not you. You would be.
• 55:35You'd be good to come to the
• 55:37Academic Medical Center,
• 55:38but you may actually be able to
• 55:40get the same treatment.
• 55:41Somewhere else.
• 55:42Maybe you get it quicker,
• 55:44maybe the access is better,
• 55:46maybe the cost for about the cost is less.
• 55:49This is happening in medicine,
• 55:51and it is shifting the way academic
• 55:54medical centers think about
• 55:56the value access proposition.
• 55:58That patients can more easily access
• 56:00quality Care now, often outside.
• 56:02These walls.
• 56:03The value for patients is
• 56:06no longer just expertise,
• 56:09but it's also access.
• 56:11Can you get to it?
• 56:13And so it's pushed the academic
• 56:15Medical Center to focus now on
• 56:18accountability and care provision.
• 56:20So benchmarks for clinicians.
• 56:21This is why Yale Medicine talks
• 56:24about benchmarks so much.
• 56:25Attending to cost and working
• 56:27to capture the market,
• 56:29working actually to bring patients
• 56:31here rather than assuming that
• 56:34patients will come here because
• 56:35of the expertise that we have.
• 56:38Bring them here.
• 56:39And so it brings the clinical
• 56:41mission and discussions about
• 56:43value based care to center stage.
• 56:46I have just about 3 more
• 56:48minutes if you don't mind.
• 56:50So there's an emerging literature on this,
• 56:52on the disruptive innovation
• 56:54in academic medical centers.
• 56:56And I think you see it most
• 56:58clearly in how the budget for
• 56:59the Yale School of Medicine has
• 57:01shifted and its clinical budget.
• 57:03So this is just one way of looking
• 57:05at the increase in clinical income
• 57:07for the Yale School of Medicine.
• 57:09Here you can see the,
• 57:11the light blue bar is the income
• 57:12from the hospital transferring
• 57:14to the School of Medicine and
• 57:15this is the School of Medicine.
• 57:17But you see it more dramatically here,
• 57:20which is just the overall division
• 57:22of the School of Medicine budget.
• 57:24And just in less than 10 years,
• 57:26there's been a 1.24 increase in the
• 57:29clinical income for the School of
• 57:31Medicine as it is shifted to have the
• 57:33clinical enterprise be its central mission.
• 57:36To three,
• 57:37only a .3 increase in research income.
• 57:40Now,
• 57:40there's a lot of things that
• 57:41contribute to that difference,
• 57:43but one is this attending to this phenomenon
• 57:46of the shift in the academic Medical Center.
• 57:51So what does this mean for us
• 57:52and for behavioral health?
• 57:54Same things happening in our field.
• 57:56Same thing.
• 57:58There is a lot now of availability may not
• 58:01be the same thing that we would support.
• 58:04Maybe some of it is not at this level of
• 58:06quality that we would actually espouse to,
• 58:09but some of it is incredibly high
• 58:11quality that you can get your
• 58:13behavioral healthcare outside
• 58:15the academic Medical Center.
• 58:17And there's even a prediction
• 58:19that by the 20-30,
• 58:20there will be that much of a
• 58:23dramatic increase in behavioral
• 58:25healthcare software for reason.
• 58:27Disruptive innovation is happening
• 58:29in our field as well.
• 58:31So I would argue that it's impacting
• 58:33us that we are a part of the
• 58:35changes in the academic Medical
• 58:37Center that we need to be very,
• 58:39very aware of and we need to learn
• 58:41to think how the clinical practice is
• 58:44managed in this changing environment.
• 58:46And thinking systemically is essential.
• 58:49It's not a single point solution
• 58:50for the the clinical challenges
• 58:52that I've been presenting.
• 58:56So I'm just going to conclude with this.
• 58:58This is the list of questions
• 59:00that I showed you earlier.
• 59:02But to think systemically,
• 59:03we need to ask what set of
• 59:06systemic conditions do we work in?
• 59:08What are the synergies that can
• 59:10be created across these systems?
• 59:11Where and how can we impact the system and
• 59:15where and how can we be disruptors as well?
• 59:19And the very first state of the department
• 59:21talk I gave when I became chair,
• 59:23I introduced you to the
• 59:25metaphor of the wicked problem.
• 59:27And the wicked problem is a
• 59:29problem that is very complex.
• 59:31They're not a single point solution,
• 59:33but most importantly,
• 59:35it actually requires collaboration.
• 59:38It requires systemic thinking.
• 59:40It requires working together as a group.
• 59:43Which brings me to my concluding slide,
• 59:46which is about the theme for this year.
• 59:50And that is that we have hard
• 59:52but very good work before us.
• 59:54That requires though it's
• 59:55going to require patience,
• 59:57mutual respect and a kind of grace
• 59:59because we're we're not going
• 01:00:01to get it right first time out.
• 01:00:03We're going to keep trying,
• 01:00:04we're going to keep trying to make this
• 01:00:06practice in this integration between
• 01:00:08research and clinical work better,
• 01:00:10but we need to keep trying together.
• 01:00:13We have to have.
• 01:00:14I would argue that by focusing on
• 01:00:16those who come after us on making this
• 01:00:18department as good as we can make it,
• 01:00:20and as strong and as nimble and this
• 01:00:24disruptive innovation world that
• 01:00:26we actually will require on this,
• 01:00:28we encourage this compassion and gratitude.
• 01:00:31But I think if we think about those,
• 01:00:33we also will work with much more
• 01:00:36lasting value than just trying
• 01:00:38to solve a problem right now.
• 01:00:40So I very much appreciate your
• 01:00:42patience for the time.
• 01:00:43Thank you for staying just a
• 01:00:45little bit later and happy 2023.