Assessing Our Department: Looking Ahead to 2023

January 11, 2023

Information

YCSC Grand Rounds/State of the Department January 10, 2023
Linda Mayes, MD
Arnold Gesell Professor of Child Psychiatry, Pediatrics and Psychology in the Yale Child Study Center; Chair, Yale Child Study Center

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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.