[Bob:] I’m excited to be here with Mark Eliason , dermatologist extraordinaire and chief value officer for the department of dermatology. Let’s start with how you got into medicine.

[Mark:] I took the traditional path of watching what my dad did and saying, I guess I’ll do that. I guess there is more to it…when I was in high school, I was looking at different professions and my counselor told me I should be a genetic engineer, he thought that was the neatest thing to do. So when I got into college, I started going that route, and then I found out that they didn’t talk to people very much. I realized if I continued down that path, I’d be in small office not talking very much, and it turns out, I like to talk. I said to my dad who is a doctor, and I asked him ‘do you like what you do?’ and he said ‘I used to, before all these regulations came out.’ But he also said, ‘well, you might find some more interesting things to do if you go into medicine.’ I finally ended up going medical school.

[Bob:] You mentioned that your dad said that the outside pressure was hard, so how have you found being a doctor different than you imagined?

[Mark:] It's funny because what I’ve become interested in is navigating regulations for people in my department. I feel that I can help other doctors not have to deal with some of the pain that can come from the regulations. Certainly when I started in medical school, I had no idea that most of my time was going to be spent in trying to navigate for patients how to get their medicines, how to get their appointments. I thought I was going to be diagnosing and treating disease. It turns out that is just a small part of what we spend our time on.

[Bob:] If we spend a small amount of our time on the things that we’re trained for—diagnosis and treating disease - what kind of skills are we missing? You took our value improvement leaders training course and really seemed to come to process improvement methodology and measurement very naturally. Do our doctors need those same skills?

[Mark:] I think that we actually have those skills but I don’t think we recognize them. That was an eye opening experience when I went through the value improvement course. Anyone who goes through medical training is already interested in trying to get the correct diagnosis and the correct outcome as fast as possible, and in the most efficient way possible. I don’t think we recognize that quality improvement is in fact the same idea, just with a different language.

One of the most important things that I got out of the value improvement leaders course was to expand my vocabulary and to recognize that the things we try to do in clinic are actually the same things. We’re just using different words, but our goals are very similar.

[Bob:] I completely agree—it's the scientific method, but using a different vocabulary. One of the things that I’ve found to be different is if I’m doing a scientific research, I do it by myself. With process improvement, it really requires an understanding and engagement of the entire team. When you reported your value improvement leader project, I remember you talked about going to the dermatology call center and really engaging the MAs in your clinic. Tell me about what you found different or challenging with having a broad perspective of the team.

[Mark:] I have to give a lot of credit to Frank Thomas, my mentor in the value improvement leaders course. He talked about going to the gemba, or going to the place where the activity that you’re trying to influence takes place. It was really neat to go the call center and start the process of a patient visit with their incoming phone call. You walk through the process of how the call center employees talk to patients, and what the patients hear. I watched what happens in the clinic where the medical assistants bring patients into the room and what they go through with them. Going through that as an observer was a very eye-opening experience for me, for a lot of reasons.

I think the most important reason was the idea of stakeholders. When I’m deciding to do research, I can be the stakeholder, I can be the guy who starts it and stops it. When I’m trying to change a process, there are so many individuals involved. It can become this top-down thing where someone who is supposedly at the top commands every one OR you can engage those people who are starting it, and say here is our vision, here is what we want to accomplish, and here is how we think it can be better. You can say ‘You guys are the ones on the front lines who are doing this, how do you think we could move the needle on this?’ It's fun to see that there are individuals that will have already thought and say ‘why aren’t we doing this, or why aren’t we doing this more?’

You get some feedback that sometimes isn’t as useful, and you get some resistance. People may say—I’m not changing, this is how we’ve always done it. You have be ready for resistance. You get resistance from people, even those you think are going to be your early adopters, and they are just are subject to inertia. Its extra effort to try to change something, and maybe they are comfortable where they are. But, there will almost always be someone who thought about it more than I have. If they can see their changes being implemented, then they run with it and I’m not cracking a whip. I can be cheerleading from the side.

[Bob:] But Mark, come on. Don’t you hear from doctors ‘I’m the doctor, I’m the leader, isn’t it easier if I just tell them what to do?’ It takes a lot of time to engage all the stakeholders. How do you tell our residents or colleagues that engaging all the stakeholders is actually worth the effort?

[Mark:] You’re right. It's always easier to just tell someone what to do. Unfortunately it's just easier for us, for the people who think they are on the top. It's all about leadership training. Most of us have had this experience, where we’ve seen individuals rise through the ranks. You can see that if they are mentored—which usually just means giving someone opportunity, encouragement and specific guidance on how they are doing—they become so much more valuable.

Engaging stakeholders is an investment. Doctors can appreciate this if they can understand the language. For example, we don’t fill residents full of answers, we demand that they find the answers on their own. We do the same thing with medical students if we want them to be any good. It's the same with our staff. If we can encourage and prod them along a little bit, they will rise up to the occasion in most situations. In the long term we recognize the value in how we train people for leadership rather than just try have them follow or dictate.

[Bob:] Fantastic advice. So, leadership is a survival skill for physicians?

[Mark:] Absolutely.

[Bob:] You’ve talked to me about the importance of having your chair be a sponsor. Tell me a little bit about why Dr. Zone’s sponsorship has been helpful in allowing you to be successful, and what his sponsorship has looked like.

[Mark:] I’d love to talk about that! I wouldn’t be where I’m at right now if Dr. Zone hadn’t supported me so strongly. The support comes in a number of ways. First. Dr. Zone approaches our department as a visionary. He has a very specific idea of where the department is going to be and how it's going to get there. He adapts that to external forces and he trains leaders in the department. When the opportunity presented itself for our department to designate a chief value officer, he gave me the opportunity and said I will support you. He told me ‘we’ll give you the time that you need, and I want you to know this is important to me.’

More so than financial support or time, it was important that the person to whom you’re reporting acknowledge what you’re doing is important. Then he followed up with me to ask about it and acknowledged my efforts. It makes me want to keep doing it. It sounds very simple, it goes back to the earliest parts of our childhood memories—we want to do things that give us positive feedback. If you want to support people in your organization and get them to do things, they have to know that it's actually valued. It can't just be words, you have to act.

[Bob:] People have intrinsic desire to do well and you like you said, at the end of the day you have to feel like you’re doing valuable work and work that you feel is valued by others. There is a book called Payoff that reinforces that point.

The other thing that I’ve heard you talk about is this idea of peer to peer comparison and what I call sense-making conversations. You described that when you first looked at your data that there was a high performer—Dr. Hull—and you had to sit down and had one of these sense-making conversations with him. You had to ask him ‘why is he doing things so much more efficiently than me?’ Tell me—is that awkward or is it productive? How important are peer to peer comparisons?

[Mark:] Peer to peer comparisons are very useful. A peer to peer comparison takes away the idea that I’m different and this doesn’t apply to me. When you’re trying to improve a process, you run into people that say ‘your ideas are all nice, but I’m unique, I’m special.’ You get a lot of push back. If you can identify a peer, someone they can identify with, then we can make an assumption that your practice is similar. It helps to give some validity to any of these conclusions you draw.

You need data before a conversation about peer to peer comparison. We definitely color our expectations with our own assumptions, but you can’t argue with data. Data is rather objective. Are the conversations awkward? Not too much. If the individuals recognize that these things are objectively measured, and no one is judging, but instead here to describe what is happening/ Then the conversation is ‘let’s have a conversation about what areas can change to make this one area look like another.’

You do have to take your ego out of it. No one gets into this business without a significant ego. But the way you approach it is important. People who are interested can make the change if it's done respectfully and with some objective information.

[Bob:] As your career moves from being a productive clinical dermatologist to being a leader in value in dermatology, where do you get your passion now? Where do you see yourself 10-15 years from now?

[Mark:] What I find is that as I get farther into the work with process improvement that things have changed. Initially I got a lot of the satisfaction from a job well done. I’ve reached a point where some of my efforts are now paying off and I can see my colleagues having an easier time with their careers, meaning that their clinics are running more efficiently. This complicated mess (regulations), as my dad said, I can see myself as someone helping other clinicians get through this more easily. There is a great deal of satisfaction. I’m making a difference for my peers and for the people that I know need help.

"I can see my colleagues having an easier time with their careers, meaning that their clinics are running more efficiently."

[Bob:] And in turn, peers who are able to deliver care more effectively and efficiently ultimately leads to what we’re all in this business for—better patient care. For that I thank you, and I thank you for spending the time with us today.

[Mark:] It's good to talk to you. Thanks.