Wednesday, September 20, 2017

Budd Shenkin's Buzzy Award Remarks

Life is strange, the way things work themselves out. One of my favorite lines comes from Kurt Vonnegut's Sirens of Titan, which I misremember as “I am here because of a series of accidents, as are we all.” It's actually “I am the victim of a series of accidents, as are we all,” but somehow I like my mis-memory better. No life plan, no God's plan, just randomness working its way. As Vonnegut also says in Slaughterhouse 5, “So it goes.”

I got to use that line last Saturday, even though it wasn't in my script but only in the back of my head, and I was so pleased. At last. The way things worked out for me, after I became a pediatrician not knowing if I really wanted to practice medicine, and in fact hadn't envisioned myself being a pediatrician until I found myself (in both senses of the word) on the pediatric wards, and after I found myself running a practice that became a big group, the way things worked out was, after thinking I didn't mesh comfortably with American Academy of Pediatrics, and I didn't mesh comfortably with my home academic university UCSF, the way things worked out was, I found SOAPM, where it turned out I did mesh very well. I found it when a competitive local colleague who was trying to build SOAPM membership and didn't really have my welfare in mind, mentioned to me that SOAPM existed within the AAP and “you should join it.” SOAPM stands for “Section On Administration and Practice Management,” which is what I found the most challenge and pleasure in doing, administering my practice. And so it goes.

So there I was standing before the group of maybe 150 at the convention center in Chicago accepting the annual Buzzy Vanchiere Award, conferred by SOAPM for excellence and service, and I used the line. SOAPM had become my home, where I had served on the Executive Committee for six years, and where I had figuratively sweated and bled for probably 15 years, and where I had found my place. Because of a series of accidents.

As I started my remarks, I noted that the Buzzy Award confers three things. One is what I chose to see as love and respect from my SOAPM colleagues, which I reciprocated enthusiastically – “back atcha!” Seriously, these are wonderful people and some of the best friends of my life. The second Buzzy thing is a $1,000 honorarium, which I am forwarding on to the AAP Building Fund, which I am more than happy to do as a sign of support and respect to the AAP (with more to follow, actually.) And the third thing is: a semi-captive audience. As I noted this, there was a small laugh, perhaps nervous.

An audience. No set subject. What to say? That was the question.

I think a lot about the health care system, and my first impulse was to give a speech about the evolving organizational structure of medicine (see
and the weaponization of EMR's by academic health centers to augment their power and control. But as much fun that would have been for me, not necessarily so much for the audience. So I discarded that idea, other reflections and recollections, and bon mots, and I focused. And what I finally focused on was SOAPM itself. As I thought more and more about it, as I thought about how SOAPM had evolved, and as I thought about the challenges facing the AAP and American medicine, the more I thought that I had something to say about how SOAPM should view itself, and what SOAPM should do, and what the AAP should do. And that became my talk.

So, here it is, my Buzzy talk, edited for readability, and missing some spontaneous emissions when I spoke it, some of which evoked applause and some laughter. But the essence of the message is what we're interested in here.

It got a good reception when I gave it, lots more in the next couple of days, and I hope it leads to action. Now, that would be a real dividend from the Buzzy award.

Budd Shenkin's Buzzy Talk
September 16, 2017
AAP NCE, Chicago, IL

Here in brief, is the message of this address:

SOAPM is a lot more important than we might think it is. It has far exceeded the objectives that the founders of SOAPM hoped for it, and then has gone far beyond them. Given the great changes of organizational structure that the medical world is experiencing, and given the evolving requirements for the AAP to be effective in that medical world, SOAPM is not just another AAP section. It is now more relevant to both the AAP and to the evolving world of health care than anyone could have predicted.

When this happens to an organization, when it becomes very successful and when the world it addresses changes, one has to reassess the organization’s structure and the resources devoted to it. Just so with SOAPM. I believe that SOAPM needs to be reevaluated, to be strengthened, and that our basic organization probably needs to be updated.

Because I think it's possible that, great as SOAPM is, you ain't seen nothing yet.

To make that case, briefly, I intend to look at the past, the present, and the future.

What we have done so far

SOAPM has been a roaring success.

  • We have increased our membership to over 1,200, and we are arguably the most dynamic section or committee within the AAP.
  • I don't know if the founders would be surprised or not, but I'm certain they would be gratified.

The Original Agenda

I think the SOAPM founders hoped that the section would:

  • concentrate on helping each other run practices.
  • educate the rest of the Academy on how to do it.
  • and show the Academy how important administration and management is.

This is still mostly what we do.

  • We help with coding.
  • We trade tips about how to organize our offices.
  • We coach on how to deal with insurance companies
  • We give lots of educational sessions on management topics – Herschel himself has become a virtual education industry.
  • We have constructed a huge storehouse of documents on how-to.
  • Not to mention that we are the world's leading repository for vaccine-refrigeration and disaster preparedness information at our subsidiary office in North Carolina.

I think this was the original agenda. No doubt we have exceeded hopes and expectations.

Possibly part of the original agenda

It's hard to know if the founders envisioned this, but SOAPM has been successful in helping Academy statements and projects to be practical and relevant. There are innumerable instances where this has happened, but just to name two:

  • No unfunded mandates – want us to do some things for Bright Futures? OK, we have to be paid to do it.
  • Practice responsibilities for vaccine refusing families – we now have freedom to refuse them as patients, and as a result we think many more families will be vaccinated.

Probably not part of the original agenda

Amazingly, SOAPM has been able to help the Academy recognize a new facet of its mission. Traditionally and appropriately, the Academy has stood fast in its determination to improve the health of children. Now, even though we recognize that the Academy is not a trade association, it is now considered legitimate that the Academy consider protecting and improving the health of our practices as part of its mission. The health of pediatrician practices, whether independent or within networks and groups, is now recognized to be strongly connected to the health of children. That is thanks to SOAPM. We have exceeded the original vision here.

Also probably not part of the original agenda

SOAPM has also exceeded its original charter by reaching out to try to affect the actions of organizations external to the Academy.

  • Trying to influence NCQA and make their measures palatable to pediatricians seeking to qualify as Patient Centered Medical Homes.
  • Trying to help CDC improve flu shot distribution.
  • Trying to rationalize the VFC program.
  • Trying to help Feds get coding straight.
  • Trying to get the American Board of Pediatrics to straighten out its act.
Truthfully, we have been only partially successful in these efforts, and SOAPM and the Academy are still not sure how assertive to be. But we seem to be on the road to becoming more successful.

Certainly not part of the original agenda

There's one thing they couldn't have envisioned in founding SOAPM – the listserve, because the technology wasn't there yet. The listserve has proved to be the X-factor that has multiplied the impact and importance of SOAPM immeasurably.

We use it:

  • To fulfill our main mission, to trade knowledge and views on practice administration, on interventions with insurance companies, on coding, etc.
  • To trade clinical information, which is so enlightening and so much fun.
  • To trade information on outrages by everyone, from government to patients and not excluding the Academy.
  • To trade opinions.
  • To keep up with and deepen our knowledge of policy
  • Etc.

And then there's something much deeper that the listserve has gifted us with, besides making sure that we “get mail.”

The listserve is what has led us to become a great virtual community. We are a community. We care for each other, we reach out to each other, we have come to know each other and help each other, and to forge bonds of affection born of discovery. We feel about each other: where were you all this time I've been looking for you?

And, the listserve has uncovered great intelligence and talents. Aren’t you just blown away by some of the things we hear that people are thinking? We have so many smart people here. And idealists. Yes, make sure we are paid for what we do – but the true idealism of people, the embodiment of the true mission of medicine, of pediatrics, shines through. You are some of the finest people I have ever known. SOAPM is a testament to the power of a listserve!

So, this is only a partial list of activities and accomplishments. SOAPM has been, and continues to be, a roaring success. We have punched far above our weight. We are all so blessed to be part of it.

The Future Agenda, and Our Organization – Aspirational Goals

KEY POINT: Even as successful as we have been, SOAPM could actually be even more than what we have become. Our task at this point, I think, is to envision our future.

First Point

Health care’s organizational structure is changing very profoundly and quickly. Everything is getting much more agglomerated and corporatized. This presents us with a very potent challenge. New entities are arising, such as RBC’s and UC’s for after-hours care, networks, other agglomerative bodies. And in fact, we need to recognize that over half of us are now employed physicians! Not that there's anything wrong with that. Employed pediatricians aren't that different from those of use who are independent. The majority of pediatricians are eager to serve patients well, and to improve the systems that they are part of, and to make sure that they themselves thrive in the process.

But while increasing size can be good, it is also a threat.

  • It's a threat to patients – bureaucratic medicine can be harmful to your health.
  • It's a threat to us – some of us would rather quit than become a cog in a corporate wheel.
  • And to those of us who are working in larger systems, we need a lot of help in coping with the bureaucracy that we are part of, to survive happily, and to improve the systems of care that we are part of.

With all this change, where is the voice of primary care pediatrics? Where is the voice of primary care that knows organization, administration, and business? Nowhere else but SOAPM. We are much more important than we realize, and more important than others realize.

Recall the Indian parable of the blind men trying to describe the elephant. One of them says, “An elephant is a round, very heavy immobile post.” Another feeling the ear says, “No, it is thin and long and floppy.” A third says, “No, it is long and round, flexible and strong, with a hole in the middle.” To understand what an elephant is like, they have to communicate and to accept what the other is saying, without the arrogance of thinking that they are the only one who is right.

What is the point of view that SOAPM has to contribute to the ongoing puzzle of reforming the health care system?

We have a point of view that is invaluable. We are where the rubber hits the road, since we actually see patients day after day, not two half days a week; we are the ones who devise the processes and implement in real time what others only imagine; we see what is actually happening as a result of policies. We know how to design systems that work.

Yet we struggle to get our voices heard, within the AAP, and in the larger medical world. Other forces are very powerful – from insurance companies, from PhD's and MBA's, from hospital administrators, from the large academic centers, from the procedural specialists. They have the arrogance of power and money. They really don't want to hear us. So we have to insist.

We need to be at the table and not on the menu! We are important and we shouldn't have to fight our way into every discussion, into every policy argument. We shouldn't be treated like step-children. The AAP should be bringing us in on just about everything, not just having things handled by a few Board members and some top staff. On SOAPM'S behalf, I want in, and I don't want to have to fight for it.

A case in point is policy on after-hours care units, RBC's and UC's. Jim Perrin tried to bring order out of chaos by developing a policy centered on the Task Force on Pediatric Practice Change, and did a good job, but then the TFOPPC's sun set. Currently, this policy just goes floating around – this policy needs a home, and it should be with us. That's just an example. More generally, the Academy needs a center to consider issues that arise on the organizational structure of health care, and I nominate SOAPM to fill that vacuum.

In sum, in these new times, SOAPM is more important than ever.

Second Point

If we are going to meet this challenge, we need to consider our own internal organization. While the world and our functions have changed dramatically since SOAPM was founded, we are still organized exactly the way we were twenty years ago, and we still have the same resources.

For one thing, we need to run SOAPM like a business! This point has been made most cogently by Jeanne Marconi and Sue Kressly on the EC. We don't need to reorganize to make money – that's not the point. (Although business is our business. We wish the Acadmy would turn to us for some business advice instead of hiring consultants – that's another function we could serve.) But we need to have agendas, a list of things we want to accomplish and means to accomplish them with timelines, on objectives that are widely accepted within SOAPM. We all in SOAPM should be aware of our agenda and have a chance to help shape it. And it should be visible to and approved by the higher administration.

We also need to make better use of our member resources. Jon Caine and Glenn Schlundt, Peter Pogacar, members of the EC, so many others, so smart! Yet, the discussions and analyses just vanish into the electronic ether of the listserve. They shouldn't! We have huge intellectual resources that are being suffocated here within SOAPM. (At the very least, by the way, our journal Pediatrics should modernize itself and have a section devoted to policy and management articles.)

The mark of an excellent organization is one that identifies, nurtures, and makes use of the excellence in its workforce. We need to organize ourselves so that we do that effectively.

Maybe it is no longer appropriate that SOAPM should be a section. I'm not sure what other form we should take, but we should be immediately accessible to the Board and the CEO, and we should be able to be the repository for policies concerning organization of care and be able to produce policy papers.

More generally, the policy world is crying for primary care leadership, and we should press the AAP to use us to supply that leadership.

We will need more resources for this – we actually need more resources just to continue what we are already doing.

For us to achieve a new organizational form and placement, we need a first action step. I propose that we establish a task force of 10-15 people, from SOAPM, from the Board, and including a representative of the CEO, to reexamine the structure and function of SOAPM and come up with alternatives for the future.

We have grown; now we need to differentiate. An organization that is not going forward is going backward. Let's not be like Kodak - they owned the world of imaging for a hundred years.  But they took their eye off the future of their industry and quickly became irrelevant.


So, my message is simple. We have been a great success. We have given to ourselves, we have given to the Academy, we have given to our patients. But it's time for us to think bigger. What more can we do with more staff, more involvement from our membership, a more prominent place in the AAP, a more businesslike organization?

I say, let's give it a try.

Budd Shenkin