Clay Johnston: The TT Interview

In December, University of Texas at Austin President Bill Powers told lawmakers that ongoing tension between his administration and the University of Texas System had made the recruitment and retention of top faculty more difficult.

That doesn’t appear to have been the case with Dr. S. Claiborne “Clay” Johnston, who last week was named as the inaugural dean of UT-Austin’s Dell Medical School, which is scheduled to open its doors to its first class in 2016.

A practicing neurologist, Johnston is currently the associate vice chancellor of research at the University of California, San Francisco, where he has served on the faculty for the past 17 years. He served as UCSF’s director of stroke services. He directed its Clinical and Translational Science Institute, which focuses on accelerating the research process in multiple health fields. And he founded the Center for Healthcare Value, which seeks to develop more affordable approaches to health care delivery.

“All of that has been about moving health forward,” he said by phone on Monday, “by engaging as large a community as possible in innovation, and particularly by being in touch with the end users — in this case, the public.”

His past experience, he said, puts him in a good position to build a medical school from scratch in Austin, which is essentially the task before him. And expectations are high.

In his introductory remarks at the announcement of Johnston’s hiring, state Sen. Kirk Watson, D-Austin, spoke of the Austin community’s hope for the school. “We hoped to create a wellspring of doctors to keep our friends, neighbors and neighborhoods healthier,” he said. “And we hoped for a hothouse of health care innovation – one built from the ground up, amid UT’s vast academic strengths and research resources, to transform our economy and our health.”

The following is a transcript of the Tribune’s conversation with Johnston. It has been edited for clarity and length.

Texas Tribune: What made you want to jump from an established medical school to one that doesn’t even exist yet?

Clay Johnston: I think the opportunity to try to get the model right without all the constraints of the existing systems and models that are out there, that’s really a very rare opportunity. Particularly when resources and partners are all in place and aligned to do things better.

So this is really a very rare, special opportunity, whereas working in an existing system is wonderful, too, but is more about stewardship than it is about creativity.

TT: When you talk about getting the model right, what is your vision for the medical school?

Johnson: Well, our current health care system has tended to really lag in terms of its change over time. One example of that is how it has embraced technology or failed to embrace technology. Finally, we have electronic health records, but only because of strong incentives set up by government in order to do that.

And those systems are really more transactional than anything else. They are like the Excel spreadsheets of health care. They are beginning to allow us, though, a nice platform in order to make better advances in improving health.

But even if you look at a really simple way in which technology has changed our lives, like the use of email, it has not been embraced in the health care system.

Wouldn’t it just be a whole lot easier to email your doctor and expect a response in a normal timeframe for email related to getting a refill or a question you have about flu symptoms, rather than having to drive in, find parking, sit in the waiting room with a bunch of sick people, finally get seen for 10 minutes, barely get your questions answered and then leave?

That current structure is largely set up because of our traditional fee-for-service structure for providing care. That’s just one example. There are many others where, if we’re freed from the traditional relationship that physicians and academic medical centers have with hospitals and payers and their patients, then we have the ability to really innovate in much more interesting ways.

So what’s the vision? The vision is to have a medical center that’s focused on training the physicians of the future, who work better in teams and embrace technologies, and use that to come up with the new models of health care that are more efficient and provide better care for the people.

Another example I like to give is hypertension. It’s a really common problem. Even in our current system, it’s one of the most common reasons for people to see a doc. It’s actually really simple to manage. You want to listen to the patient and make changes in their medication based on side effects and whether they’re responding to the medicines and what their blood pressures are.

In our current system, we do not do a good job, and fewer than half of patients with hypertension do have it controlled — even when they’re going to a physician.

So we’ve got to have a better system.

Imagine we have a system in which we have a physician or team of physicians working with pharmacists and social workers and others taking responsibility for hypertension in Austin.

What might that look like?  It might allow you, if you’ve got hypertension, to take your blood pressure at home and have that fed up into the system. It might automate — based on guidelines, based on your symptoms, based on your blood pressure — recommendations in how you change your meds, and it might just send you the script so you don’t have to come in and wait at the doctor’s office and then again at the pharmacy.

It’s just another example of how rethinking these things — taking a step back and saying, “Logically, how could we do this better?” — opens up the possibilities to get the models right.

TT: Is there anything lawmakers in the state could do to help change the model?

Johnston: One of the things that has frustrated me is when we in the health care delivery side have insisted that, in order to make progress, we need to have policy overhaul. And obviously there are diverse ideas about what that policy overhaul should be. Experts don’t agree, and of course the politicians don’t agree. And there are fundamental ideological issues with the various solutions that have been proposed.

In my mind, yes we need to think about policies that will work better. But even in the current policies that exist, we have a responsibility to move medicine forward. And that is actually possible.

That may mean disrupting the relationships between patients, insurers, physicians and payers, but I do think we’re at a point where we can start to work on those models. As we work in the space, will it become more apparent that policy changes — things everyone agrees make sense — would make a big difference in our ability to pick up the pace in doing this work? Absolutely.

But right now, I think there’s plenty for us to do even within the constraints of current policy.

TT: Hopes are high for this institution. Realistically, how long does it take to build up a world-class reputation like that of, for example, UCSF?

Johnston: We will have the reputation that we deserve, plus we get a little extra by being nicely resourced and strongly supported by the community, including the state, and being associated with this fabulous university. From the get-go, we’re going to take advantage of all of those things.

There is absolutely no reason to build out expertise in the many areas where it already exists in UT. We will pull in those really strong partners from the beginning. That helps to create the reputation that we will deserve.

UCSF is successful in part because it’s huge. You can have Nobel laureates when you’ve got a faculty of 2,400. Some of it is brute force size. You can accept a very broad agenda when you’re that large. However, I think that here, the key is going to be to focus in areas where we think UT is positioned to really have a leadership position and to launch in those areas in really powerful ways. That’s the plan.

TT: When you were thinking about taking the job, did the tension between the university and the system give you any pause?

Johnston: Honestly, yes. This is obviously a very visible position. I think that is appropriately the case. There is huge potential in this position, and there’s also tremendous investment at the local and state level.

Getting pulled into the politics, for me, is a potential distraction from getting this job done. I really do feel like the health care can move forward dramatically, independent of the political process. It needs to. Having that sort of instability and scrutiny at the system level is a potential distraction if I get pulled up into it.

But it’s clear from the chancellor and others that there’s major commitment not just locally at UT-Austin but across the UT System. They did a tremendous amount of homework to set this thing up, and they are definitely aligned to make it successful.