Medicine with a Mission
Q&A with President and Dean of Morehouse School of Medicine Valerie Montgomery Rice
Macon native Dr. Valerie Montgomery Rice, a graduate of Georgia Tech and Harvard Medical School, last year became the sixth president of Morehouse School of Medicine, which is celebrating its 40th anniversary in 2015.
An OB-GYN by training, she presides over an institution that was founded in large part to address a physician shortage in Georgia, particularly in rural and underserved communities. The school began as part of Morehouse College but is now separate. Previous presidents have included former U.S. Health and Human Services Secretary Dr. Louis Sullivan, who served under President George H.W. Bush, and Dr. David Satcher, who was surgeon general in the Clinton Administration.
Georgia Trend Editor-At-Large Susan Percy talked to Montgomery Rice in her office on the campus at Atlanta University Center. Following is an edited version of the interview.
GT: Morehouse School of Medicine was founded for some very specific reasons. Tell us about them.
VMR: We were founded to address the physician shortage in the state of Georgia and in the nation, to expand the scientific workforce and to diversify that workforce. We were founded to improve the lives and well-being of our citizens through elimination of health disparities.
GT: And have you been successful?
VMR: You can look in the state of Georgia and look at the number of minority physicians before Morehouse and after Morehouse and see the difference. We have diversified this healthcare workforce in the state of Georgia and in the nation. We have continued to bring and help identify more students who will practice primary care – 64 percent of all our graduates practice primary care or one of the core specialties [like ER or surgery]. We have targeted research that has made a difference in elimination of health disparities. We know we are seeing an improvement in the quality and quantity of care that is provided.
GT: What makes it so hard to attract doctors to rural areas of the state?
VMR: We have 159 counties, and 110 to 119, depending on which data you are looking at, could be rated as underserved – meaning that for the population they don’t have enough healthcare providers, particularly primary care providers. Part of it is what are the opportunities for a primary care provider to come there and [for his or her] practice to flourish and have the support they need in order to deliver the optimal level of care.
GT: And the other part?
VMR: The hospital system. Is there a hospital network or specialty care network that would be able to support this primary care provider when they identify challenges that need specialized care? One of the most obvious ones is obstetrics and gynecology. Family practice doctors can clearly take care of patients who are pregnant, and many of them do obstetrics in their practice. But what happens when that patient needs a C-section, or when there is a premature birth? Many of those factors measure in or contribute to people making decisions about where they practice.
GT: How does the training at Morehouse address this?
VMR: One of the things we do so well is that every one of our programs has some community engagement experience. We take [the] learning to the community. We know the highest chance of students going back and practicing in a rural area is whether or not they are from that area or whether they have had a rural educational experience.
GT: Has your original mission changed at all?
VMR: We recognized that because of a number of discoveries that had occurred in this country in science and the advancement we had seen in the scientific workforce – with some element of improvement in diversity – we still were not seeing the improvement that we would expect in the lives of individuals, particularly those in underserved or under-voiced communities. We recognized the conversation needed to move from the elimination of health disparities to that of how do we create health equity.
GT: What exactly does health equity mean?
VMR: Giving people what they need when they need it in the amount they need to reach their optimal level of health.
GT: So there’s a difference between giving everybody the same thing, and giving them what they need?
VMR: I ask you to envision three people at a baseball game standing behind the fence. One person is short; his sight is below the fence. Another person’s eyes are just above the fence, and the third is two head lengths above the fence. They all paid to see the game. So somebody says let’s give them all a box. The little short person would still not be at eye level to see the game. The middle person would finally be able to see over the fence, but the tall person would be even taller – and there’s people standing behind him. Remember what our [desired] outcome is: for everyone to reach their optimal level. We have to give them what they need in the amount they need. If I give the short person two boxes, the middle person one box, the tall person not a box at all – everybody gets to see the game.
GT: You have used the term “cognitive diversity” in talking about recruiting students to Morehouse. What exactly does that mean?
VMR: We assume that when people come to medical school they have a baseline level of knowledge, typically in the sciences. Because of complex problems we are faced with in this country, it’s not just about being smart, is it? It really does require people to bring their life experiences to the table, to be able to competently relate to the individual who will be sitting across from them or seeking their guidance and their care. Data has shown that when you have cognitively diverse people, people who think differently about how to solve these problems, people who factor in different histories, their different experiences, you know you will have a richer solution.
GT: Could you give us an example?
VMR: Imagine you were trying to address a healthcare problem. Say in this zip code, 30318, you were seeing a higher incidence of cervical cancer and you know that in that zip code there is also a decreasing incidence of people having Pap smears. Now we know there is a connection between people having Pap smears for screening and then early detection of abnormal cells that may lead to earlier detection of cervical cancer. One may say if we know this and we go out and tell people in the community then they ought to adhere to it because we have evidence that supports that.
GT: But that doesn’t always work, does it?
VMR: What if in that community you have people who maybe have had someone die from cervical cancer or someone who’s not had a positive experience in the healthcare environment? Or maybe someone has a cultural belief that does not allow them to participate in diagnostic screening such as a Pap smear. Now what if you had someone who was from that community? They’re going to bring in some different life experiences that may help you create solutions that will enhance the education of that community or remove some of the barriers and build some trust.
GT: Is this approach a departure from traditional medical school training?
VMR: I think so. Every medical school now realizes we must bring cultural competency to our educational experiences. We have always recognized that; we were founded under that premise. We have always appreciated diversity – not just diversity based on race and ethnicity. We see it in students who come from rural populations.
GT: What’s it like to follow in the footsteps of people like Louis Sullivan and David Satcher?
VMR: For me personally, it’s clearly always a humbling experience. When I think of Dr. Louis Sullivan and Dr. David Satcher – both of them were practicing physicians for a long period of time before they came into an administrative post. Having served as a practicing physician myself and then making my way by serving at every level of academia – instructor, assistant professor, associate professor, starting a women’s center – it really keeps you in touch, keeps your finger on the pulse of what is important. What’s important at Morehouse School of Medicine is how we educate and train the next generation of healthcare providers and research scientists and public health leaders. And also ensuring that we don’t lose sight of who the end user is – the patient.
GT: How do your strengths complement your role at Morehouse?
VMR: I have this awesome responsibility to ensure that I serve as a role model in guiding this institution. One of the things I recognize is that you have to empower others to bring their best selves to the table. What I have to be committed to is creating an environment where people feel they can bring their best selves to the table and that their opinions, their diversity of thought, their hidden assets, their bright spots are valued. And even more importantly than just being valued, they are actually required for us to be successful. I try to lead by example. I try to listen more and try to create this environment where people are allowed to speak and be heard and can actually pinpoint that what they said translated into something that made a difference.
GT: What are the challenges for Morehouse?
VMR: Our challenges are similar to most academic health institutions: not enough resources for all we want to do. Because we are a community-based medical school – meaning we do not own our own hospital – we don’t have the opportunity to realize some of those revenue streams, so our partnership with Grady Health System, the VA health system, Atlanta Medical Center, all of those partnerships are critically important. Our partnership with the CDC, with the Department of Defense – all of those allow our public health professionals and research scientists to have a diverse place in which to train. We rely significantly on collaboration and partnership. We need to increase that.
GT: Tell us about the research going on at Morehouse.
VMR: We have four areas that we focus on. We recognized that we couldn’t be everything to everybody, so we did a deep dive and said if we are true to our mission, our goal is to eliminate health disparities. What are the disparity-based diseases that impact communities that are underserved and under-voiced? It came out to four: cardio-metabolic disease, cancer, neurological disorders, and HIV/AIDS and infectious diseases.
GT: And that has guided your research?
VMR: That allowed us to look at cardiac diseases, allowed us to look at stroke, allowed us to look at other neurological diseases. Clearly breast cancer, prostate cancer, uterine cancer. What are common themes across each of those? Clearly there are behavioral components to many of these diseases. We also knew that the disparity a lot of time was secondary to access. So we have advanced our ability to look at research from a disease focus but also a population health focus: You focus on understanding some of the root causes. That requires that you do basic science research. But then you also talk about what the interventions [are] that have been proven or shown to be successful in impacting the disease. Are they really permeating out to the communities that need them? We’re really talking about health equity, right?
GT: Do you have an example?
VMR: Look at HIV/AIDS when antiretroviral drugs became available across the country. African Americans at that point had the highest rate of HIV/AIDS as compared to other racial or ethnic groups. When drugs became available, you saw a decrease in mortality in every group, but what you didn’t see was a narrowing of the gap. So if it was 15:5 black to white, it stayed 15:5 black to white. But what you then started to see, the rate of black people dying from HIV/AIDS increased after the drugs were available as compared to whites dying.
VMR: Part of that was lack of policy, [and] that ensured that antiretroviral drugs did not permeate to those communities that needed it the most. Remember my box analogy? If there had been policy that said we’re going to look at communities that are disproportionately impacted by the disease and we're going to ensure that they have as much as they need based on the rate of the disease – what would we have seen?
GT: Now that it has cleared the legal hurdles, what do you see as the likely effects of the Affordable Care Act?
VMR: It’s more than just access. It’s way more than just Medicaid expansion. It really is a federal policy that is prioritizing pay-for-performance (P4P) models. So no longer will we pay for just volume. We are asking the question: Is this care you are providing high quality and leading to an outcome that allows individuals to reach their optimal level of health?
GT: What is that going to mean for doctors?
VMR: Providers are having to practice smarter. We’re having to accurately provide patient care when they need it, in the amount they need in order for them to reach an optimal level of health. We are having to introduce something called comparative effectiveness research, so we are having to ask this question: Is this the right drug for this individual based on attributes they bring to the table? How does that compare to another drug? We are having to individualize care.
GT: And that’s a significant change?
VMR: This precision medicine that you have heard the president talk about is an opportunity now because of two things: We have the genome – genomic medicine – and electronic health records. So now we can do the type of data analytics that help us to understand more about what happens at an individual level when someone is exposed to an intervention.
GT: Any other changes?
VMR: We are seeing a decrease in the number of uninsured Americans. I believe in 2014 alone we saw a drop of 12 to 13 percent; in 2013 it was a drop of about 18 percent. What that says is more people are going to the doctor who previously used the emergency room. We are hoping that they are now receiving education and strategies along the lines of prevention and wellness to prevent their disease going from acute to chronic.
GT: How is all this impacting the teaching you do here?
VMR: How we educate and train our students has not changed much except we really do now talk a lot more about outcome and analytics, integrating information from electronic health records into research information that we get and coming up with algorithms that may predict a certain outcome. We also are exposing our students to many of the aspects of healthcare that allow them to operate more cost effectively, because there is going to be decreased reimbursement per encounter with patients. And there’s going to be decreased encounters if you actually implement prevention and wellness. We believe it is going to mean there is a greater need for primary care providers. So what we do at Morehouse School of Medicine becomes even more important.
GT: Anything else you’d like to say?
VMR: What I would like to say to this state – the state legislators and governors who have been with Morehouse School of Medicine for the last 40 years – is thank you. Thank you for recognizing that there was a need, and thank you for what you continue to do every year in assisting us in maintaining our opportunity.