Faculty Development Digest

Swimming Upstream

The first time I visited Seattle six years ago, a good friend took me to Ballard Locks to see the salmon ladder. What a sight! The salmon faced an incredible challenge-swimming against rushing waters, upstream and up ladders, but they made it.

Over the past year, I’ve been impressed by the amount of editorials in major journals, conferences and organizations focused on upstream medicine and “right care”, that I am hopeful we are at a tipping point.

I attended the Lown Institute Conference in March. The motto of the organization is “Right Care, Right Patient, Right Time. The vision is:  “A society that fosters health. We seek a society where health and healthcare are seen as rights; where physicians and nurses serve as healers and as advocates for those who are vulnerable and most in need of care; where patients are safe from avoidable harm; and where spending on healthcare exists for the benefit of patients, communities and nations.” Highlights of the conference were hearing America Bracho, MD speak about Latino Health Access, Mitchell Katz, MD, director of Los Angeles County Department of Health Services speak about his housing the homeless initiative and Steven Nissen, MD, Chair of Cleveland Clinic Cardiology speak about overuse.

Cindy Haq, MD along with Drs Crouse, Frey, and Gilchrist attended the Beyond Flexner conference that featured Don Berwick and Jack Geiger.

Cindy had these reflections on the conference:

“The bottom line is that a new model is emerging, the community centered health home, that extends beyond the 'patient centered medical home'.  Additionally, we had the chance to hear fromDr. Rishi Manchandra, aka the upstream doctor

Momentum is building to address the social determinants, to set metrics and measure progress (ie accountability for social accountability).  One of the sessions I attended was the Rationale for Investing in the Social Mission, ie funding to address the 'upstream determinants' of health.  Maureen Byrnes (Human Rights First) discussed the history of community benefit dollars that flow from Medicare to not-for-profit hospitals. In the past most of these funds have been applied to 'charity care' for uninsured patients.   Now through the ACA, Section 9007, Schedule H, Part II, there are many more categories of spending that can qualify for funding (such as housing, economic development, community support, environmental improvement, etc.). 

Maureen is working with the Robert Wood Johnson Foundation and George Washington University to develop a community benefit web-based tool.  This tool will provide more transparency so communities can track the use of these benefit dollars to increase and ensure that health systems deploy these funds to meet local needs and to improve community health. 

Gail Christopher, VP for policy of the Kellogg Foundation, discussed the importance of community engagement, how access to health care is also a social determinant of health. She discussed the National Collaborative for Health Equity and called for new partners.  She noted the importance of the County Health rankings as an important barometer of progress!!

Chris Koller, president of the Milbank Memorial Fund, discussed the importance of mobilizing assets and influencing policy.  He stressed the importance of access to high quality primary health care.  He noted that states that have passed legislation requiring community benefit reporting from hospitals are more likely to make substantial progress and cited several examples.  He added that the ACA is the most significant social movement for health equity in 40 years. Local communities should be poised to advocate that these funds be applied to meet local needs.”


We have a lot of ladders to climb, but at least we have turned upstream.



Melissa Stiles, MD


Articles Worth a Read

Atul Gawande “Overkill”

“Getting the Right Medical Students”