October 7, 2026 Salus Forum

Warren

Several comments. First, for both my prior collaboratives with residencies and with the MP3, they participate in teams for a variety of reasons. So I agree with that completely. Second, I think development does occur over an entire career. The issue is how can you create structures where people get feedback and learn throughout their career. What I think is missing now are two things. One is, how do you train vision? It’s a muscle. I think it’s partially trainable. In a lot of the traditional management training programs you assume that somebody knows where they want to go. However, I’m worried about whether or not they know where they want to go. Furthermore, I think a lot of current quality improvement initiatives are really mechanical and dashboardy without focusing on the why.

The other thing that’s missing is a system sense. This is my term, but I think it’s embedded in what Jeremy sent out. How do you develop a sense of systems theory that people at MIT have developed. These things are all interactive. I remember in 1997, that the CEO of the hospital brought us together and said, “I want you to come up with a completely different way of admitting, discharging, and transferring patients.” For me, this meant spending three or four years understanding the dynamic of a hospital and how changes in one thing would affect other things. It’s chaos theory writ large.  And I think the same thing is true for practices. But can you train system sense? I don’t mean labeling the various influences. I mean, can you train somebody who is looking for perturbations in the environment and thinking about what’s causing what?  So the issue for me is how do you train vision and how do you train system sense? Does that make sense?

Mark

The last part of this discussion addressed some of what I was going to ask. Warren, you were talking about making it a four-year residency program instead of a three-year plus a fellowship. I was just wondering if that fourth year would in fact try to train this vision or system sense or certainly leadership, management, talent, budget and quality control issues.

Warren

That would be a major focus of the fourth year. The issue for me is one that Dr. Bergquist raised. I think the American Board of Emergency Medicine is entirely wrong along with the ACG. They think that the right stage for this is right after the end of residency. But the vast majority of family docs are doing something for four or five years. They discover they’re good at it and are interested in it and that’s when they get in. For our 200 people, every single one of them is joining not after residency. You don’t know you’re going to be good at this until later on. And I’m having a loving discussion over many years with ABEM to say, “look, we need almost a practice pathway permanently because the notion that you’re going to have a fellowship right out of residency that’s like, do you want to be a CEO?