The following is a transcript of my interview with Dr. Nirav Shah. To find links to the audio files and more information about the interview, please click here.
Bonica: Welcome to the Forge, Nirav.
Shah: Thank you. It's great to be here.
Bonica: Usually, I start my interview with my guest's college experience because most of my listeners are of college age, but you had an interesting upbringing having spent your early years in India even though you were born in the U.S. Can you tell us a little about your background and how did that influence your interest in medicine?
Shah: Well, I have a twin brother and when we were born he was a full-time job for my parents. He was born at two pounds, I was born at five pounds. My grandparents decided that they would take me to India for a few years. From age four months to four years old I grew up in India by my grandparents and have been back to India almost every year subsequently, sometimes for months at a time, and living between two cultures.
My father came from a really small village in rural India and having gone there many times, seeing the kids playing barefoot in the dust, knowing that there is a very thin line between my reality growing up in America and his reality growing up in rural India has really driven a lot of my decisions over time in terms of how I approach things, how I prioritize things in my life, and hopefully, the kind of impact I will have over time.
Bonica: Interesting. You did your undergraduate work in biology at Harvard. When did you know you wanted to go into medicine? Did you go into your undergraduate knowing you wanted to do that?
Shah: As an undergrad, I knew I was always interested in the sciences and biology allowed me to fulfill my pre-med requirements while at the same time exploring deeper into a specific science. At the end of college, my parents gave me three choices that most Indian-American kids are given. You can be a physician, you can be a doctor or you can be an MD.
Bonica: That's very nice.
Shah: As Indian kids tend to, I did listen to my parents and started down the medicine pathway and I've been very happy with that decision.
Bonica: Very nice. Did you know you wanted to do research as well as do medical school? Most doctors do not do that.
Shah: As an undergrad, I actually had started in research labs and I really enjoyed it. While a physician can help 1 patient at a time and 15, maybe 20 patients in a day, theoretically, as a researcher or a scientist, the findings may have broader implications for population. I wanted to manage the immediate gratification you get from being a physician and caring for a patient at a time with a broader societal implication potentially making discoveries or breakthroughs or implementing things that would have impact for more than a few people.
Bonica: That's neat. You did in fact graduate from Harvard with a degree in Biology and you went to the Yale School of Medicine where you did a dual MD MPH, Master's in Public Health degree, with a concentration in chronic disease and epidemiology. Why did you choose the MPH orientation and specifically chronic disease?
Shah: Back then I knew that I wanted to study more public health. Having seen Third World problems firsthand when I visited India, I knew there was much more to healthcare than just healthcare delivery and that public health degree would give me the tools I needed to have the broader understanding and hopefully impact over time. Unfortunately, Yale was quite myopic at that time. They didn't recognize public health as a degree that you should get a PhD in. They were very basic science focused and so they steered me away from MD PhD program. Just to do it anyway, I took on the MPH and instead of my fourth year of medical school, I received an MPH.
Bonica: I wanted to ask you, I like asking this question to my physician guest, was medical school what you expected? Where there any surprises when you got there? Anything surprising about the experience?
Shah: I went to Yale because they had no grades. It was one of those schools where once you're in, there really is no distinction between the ones who are the gunners and everyone else. Having that kind of atmosphere where everyone helped each other get through medical school was the collaborative environment I really wanted. Yale was real joy to be in for medical school. I learned a lot from my colleagues. It was a great place to lean medicine, long, rich history, and gave me the tools I needed to get onto the residency and fellowship. Not to mention world-class faculty, and buildings, and opportunities which allowed me to get to the next stage very easily.
Bonica: That's interesting. I didn't realize they didn't give grades. You think that the fact that they don't have grades allowed you all, you, the students, to cooperate more and didn't compete as much?
Shah: Yeah. There's a pre-med mentality whereas at Yale, if we found something that was useful for our next test, we would leave a copy of it at the library reference desk and email all our classmates saying, "Hey, I found this was very helpful. You can make a copy for yourself at the library." I don't think that that happened where there were grades and people were ranked. The person who graduates last in the class at Yale, what do you call him?
Bonica: Right.
Shah: Doctor.
Bonica: Doctor, right. You chose to stay on at Yale and do your residency in internal medicine at Yale New Haven Hospital. Why did you choose internal medicine?
Shah: Internal medicine, of all the specialties, is one of the most generalist. It allows you to still say active in many, many aspects of your patient's life. Not so much as a gatekeeper but really, it is the point of contact for just about every adult patient. For me, having the ability to have that broad overview allowed me to take my research in different ways as well. One day I could be doing a meta-analysis on breast cancer treatment and the next it could be around pulmonary treatments for idiopathic pulmonary fibrosis. As an internist, I had credibility in both since I saw all of those patients.
Bonica: I see. You followed your internal medicine residency with a fellowship in Epidemiology Health Service and Outcomes Research in the Robert Wood Johnson Clinical Scholars Program at UCLA. What is a fellowship in epidemiology? What do you do during that kind of training?
Shah: Epidemiology allows you to study diseases in different ways than a traditional physician would study a disease. Think of it like an MPH steroid. As a fellow, you have the clinical training you need but then you're also given the tools to manage populations in different ways. Going to UCLA in this specific fellowship program gave me an outstanding set of mentors, long track records in health services research, policy, and other areas where you don't necessarily get that kind of exposure in an academic setting as well as gave me two more years to figure out what I wanted to grow up to be.
Bonica: I'm stilling working on that myself. Why epidemiology as opposed to say any of the other number of specialties that internal medicine residency-trained physicians can go to?
Shah: Epidemiology also gave me that opportunity to have a broader impact. When you're making policy to understand how 1 liver affects 10 other livers is really important. When we get into subspecialties and sub-subspecialties, you tend to see the world through a very, very narrow lens. Epidemiology does the opposite of that. It forces you to understand many different perspectives including the social determinants of health and other implications that really matter more than just the given drug or the given healthcare delivery system that you're working in.
Bonica: Society holds physicians in a high regard and being a physician is usually a pretty important of a person's identity once it's been achieved. When did you really feel like you had become a physician? Was it immediately upon graduating from medical school or sometime later and how did you know?
Shah: I remember being a senior resident at the VA Hospital in West Haven and when you're the senior internal medicine resident, you basically run the hospital from late evening until early morning. Anyone in any part of the hospital who's not doing well, they call you. When I knew I could keep any personal life for about 24 hours or at least until the morning, that's when I felt I became a doctor. Whether it's the right to do or no, that clinical acumen of keeping the blood pressure at a certain level and the other parameters working gave me my first taste of being a true doctor as an independent practitioner.
Bonica: It's the independence and ability to manage it on your own. That was what helped you say, "Yup, I've achieved this identity."
Shah: That's right.
Bonica: You finished your fellowship up at UCLA. Tell us a little about your early career following the fellowship. Where were you? What were you doing?
Shah: I really loved being in Los Angeles and my wife got a job at American Express in New York that's why we moved to New York. I followed her there after finishing the fellowships a few months later and landed at NYU Medical Center, which was really the perfect place for me because I could still be clinically active, I could still pursue research, and they were willing to split my time between the rural setting of Danville, Pennsylvania where Geisinger Health is located and the inner city environment of Manhattan with very different but still undeserved population that was urban and multi ethnic. It gave me a learning lab in Pennsylvania at Geisinger, one of a mini Kaiser-like health system and then effectiveness lab, if things work in that setting, then maybe they will or will not work at Bellevue Hospital in downtown New York.
Bonica: You were learning things at Geisinger and bringing them back to your work at Bellevue?
Shah: That's right. For example, what medications work in large populations among diabetics to stave kidney failure? Once you've done a study there in a perfect setting where they use electronic health records for our millions of patients where the average patient stays in their home for 25 years, where race and ethnicity are not an issue. Everyone is pretty much white in rural Pennsylvania. Then when you figured out the 3 things that worked out of 20, you take those 3 back to the messy environment of an urban public hospital and see if any of those three still stick. That was a very interesting ricochet that I did on a weekly basis. Two days in Danville and then the rest of the week in Manhattan.
Bonica: Wow. That must have really been head spinning to jump between those kinds of environments.
Shah: It was. I could tell you, the price of gas in Danville is a lot cheaper than Manhattan, but I really did get the best of both worlds and it was some of the happiest, most productive years where I was able to leverage the experience from one into another and get two grants for the price of one and two papers for the price of one at just about every turn.
Bonica: Nice. You were running some sort of clinical trials and trying to test out different kinds of treatments?
Shah: Yes. I was funded by the NIH. I was funded by the NIH to do large scale studies both retrospective and prospective studies in Geisinger's population in Pennsylvania. Then I'd rewrite the same grant replacing a rural underserved with urban underserved and do that work in New York and in Manhattan.
Bonica: Fascinating. You were very successful. You have over 100 peer reviewed publications. What was it like trying to be a clinical and a researcher at the same time? How did you balance those roles out?
Shah: I think being a clinician really helps informs the science. What are actual problems faced by physicians and patients, not filtered in any way, that you need to solve? That helped me become a better researcher. Also, understanding the science and which way the science was going helped me inform my clinical practice as well. That bi-directional flow was important. It's hard to do both well because you need to spend time with your patients and you need to spend time with your research. Over time, unless you keep ungodly hours, it's very hard to keep up with the best of both.
Bonica: I have an interest in mentorship so I saw you, you made a comment about your early career where you said, "I had a series of amazing mentors who helped me in so many ways. Privilege begets privilege." What do you mean by the word mentor and what did you mean you said that in terms of what did your mentors do for you?
Shah: I have had and I continue to have publicly about a dozen mentors who continue to look for new opportunities and say, "Nirav, instead of doing this, try this," or, "I'm going to ask you to do the speech for me in Sweden because it'll be good for you." These are folks who are selfless, who understand where they've come from, and have no egos involved when they're trying to help me in shaping my career and understanding my interest to stretch me in new directions, to push me beyond what I'm comfortable, and ultimately, hopefully, make a bigger impact as a result.
Bonica: You make the comment, "Privilege begets privilege." What did you mean by that?
Shah: No, I don't think it's fair that I had such amazingly talented mentors and sponsors throughout my career. Just having physically been at Harvard meant that one of the deans of Harvard would mentor me. Going to Yale meant that I had the chairman of medicine at Yale mentor me. Standing on the shoulders of such giants, you can't help but have a different perspective very quickly. I know that other more talented colleagues of mine who hadn't had the advantage of such amazing thought partnership may not have had the same opportunities as a result and for whatever reason, our society and science values papers and grants. If you don't get the papers and grants, you don't advance. For me it was easier to advance because I had co-authors on papers and grants of the highest caliber.
Bonica: I agree clearly having the benefit of some great mentors is really valuable, but those papers didn't get written by themselves and you make a comment about grit. I wonder if you'd talk a little bit about that. What is grit to you and why is that important?
Shah: I remember my very first paper that I wrote as a first author and I submitted it and it was rejected. You revise it and you resubmit it and it was rejected again. Fully six times it was rejected. It was on the seventh try that it was finally accepted. Now, most people probably would have given up after the third or fourth try. All that people know is that that paper was accepted and that I was the first author on an important paper in a decent journal. They don't realize the six times I could have given up in advance.
That kind of persistence or grit or being dumb enough to just try again and again is what happened not only for papers but for many of my grants. If you submit three times as many grants as everyone, you'll get three times as many grants as everyone. It wasn't a difficult equation to figure out. It was just about having that thick skin, realizing that it wasn't a reflection of your intelligence or of you when you got a rejection for a grant or paper, but that you hadn't cracked the formula yet and so you have to try again, and again, and again until you figure it out.
Bonica: I'm going to make a clip of what you just said and I'm going to play it to myself every day because I've got a small stack of rejections I'm trying to deal with right now. When did you start to get interested in the administrative and leadership work? To that point, it sounds like you'd been working, you'd been doing research, you'd been doing clinical work, there's some leadership there, inherently, in what you were doing, but when did you say, "I'd like to maybe move into administration"? When did you start thinking about that?
Shah: By my fourth or fifth year on the faculty of NYU on the tenure track for being a professor of medicine, I pretty much understood that the formula was grants and papers. That's all you're being rated on in academia. Yes, it's nice to be do service. Yes, it's nice to be on all these committees and give talks and all, but at the end of the day, the tenure decision is going to be based on grants and papers. Once you figure out what it takes to write a successful grant, then you just write a bigger grant, and a bigger grant. Once you write a successful paper, it's the same formula.
At that stage, I knew what I was doing right with grants and papers and I was getting bored of that saying, "Is this really what impact is about, getting more papers and getting bigger grants or is there something else?" That's where I started exploring a lot of unusual opportunities. Joining the scientific advisory boards of different companies, giving talks at random meetings that I shouldn't be in as a physician but I thought were important for them to understand a physician's perspective. Those opportunities really broadened my perspective and my network exponentially overnight.
It was in the process of being on a scientific advisory board for a private company that the governor's transition team found me and they asked if I would help select the next health commissioner for New York State. I didn't know what a health commissioner did. I still asked. I didn't know what a health commissioner did, but I was happy to help select the next health commissioner and a weekend to the process, they decided that they wanted to consider me. They moved my resume over to the other pile and within a week, I was offered the opportunity.
Bonica: Wow. In 2011, you did in fact become the commissioner of the New York State Department of Health. This came about as a result of your extending your own network, trying to look for opportunities to serve. That's really fascinating.
Shah: Yeah. I was only told to stay away from policy work until you turned 50 and so I was actively not looking to do any policy work but I was happy to help in any capacity I could. That opportunity came about because number one, I was from Buffalo and for the governor having someone from upstate, not just everyone from New York City, look good. Number two, as a primary care doctor working in Bellevue Hospital, the crown jewel of a municipal system in New York City, so I knew what that system was facing. Next, I was an Indian doctor and thanks to Sanjay Gupta and others who made us look good, our stock was rising. On paper I look good with Harvard and Yale on my resume. Most importantly, at age 38, I was an unknown. I was too young to have enemies. Many very qualified people were disqualified because of a tweet or two and everyone was like, "Nirav who?"
Bonica: They didn't knock you out automatically because somebody would have been mad. Fascinating. You noted here you jumped from a staff of 1.5 FTEs to running the Department of Health with 5,000 employees, you're regulating 80,000 doctors, and managing a $55 million budget. That's amazing.
Shah: Yes. $55 billion budget.
Bonica: I'm sorry. Managing a $55 billion budget. Did I say thousand? I meant billion. Yeah, billion, with a B, which is amazing. What was it like to suddenly be in charge of this enormous organization with this huge budget and even bigger scope of responsibility?
Shah: Well, it was breathtaking when you first drive into Albany and you get into your parking spot in Corning Tower and you realize that that building above you is your Department of Health. I reverted to what I always do in such circumstances. I frantically called up my mentors and asked for help. They were able to really put me in touch with the right folks who could help us shape and craft an agenda. Many folks were very generous with their time.
The example, when Don Berwick would be visiting New York he'd spare me an hour and say, "Nirav, you should work on mental health issues this way. You should call so and so in Washington about this issue." When he said jump I would say, "How high?" Having folks like Don Berwick and Bob Brooke, and others from around the country and around the world as unpaid advisers or a kitchen cabinet really made it easy to understand what true north look like.
More importantly, at the Department of Health we have hundreds and thousands even of career civil servants who are there not because they're going to make any money, you don't get paid well at on-state service, and not because you have job security because the top folks get fired every four years with a new administration, but because you want to do the right thing. Allowing Dr. Foster guesting, and Pat Wilhen, and Donna, and many others on my staff to just give them the air cover to do what they need to do meant that great work was done.
Bonica: Just as a point of interest, why is it important to have a political appointee? You are a political appointee as the commissioner. Why is it important to have a political appointee as the commissioner and not one of these really fine, committed civil servants?
Shah: The political appointee has a very different set of skills than the civil servants. A political appointee has to be able to manage numerous stakeholders in a complex environment and almost anticipate what his or her boss needs. For me, it was very simple. You need good news above the fold in the New York Times and performance by the autonomy. Knowing that I had to have so many meetings with labor leaders, with trustees of major hospitals, with folks from around the state on their terms, in their offices, at their convenience, that's the work that a political appointee can do and that you don't want to bother a civil servant with because they don't have the training skills or, frankly, that's not their job. That ability to manage what needs to be done from the external stakeholders while giving the protection to the inside of the Department of Health and other state agencies to get the work done is a special sauce.
Bonica: Okay. Where did you learn some of those skills? Where do you think you learned how to do that?
Shah: I would say that there's a difference between leadership and management. From early on in my career, I've been given many leadership opportunities. Yes, I had managed more than one and half FTEs at any given time, but that's management and you can buy good management on the market. Leadership came from having incredible mentors who led by example, who set me up for leadership opportunities where I had no role in them. I have no business being the head of a study section for the NIH at such a junior age and yet I had been set up for such opportunities and learned in the process about the one-on-one relationship-building that is leadership that leads to building trust and allows you over time to do great things together.
Bonica: I'm hearing some interesting trends. You've talked about your mentor network that you developed. Yes, you went to Harvard and Yale and it gives you a ready-made set or an entree into a very nice network, but you were talking about while you were working at NYU that you continued to reach out, it sounds like, beyond the network that you would gotten into through your education. How important is building networks like that for people who want to be in leadership roles?
Shah: When you talk about network building it sounds almost vulgar.
Bonica: Okay. What's a better word?
Shah: No, no. I mean it in a good way that it's not about building the network so much for me as it was a curiosity of understanding how folks got to where they're doing, what they're doing in what I felt were very interesting jobs. I had no problem when I would go to a national meeting writing the head of that society and saying, "Hey, could we meet for coffee? I'd love to learn a little bit more about you and your journey?" It was that hearing their stories and understanding what drove them that got me hooked, but then in the process you'd learn things about how they managed their time, how they managed their energy, how they leveraged the work they did through your fourfold relative to peers. Those were the leadership lessons that almost were a side effect of trying to understand their lives and their stories that I learned about very quickly and over time.
Bonica: Fascinating. Coming back to your role as commissioner, can you describe what is the role of the commissioner?
Shah: The commissioner of health in New York State is actually a very expensive definition of that job. There are different roles and different states. Most commissioners are responsible for public health. In the State of New York, in addition to public health, the commissioner is responsible for the state's public health insurance programs like Medicaid, is responsible for all of the regulatory oversight of 220 hospitals and 80,00 doctors. Responsibility includes things like setting up the health insurance exchange and many other functions depending on the day of the week or the hour of the day.
Bonica: You did some really exciting things while you were the commissioner. One of those was, what you just mentioned, setting up the exchange. What was that like? The Accountable Care Act had come online and states were required to create an insurance exchange. What was that process like? How did you go about doing that?
Shah: We certainly had some of the brightest minds like Donna [inaudible 00:27:56] already working in the department in different roles and it was really about enabling them and allowing them to do their work in a complex politician environment. The smart thing was to really provide a place where people had a voice but not necessarily a vote or a veto in the process of setting up an exchange.
We had multiple stakeholder engagement groups that took voices from across the state at every level from providers to patients to advocates to physicians and allow all of that input to funnel into a process that was actually very well aligned with what we know we needed to do. Hiring the best consultants out of Massachusetts where they already have a system set up, a website set up allowed us to succeed where many others failed. When on day one, healthcare.gov was not really working, we were able to process 10,000 people who signed up as Barack Obama in the first hour and still have our website work.
Bonica: Wow. You made some major reforms to Medicaid in New York. Can you describe what that process was like and what were the outcomes?
Shah: This is where a scientific approach really helps. Knowing that we had the data and we could say almost to the penny where every penny was spent in our $50 plus billion Medicaid program allowed us to shine a light and say, "Do we really need to be spending this much money on these kinds of services where the ROI is X versus there's an opportunity to spend so much money on another kind of services which would lead to higher quality care, lower cost, a preventive approach, and by the way we can retrain some of the workforce from A into B to make it happen?"
That kind of clarity along with a top-down process of support of data and analytics and a bottom-up approach of which ideas we should pursue gave everyone in the State of New York a chance to put their thumb print on the final plan. 4,000 ideas solicited from across the State of New York of which we implemented just under 200 ideas. If I had sat in a room with 15 academics, we could have probably come up with the same ideas, but having it come from the people of New York, it made it their plan.
From the beginning, the unions were onboard, management was onboard, the advocates were onboard, the physicians were onboard. It allowed everyone to take ownership in a way that allowed us within a year save $4.6 billion and then over time save $34 billion over 5 years while improving quality and population health in measurable ways where we were last on quality on so many metrics. Within two years, the NCQA ranked New York State's programs number two in the nation after Massachusetts.
Bonica: That's amazing. There must have been some conflicts in terms of people who probably had good intentions but saw changes to their programs as being harmful to the populations that they were trying to service. How did you bring together and overcome those kinds of conflicts?
Shah: It wasn't me. Remember, all of this was large teams and I can't take credit for what all of the teams did, but what we did was we had those open stakeholder processes over time that led to building of trust. I'll give you one example. When Kaiser Permanente was reducing debts from sepsis by 60% in their hospitals, we saw that an aggressive identification and treatment of patients made all the difference early on in the stage in a patient's course in a hospitalization where if you don't see the sepsis, a patient will die.
When we mandated that we wanted every hospital in the State of New York to care for sepsis like Kaiser Permanente did, it wasn't just a mandate handed down that says, "Okay, now figure it out." It was really a process where that was the beginning of a process and we said, "Tell us what data you already collect. Tell us what data you need to collect to make this happen. How do we get to a small set of metrics that matter and that everyone can agree to and that will ultimately lead to the outcomes we care about?" What was a fiat from Albany was really a process led interdependently with hospital leadership and clinical leadership around sepsis care that saved 8,000 lives the first year it was implemented and will go onto save many more over the course of the next few years.
Bonica: That's remarkable. If we have those kinds of insights, why are we not able to implement more things like that, you think? I mean, there's got to be other solutions out there like yours ...
Shah: I think you have to respect where people are coming from. Folks are experts from wherever they sit or wherever they stand and if you recognize that excellence and give credit to them where it's due but then also help bring them into the broader perspective, they are willing to make changes. A good example came around with the end of AIDS initiative. In the State of New York, 130,000 people know their diagnoses of HIV. Another 20,000 have HIV but don't know their diagnosis. We put together a credible plan to end the AIDS epidemic in the epicenter of where it is by 2020.
This was widely hailed by the World Bank and many others as the best plan they've seen and it came about not because of a top-down you must do the following, but about engaging folks. The superintendent of police speaking to him about how when we use condoms as evidence against prostitutes to throw prostitutes in jail, it's really against that public health objectives of ending the AIDS epidemic. Speaking with the HIV advocates and saying, "We need to go beyond written consent for an HIV test to oral informed consent and change the privacy law so that when someone falls out of treatment in Buffalo, we can use that data and knowledge to pull them back into treatment when they show up Brooklyn."
Those are the kinds of forward-thinking policies that will collectively allow us to end the AIDS epidemic and then going back and giving credit where credit is due and saying, "AIDS will end in New York. Thanks to the AIDS advocates." Then going to the police commissioner, "AIDS will end in New York. Thanks to the superintendent of police," and, and, and/or other groups like that. That reflected glory from ending AIDS will go back to the people of New York, but in the short-term I needed to go and speak in front of the AIDS advocates and give credit where credit was rightly due to the advocates themselves, and similarly to the police, and to the education, and to other groups.
Bonica: You mentioned sepsis and some other ideas that you implemented while you were the commissioner were developed at Kaiser Permanente. What was your relationship with Kaiser Permanente prior to becoming commissioner and how did you come to be in touch with Kaiser Permanente while you were commissioner such that you could borrow their ideas for implementation in New York?
Shah: When I was a researcher, as I mentioned earlier, I would always go and ask people about where they were, and how they go there, and developed mentors across a broad spectrum of interest. The same thing happened when I was commissioner except the scope was a little higher. When I knew that George Halvorson, the CEO of Kaiser Permanente, was going to give a speech in New York, I could ask his secretary if I might meet with him for an hour afterwards. Because I was the health commissioner and everyone thought I had a $50 billion checkbook, they would say yes. George Halvorson, the CEO of Kaiser Permanente, would say, "Nirav, you should do sepsis like we're doing in Kaiser." I would then connect my folks up with his folks and we would do it.
Similarly, those kinds of opportunities with the health minister of UK led to some interesting observations that were applicable to the U.S. and to New York. Many other opportunities based on access to incredible folks who were generous with their time and then my role allowing us to do it as scale across 90 million people across New York State.
Bonica: What would you say were the most important lessons you learned about leadership during your time as commissioner?
Shah: I think probably the most important was to approach people with an attitude of humble inquiry where you won't know where the next best idea will come from, but if you go to them and ask them what are they thinking about, what are they working on, they will often blow you away. The end of AIDS came about by someone who was probably eight levels below me in our AIDS institute who had been thinking about this for years saying, "If only we can get these 16 things to happen, we could end AIDS."
Allowing that to happen, facilitating it with my friendships with the police superintendent and others is what helped catalyzed that to happen. Those kinds of opportunities are there everywhere and going to the frontlines, going to the people who are actually doing the work, who care about it deeply, who live it every day is where most of the best ideas will come from if you just listen.
Bonica: You left the Department of Health in 2014 and took what you referred to as a dream job with Kaiser Permanente's Southern California Region as the senior vice-president and chief operating officer for Clinical Operations, which is where you are today. I'm wondering, how did that come about?
Shah: After having met the CEO, George Halvorson, I also was lucky to meet many other senior leaders across Kaiser Permanente to understand initiatives. Over time, over about two years, I got to know many of the folks very well. One of the leaders was Ben Chu. Dr. Chu is currently the CEO of Memorial Hermann and was formerly the head of the Southern California Region. He said, "Nirav, when you're done with public service, think about Kaiser Permanente," and so that got me thinking about it.
Over time, understanding the Kaiser Permanente model, which is almost unique in America, showed me that this was probably the next best place to be in terms of actually effecting changes at scale that could prove to be national models. The Affordable Care Act, much of it modeled on what Kaiser Permanente does. It is about having an integrated delivery system where the physicians run the same hospitals, and nursing homes, and home care, and primary care. Specialist and primary care work together. It's that integrated delivery system that is in partnership with the insurance company so that we could make rational choices that otherwise only an insurance company or a hospital or a delivery system would never make on its own.
For example, if you spend a dollar on preventing something, it saves money and it's the right thing to do, but from a clinician perspective there's no way to invest in prevention. You only see the patient when they end up in your exam room after having lived with the disease for many years. That combination of a provider and payer together under one roof allows you to maximize total health in ways that you can't do in most of the systems that are single systems, either a payer alone or a provider alone in the rest of the United States.
Bonica: How does that relationship work together to take advantage of ... what are the advantages of having the payer and provider holding hands? Is it additional information or is it permission to do different things? What is it?
Shah: I'll give you an example. Today, the average length for stay for a hip replacement surgery done electively in the United States is between three to five days in the hospital. Yet today, if you go to our Downey Medical Center in Kaiser Permanente where they do a lot of hip replacement surgeries, up to half of all patients can be discharged from the hospital on the same day as the surgery.
That can happen only because before the surgery is scheduled, Kaiser Permanente will send a nurse into your home to do a safety evaluation and make sure that that rug you tripped over is removed or handrails are installed. Before the surgery is scheduled, pharmacy will explain all the medication changes you will have to undergo. Before surgery is scheduled, we will have durable medical equipment, like walkers and canes of the right size, delivered to your home. Before the surgery is scheduled, we'll get all of the patient and family education materials to you so you know what to expect on recovery.
If your surgery is scheduled for 6am, when you're done with your surgery you are sent home and your physical therapist is waiting for you at home. You are having your first physical therapist appointment at home. That evening before you go to sleep, your doctor calls you and says, "Mrs. Jones, I'm not going to sleep unless you can sleep tonight." She sleeps very well. The next morning at 9am, physical therapy is in your house again. At 10am, a nurse is in your home. At noon, a physician reviews both notes in the electronic health record, makes any changes needed, and at 3pm a physical therapist is in your home again. The next morning, you have your outpatient appointment with your surgeon.
Now, the length of stay of zero days means lots of good things happen. What is the hospital acquired infection rate with a zero day length of stay? Zero. How is the quality of food at home compared to in the hospital? Pretty good. What are the visiting hours like? Pretty good at home. Not only do you recover faster at home with multiple safety nets, with reliably excellent care, you also save the system as a whole thousands of dollars because every day in the hospital is $5,000, but no other system can invest some of those savings into home physical therapy, home nursing, home delivery of durable medical equipment, and patient education, and all of those things as an integrated system around a patient and his or her needs as opposed to after the fact.
Bonica: Why doesn't a physician and a hospital that's not part of an integrated system, why doesn't just this happen? What's the secret that makes it work or not so much secret that makes this work?
Shah: The secret is this 71-year commitment between the Permanente Medical Groups and the Kaiser Foundation Hospitals and Health Plan. It's an arranged marriage where divorce is not option. Whereas if you look at every other accountable care organization around the country that has formed since the Affordable Care Act where you have a partnership between a hospital, and a nursing home, and home care, and others, those are more like shotgun marriages of convenience where they have the anatomy of integration, they have all the parts and pieces, the bones and muscles, the hospital, the nursing home, et cetera.
They have none of the physiology of integration. They don't have the real-time flow, the circulatory system, nervous system, the real-time flow of data from the home care into the hospital, into the clinic as we do at Kaiser Permanente. That anatomy is now sufficient. You need the physiology of integration and that's very hard to do. To put real-time data at that point of decision making in front of a clinician from whatever it's sourced, that is very, very hard to do at scale to achieve these kinds of opportunities.
Bonica: One of the things you said when you were describing the preparation prior to the patient having the surgery was something about a nurse coming to visit the home and fixing a rug. I can't imagine that most insurance companies will pay for rugs.
Shah: That's the point. If you're paying for prevention, you know that the dollar spent upstream saves you $5, $10, $50 downstream. Anything you can do upstream is going to help exponentially downstream, but it takes that integrated system where the incentives are aligned, where all dollars are green, not just the dollars that are in the hospital are green, that allows you to make those investments upstream.
Bonica: Yeah. We're all trying to move towards bundled payment now and so forth, but Kaiser has really been doing that for a long time.
Shah: Yes and we are working more and more in partnership with our community, relying not just on ourselves but working with the food pantries of L.A., and the housing assistance organizations, and other groups that are traditionally not counted as healthcare but absolutely make a big difference on improving health.
Bonica: Give me a sense of how big Kaiser Permanente is an organization and then I'd like to ask you a little bit about the Southern California Region where you are one of the leaders. What's the scope of Kaiser?
Shah: Kaiser Permanente is currently in eight states. It has about 10.3 million insured lives and runs around 38 hospitals and hundreds of medical office buildings, north, south, east, and west, across the country. From Washington, D.C. to Portland, Oregon, now in Seattle with our partnership with Group Health, but the vast majority of those folks are in California here we are approximately a third of the market of California.
Bonica: You are the senior vice-president and chief operating officer for the Clinical Operations for Kaiser's Southern Region. What is the scope of that portion of the organization and how does it fit into the larger organization?
Shah: The Southern California is the largest of all of the regions in Kaiser Permanente. We have 4.2 million insured lives, $24 billion system with 14 hospitals, 6,600 physicians are part of the Southern California Permanente Medical Group. I have 18,000 nurses working for Kaiser Foundation Hospitals in Southern California. My specific roles include overseeing nursing, quality, regulatory services, clinical operation support, and I also help with pharmacy, Medicaid, and a few other functions.
Bonica: What's a day in your life like? You just listed a number of different broad programmatic responsibilities. What are you working on any given day?
Shah: Today we started our annual survey by the regulators. At 9am I said hello to a room full of Department of Managed Care of California regulators who are going to be inspecting our hospitals for the next week. That's not an everyday thing, but those kinds of official duties where I'm kicking off a group or introducing folks or otherwise emceeing are not uncommon. More important is the strategy and the direction of this organization. How do we take integration to the next level? How do we improve affordability of healthcare for Kaiser Permanente and by example for the rest of the nation by improving quality, improving population health. Those are the day-to-day issues that we face whether it's in our pharmacy, whether it's in our lab, whether it's in our hospital that end up on my desk, and that I get a chance to play with many really, really smart people to figure out.
Bonica: How are you using data and analytics to help produce better patient outcomes?
Shah: We are very lucky to be blessed by a fantastic electronic medical record that tells us more than most folks know about patients and their journey through the healthcare system and the insurance system. What we've been able to do is leverage that data into information that allows us to optimize processes that will result in better clinical outcomes.
A good example is colorectal cancer screening. Today, the five-year survival of a patient diagnosed with colorectal cancer in America is about 65%. 65% will live 5 years. If you are a member of Kaiser Permanente and you get your care with Kaiser Permanente, that 5-year survival rate is 75% and we have the data and the plans to take the death rate and cut it in half by 2019. I've seen the plan. They're very credible and I know we will do it. That kind of opportunity doesn't happen often. It happens because when I go to get my glasses prescription filled, my optometrist will remind of my colorectal cancer screening or my overdue cholesterol screen. Everyone in the system is responsible for prevention of those high quality, evidence-based interventions like preventive screenings. When it happens at the system, you achieve incredible results.
Bonica: Can you describe the divisions that actually report to you or departments that actually report to you? How many direct reports do you oversee?
Shah: I try to keep my direct reports to four or five on any given day. It varies a little, but the quality infrastructure is shared between the regional office, which is where I sit, and our 14 medical centers. For example, in my regional office we have about 50 people in the quality functions that's complemented by each hospital having dozens of people working on quality full-time. My direct reports across the regional functions of quality, regulatory, clinical operation support, and patient care services, which is nursing, comprises approximately 150 people.
Bonica: I was surprised to see nursing listed as one of the areas that reports to you. I just would have expected to hear we have a senior nurse that oversees nursing.
Shah: We do and that senior nurse reports to me.
Bonica: I see.
Shah: That happens historically because the hospitals are run by ... as I mentioned, there's two sides to Kaiser. There's the Permanente Medical Groups, which are the physician-led organizations that drive much of clinical care, and then there's the Kaiser Foundation and Hospitals Health Plan side, which actually do the day-to-day business of running an insurance company and running all the hospital. In this case, all the nurses who work in those hospitals report into Kaiser Foundation Hospitals which is the side I sit on.
Bonica: How do you, you meaning you, your region and your regional office, help the hospitals? How do you improve their performance? Why is beneficial for the hospitals to belong to or be part of the region?
Shah: When you are part of the region and part of the broader organization beyond the region across all of the regions, there are many economies of scale. For example, our mail order pharmacy business. We have the fourth largest mail order division in the country across all industries and that happens because we do a fantastic job of converting folks who are getting their prescriptions to get them by mail order. That leads to shorter lines in pharmacies and increased satisfaction by patients, and economies of scale when you're processing 15,000 prescriptions a day or 80,000 prescriptions a day across Kaiser Permanente in our mail order pharmacy department. That same kind of order of magnitude efficiencies are realized not only in pharmacy but also in laboratory and just about every other back office function short of the actual doctor-patient encounter in a clinic or in a hospital room.
Bonica: I guess the same question I have is what does the corporate headquarters, how does corporate headquarters support the regions? What do you, as the region leader, look to get from corporate? What's done at corporate that really enhances your work?
Shah: There are many opportunities. Just like I mentioned, all healthcare is ultimately local. What happens between a doctor and a patient is ultra local. At the same time, there are efficiencies to be had in a given clinic. There are bigger efficiencies and different ones across multiple clinics in an area, across multiple areas in a region, and across multiple regions and across the country at the program office level.
It's tenuous balance between local customization, local culture, understanding local needs, and the efficiencies of standardization and scale and spread so that we see the best practice occurring in Colorado about integrating behavioral health and physical in our primary care clinics. We can learn from that one clinic and then scale it across our entire program including Southern California. On the other hand, there are some things that you will want to keep ultra local based on dates give regulatory environment or other factors that are very specific to the cultural makeup of a population that don't want to be standardized across an entire 10-million program.
Bonica: Does corporate help bring improvements like that from say Colorado to California if something is seen?
Shah: Absolutely. They make the large investments. They help with the overall strategy and direction of the organization where we, for example, have one pharmacy software program across the country. You don't need them local. On the other hand, many of our local and regional leaders serve on many national functions. I don't have to be working in Oakland to lead four different IT programs for the entire program. I'm leading them from my role in Southern California.
Bonica: Okay. Who else is in the senior leadership or the executive team at the region? There's you as the COO. Who else plays in that same level with you at the region?
Shah: We have two parallel teams, one with Permanente side and one with the Hospital Health Plan and Foundation side. I'm on the hospital health plan side where I have counterparts in the Permanente Medical Group side, the Southern California Permanente Medical group. While I'm the head of quality, there's a head of quality over there. While I oversee clinical operation support, there's an operational leader over there. It's the traditional hierarchy that you see in any give health system times two because of the complexity of both being an insurance company and the clinician provider organization.
Bonica: You've talked about what a day in the life of CO is like. What keeps up night? When it's not daytime, what do you worry about when you're lying in bed and you're staring at the ceiling?
Shah: Usually, it's my six-year old that's keeping me up at night because he can’t sleep or something like that. We are very blessed to have incredible folks at every level of our organization and what keeps me up at night is that healthcare in America is becoming less and less affordable. The average American family cannot afford the average American insurance plan. It is my responsibility, it is our collective responsibility to fix that.
How do we continue to provide world-class care, give folks access to the latest technology, and drugs, and other improvements while not just bending the cost curve but actually stopping growth of cost because today, with healthcare consuming 17¢ or more of the dollar, education infrastructure such as transportation, and everything else is suffering because healthcare gets a free pass to grow at 1, 2, 3 or 4% every year. What keeps me up at night is how do you achieve that triple lane at scale in real-time and create the model that are replicable not just at Kaiser Permanente but across the rest of the country.
Bonica: It's interesting looking at your career because your role now at Kaiser is almost like a third career. You started out a clinician researcher, you moved into government, and now you're a leader in a corporate structure that's known around the world for equality. How did your prior experiences prepare you for the role you're currently in?
Shah: What I like to say is that when I was at the health department, it was 5,000-person giant bureaucracy, ad what I am doing here at Kaiser Permanente I'm just doing a different bureaucracy. You lead through influence. You don't lead by telling people what to do. You understand where innovation comes from and protect it, and support it, and give it wings. You do all the things that I did in my prior two roles but maybe with a slightly different scope or scale now that I'm a private organization that's looked to as the example.
The example I gave you earlier of hip replacement, when you're doing 8,000 hip replacements in Southern California and many more, shoulder joints and knee replacements, the economies of scale, if Kaiser did this, times three or four other large systems, that's all you need. That's the answer. That's the answer. That's the answer to healthcare. It's lower cost, and higher quality, and more patient centered care and yet we can't do it yet.
Those are the kinds of things that I've learned over time by marrying the bottom of approach whether you're in the State of New York and learning how to reform Medicaid from interviewing folks across the state and getting 4,000 ideas from the frontlines to Kaiser Permanente's innovation from the bottom up as well and then supporting it from top down. That kind of building community, building trust, bridging folks who all have the best of intentions but are sitting in different places where they have different perspectives. Bringing them together for the greater good is the role that I'm learning more about every day.
Bonica: What do you think people least understand about Kaiser Permanente and how it works? What's the most common misperceptions about the organization?
Shah: My misperception when I came from outside was that there is such a thing called Kaiser Permanente and what Kaiser Permanente today is there's different leadership at local level, 14 medical centers in Southern California, regional level across multiple regions across at the country, and at the national level. By the way, there's two sides of the house or three, if you want to count it a certain way, where you have to work interdependently together to drive change and make those meaningful results that I've talked about.
That kind of skill set is what allows us to move forward at Kaiser Permanente. It also applies very equally to just about any complex political structure as well as many corporate structures. Leadership has, for me, been redefined from leading from the front to really understanding what drives and motivates people, allowing them to have purpose and fulfillment in their daily work and then engaging them in ways, in partnership with others, who they may not necessarily meet, to achieve astounding results that raise all boats.
Bonica: How often do you get a change to practice medicine in your current role or do you at all?
Shah: I gave up medicine a few years ago because at some point when you're not seeing patients more than one or two days a week, your clinical skills start to deteriorate. You can't be as good a doctor as someone who's spending five, six days a week practicing and reading about medicine, and learning from one patient to the next, and diving deeply into the literature. For my patients' sake, I gave it up when I became health commissioner. I still took the boards again and passed the boards and I still do give my flu shots to friends, and family, and other folks, but I practice on a few oranges before giving those flu shots.
Bonica: I'm sure that your friends appreciate that. Do you miss it?
Shah: I do. I mean, I trained for most of my adult life to become a doctor and while there was a lot of fulfillment from being the clinician to people who I cared deeply about, I can see that what I do every day here allows folks to do that better and allows me to have a different kind of perspective and impact than I would as a physician seeing a few patients every day.
Bonica: I'd like to ask a few questions about leadership specifically. We've talked about it. You've made some great statements about it so far, but I wanted to ask a few specific questions. Starting with how would you define your leadership philosophy?
Shah: I think what I try to do, and I'm not that good at it yet, is I try to recognize the spark in everyone. Everyone has something interesting, important, and meaningful to contribute whatever their role is formally on paper or whatever their title is, and getting to that, understanding that, and setting it free or enabling it is my job as a leader. Connecting purpose to the job of a janitor who is really a patient safety officer making sure folks don't have infections in our hospital is an example of that. Every role has vital meaning and connecting people to that purpose, and making it clear, and giving them the tools they need to succeed is our job as leaders.
Bonica: What would you say specifically are the characteristics and behaviors of a good leader and how do you aspire to them?
Shah: I start it by saying something about humble inquiry. That ability to listen, and understand, and not interject, and not necessarily come with your own agenda. You are allowed to come with your own ideas but really come to the table and bridge multiple ideas together and still achieve that broader vision is what makes for a good leader. I think that inspiring folks to recognize that is an important part of leadership and having the ability to communicate effectively is something that all of us can work harder at and train to be better speakers and listeners.
Bonica: Who did you learn these ideas from?
Shah: I learned from many different people and many different sources. When I found out that I got the job of commissioner, I went to TEDMED and spent a week taking notes on how people give good speeches because I knew I'd be giving about 250, 300 speeches over the next few years. When I became a consultant I bought 10 books from amazon.com on how to become a consultant. Most importantly, I learned from many of my mentors and sponsors over the years. Going back to my father, and grandmother, and grandmother, and others and just see how they conducted themselves, and what was important for them, and how did they live real meaningful lives through what they did every day.
Bonica: Can you give an example of a difficult leadership lesson that maybe you had to learn the hard way?
Shah: I mentioned a unique structure at Kaiser Permanente of physicians owning the clinical side and health plan hospital owning the hospitals and the bean counting, so to speak. When I came early on and joined, we, as the rest of country, were not where we needed to be in terms of addressing issues in behavioral health. People with depression and other diseases deserved a higher level and a higher quality of care that integrated with how we treated the body, not just treat the mind separately. Early on, I had an urgency to say, "Let's fix this," and I wanted to roll up my sleeves and fix it and learned right away that it wasn't my job to fix it. It was my job to support and to help, but it was someone else's job to fix it. That's fair and I learned about that very quickly.
Bonica: What do you look for when you're hiring leaders and also when you're evaluating them?
Shah: I try to take on folks who can rise two levels. Generally, if I'm interviewing them, they should be able to take their boss's job and their boss's boss's job, which is me usually. If they don't meet that for whatever reason, we haven't been looking hard enough. There are folks who are really good at something, but you don't necessarily need a subject matter expert for every given role and that's the tendency.
We tend to hire the subject matter experts as opposed to the undifferentiated stem cell rock star learner who can get the subject matter expertise needed from others but really manage change, inspire those below, understand and listen, and drive to results that the organization needs in ways that a subject matter expert who knows that very specific set of knowledge may not know how to do and may come with more baggage, actually, than some of the opportunities that new people in a given field have. I've always been lucky to be given jobs way above my station and expertise and so I tend to go for the underdog who has no business doing a given job but shows lots of promise, gumption, grit, whatever you want to call it.
Bonica: How do you work with somebody like that? If they come in and they've got lots of gumption and grit but don't have the skills just yet, that's got to be a different kind of management or leadership challenge than somebody coming in who's fully formed.
Shah: Yeah. What I tend to do is I tend to give these folks an impossible task and they don't know it's an impossible task. Surprisingly, 9 times out of 10, they'll have solved it in 2 weeks or come up with new ways of thinking about it that really challenge the established ways of doing things that lead to greater efficiencies or improvements that wow you.
A good example is when I was junior researcher writing grants, I hired the smartest undergrad at NYU and I gave her five funded grants and I said, "I want you to write a grant on X." She Googled it, she bought a few books on how to write grants, and her first effort it probably took her a hundred hours to do what would have taken me maybe five hours to do, but that five hours she saved me so much time, and effort, and energy that it took me only an hour to polish it to a place where I could submit it. She saved me four hours and in the process she learned and she's gone on to have an incredibly successful career as an academic neuroscientist at Stanford. That gumption and intelligence where she's obviously much smarter than I am, and hardworking, and willing to roll up her sleeves, those are the kinds of people I look for.
Bonica: Okay. Once you've got someone on board and they've been performing, how do you evaluate them? What are you looking for in performance of the leaders that work for you?
Shah: I maintain a high level of trust with such leaders. With all of my direct reports, they make all the decisions they need to make on their own and they inform me after the fact of some of these decisions and say, "Nirav, by the way, you decided this. Just so you know if you're asked about it in such and such meetings." That has allowed leverage at a scale where if you trust these folks ... yeah, on occasion they may fail, but that's okay. I probably would have failed many more times on my own and it allows them to grow in ways, and stretch in ways, and achieve things together. I set operating principles. We are fully transparent with each other. We work together. We look for ways to partner at all levels these are the kinds of generic principles of transparency and accountability for yourself that allow us to tend achieve incredible results at lower budget in faster speed and at scale.
Bonica: I wanted to ask about organizational culture. What is organizational culture and why is it important and what aspects of organizational culture are particularly important to you?
Shah: Many organizations that I've been in have a fear-based culture where people try to performance manage other people, they're given very specific targets, and you meet those targets or you don't. That works to a certain extent. Fear-based cultures can lead to sometimes impressive results when you're driven by saying, "I have to make margin or my target," or something like that.
What I found though is that what's really empowering is when you build that culture that is based on trust and on mutual accountability around communities of all different sizes. Then you share with each other and deliver results no one would have expected because no one's ever measured or tried to measure something like that. The example of the same day discharges for hip replacement, we could have made the process marginally improved over time. It went from 3 days to 2.9 days to 2.8 days, but to get it to 0 days overnight for half our patients took that kind of trust.
It took trust that when a surgeon discharges someone to home, they know that that person is going to be seen as soon as the patient reaches home by physical therapy and if anything has gone wrong, the physical therapist will catch it and report it in and on and on. That kind of trust built across multiple normally silos, nursing, physical therapy, durable medical equipment, patient education, and on and on, that kind of trust allows for exceptional performance by all involved. The sum is much greater than the parts and that never can happen in a fear-based culture where you're only graded on your specific metrics or your specific budget. You have to be much broader than that.
Bonica: We've talked about mentors already a bit. One of the things I'd like to be able to advice my students is to go out and try to develop mentor relationships. What kind of advice should I give them, in your opinion to develop good mentorship relationships?
Shah: I think this is a stuff that your grandmother teachers you. It's about answering emails on time. It's about treating people with respect. It's about the hygiene that most people don't necessarily remember that it is hygiene, that is you treat people as you want to be treated yourself. That's 90% of being a good mentee and the other 10% is understanding, and learning from, and teaching your mentor as well.
For example, I had two mentorship meetings today and I can guarantee you I think I learn more from my mentees than they learn from me, whether they knew it or not, and I actually have a formal reverse mentor. She's a millennial and she just taught me about what generation Z is, everyone born after 2001, and how they differ from generation Y. It's great stuff. I would never have come across this. She is mentoring me. In the meanwhile, I'm helping guide her in other ways. We have fun together, we learn from each other.
You can make it as formal as you want. You don't have one mentor for all aspects of your life. Someone you follow because of how they manage their time. Another person you have as a mentor because of how they manage their family life and understand how they plan aggressively months in advance for all of their family vacations and things like that. You bring together a group of a kitchen cabinet or others and I guarantee you that a mentor gets much more out of it than a mentee. If you go in with that, most mentee should not be afraid. Reach out, ask. Almost everyone has been mentored so you'll be surprised that most folks will say yes.
Bonica: You mentioned just now that you have some formal mentor relationships. Does Kaiser Permanente have a formal mentorship program throughout the organization or is this something you do?
Shah: There are many levels of mentorship programs that exists at Kaiser Permanente. My own I've developed over time from my time in academia. I come in with very clear expectations around the system I've created where I have a one-pager which is not your bio, but I want you to talk about your aspirations and your trajectory of who you are where you're going in your values. That then leads to my introducing folks to other formal mentors who can fulfill other parts in a fashion complementary to my own other skill sets, other things folks can learn.
What has happened over time is that like at the Department of Health I probably had about 50 folks I was formally mentoring. At Kaiser now over the last two years I've probably got about two dozens of folks that I've formally mentored. It's not about checking in with them every day but every few weeks or a month or two I'll check in with folks and say, "How are things going," and make sure that they're getting what they need to move along in their journey.
Bonica: Someone comes to you and says, "Nirav, would you be willing to mentor me?" You say, "Sure. I want you to give me some information about yourself," and you have a standard set of questions you ask them?
Shah: Yeah. I have a one-pager. I give them a few examples including an example of myself writing up my one-pager and say, "Come back when you're done," and 70% show up again.
Bonica: Then you help them build a cabinet, as you called it, of supplementary mentors.
Shah: Yeah. For example, one of them today said, "I'm going to go to this national meeting in June," so I said, "Let me introduce you to the president of that organization who happens to be a friend and she'll have coffee with you because I could see you in that role in 20 years." That's an example of something where it's a win-win for that leader to have a reference from me and for my mentee and, certainly, everyone benefits. It's the price of an email. It's nothing.
Bonica: Sure. How important are professional associations for development and how important have they been to you in your development?
Shah: I've always been lucky to have great, strong, professional associations at every stage of my career and what it does is it's instant community, it's instant friends. It's people who think like you who are on the journey like you and there's a lot to be said for that. I think though with professional organizations you can fall into certain traps of seeing only certain pathways of advancing and proceeding. While it's important to go to those professional organizations because they're comfortable and you do feel benefit from them, it's important to go where you're too comfortable and where you're stretching yourself. That may be outside of the space you're used to. I tend to try to join one or two professional organizations where I have no business being there and then learning from that group.
Bonica: Okay. Final question because I've kept you long time, based on your experiences, what advice do you have for either clinicians or young people who are in my program who are going to be administrators? What advice do you have for them as they're thinking about going into leadership in the healthcare environment today?
Shah: I think that most clinicians today by the nature of how we practice medicine are already leaders. They may be leaders of a smaller team. They may be leaders of a clinic, of ward service, of a specialty group within a larger practice. Leadership is not the problem. It's about how big is your ambition and impact that you want to make and how willing are you to leap and believe that the net will appear. I know that I've been blessed by having phenomenal folks who did everything from rewrite my bio when I told them I was going to be considered for commissioner of health. They literally rewrote it, understanding what the government and his or her team would need to setting me up for places where I would fail but learn in the process.
I talked about grit earlier. Knowing what's the worst thing that can happen. At the end of the day, you're still a doctor. If I get fired as health commissioner I could still go back to my practice at Bellevue and make three times as much as money as being a public servant. That ability to say and put things in perspective, and just do it and go out, and try it, and go out and write to that leader that you want to talk to and say, "Can we have coffee at some point? I read your paper on X and would love to learn more." Those are the things that you have to just be active about and do and dust yourself off when you fall and try again.
Bonica: Thank you so much for your time today. This has been terrific.
Shah: Thank you. This is really an honor.
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