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Change is inevitable but there are a variety of techniques that leaders can employ during times of change to help your team embrace the change. Jonathan Breslau, MD, FACR, Chief of Sutter Imaging, discusses how the culture of Radiological Associates of Sacramento (RAS) led to it becoming a dominant radiology practice in the Sacramento region but also how that same culture led to its downfall as a physician led entity. He shares both the challenges and rewards of managing the transition to employment and how he had to adapt his leadership style.
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RLI Taking the Lead podcast series explores the unique career journeys of radiology's most influential leaders to provide practical insight into how to structure a career in leadership and find success across a spectrum of clinical environments and organizations. Learn more
American College of Radiology, through its Radiology Leadership Institute (RLI), offers this podcast as one of a series of educational discussions with radiology leaders. The podcasts reflect the perspectives of the individual leaders, not of ACR or RLI. ACR disclaims liability for any acts or omissions that occur based on these discussions. Listeners may download the transcript for their own learning and share with their colleagues in their practices and departments. However, they may not copy and redistribute any portion of the podcast content for any commercial purpose.
Geoff: Hello and welcome to “Taking the Lead,” a podcast from the Radiology Leadership Institute that profiles radiologists as leaders seeking insight and inspiration from a variety of perspectives and experiences. I'm Geoff Rubin.
In the first half of my conversation [00:00:30] with Jonathan Breslau, we learned about the conditions that lead to radiological associates of Sacramento becoming a dominant presence in the city of Sacramento and it's Sutter hospital for over 90 years. How an iconic leader like Arliss Pollock inspired a culture where clinical quality and service to referring physicians and patients were paramount in creating a powerhouse practice. A practice that served as a national exemplar that also led to an unhealthy sense of bravado [00:01:00] and an unrealistic belief in the strength of RAS's market position. The second half of our conversation picks up with Jonathan and I discussing his difficult position as Chief of Staff for Sutter hospital at a time when RAS was told that their 90 plus years of consistent contracts to provide radiology services at Sutter Medical Center would not be renewed.
So, as you look at the relationship that a medical staff organization has to its hospital and the role of physicians in directing healthcare within that hospital, how do you reconcile Sutter's apparent power play with the principle that physicians are the primary directors of patient care and should therefore have a voice in determining who will be [00:02:00] their imaging consultants?
Jonathan: Well, it demonstrated that the medical staff had a much less powerful role than we thought we had. And I think if you look at the hospital administrator perspective on it, their job isn't to provide X doctors, it's to provide doctors. And their position is, yes, medical staff you want quality and that's what we're gonna do. [00:02:30] You don't get to pick if it's this person or that person or this group or that group. That's our job. If you think they're doing a bad job we can hold them accountable. But I think that was the process and the fact is, if we could have gone through our entire careers and not seen that kind of power play we would have been just fine. But it turned out we have a lot less control than we thought we had. And in this, I mean, by we in this time I mean we the medical staff, not the radiology group.
Geoff: An important though tough lesson to be [00:03:00] learned, no doubt. So you describe what sounds like a loss of about 40% of the group's business.
Jonathan: Well, let's be clear, there was…it was sort of phased in. The only thing that was immediate was 10%. Because they could turn off the hospital thing overnight, which is what happened. I mean, you know, we had almost six months warning, but so the only thing that went away at one point was 10%. The… All the [00:03:30] outpatient imaging that we did was still under a single contract that hadn't expired yet. So we had and I don't remember precisely, but let's just say 18 months left or something. And they were adding capacity, but it's not even clear that they would have been able to replace us fully at the end of 18 months. It just doesn't go that fast when you look at the size of our footprint. So we… The only thing was a quick thing was 10% and then we had a lot of time to think about the rest of [00:04:00] it.
Geoff: And so during that time how did the partnership respond? Did everyone do their share in absorbing the losses or was it contentious?
Jonathan: Yes. Both. But I think we had, I think we had… The immediate thing that we did was like, “Okay, it's loss in the diagnostic side.” So the diagnostic doctors are gonna, I can't remember what it was but we did a little bit of a furlough thing and everybody did a couple of less days, it wasn't a big deal. At least [00:04:30] half of the people were happy to do less days because they kinda wanted to anyway. And that was very quick. And then we also started some other ventures to try to make up for the revenue both acutely and then what was the projected further revenue loss over time.
Geoff: And so what were some of those ventures?
Jonathan: One was the teleradiology business and we pretty quickly started doing work in Texas, Arizona, there was a Nevada thing lined up and then we started reading [00:05:00] all the imaging from urgent care centers in the area. And then we were looking for more stuff, that's one. An imaging core lab doing contract, you know, research for farmer…
Geoff: That sounds very entrepreneurial.
Jonathan: Yeah. And the other thing that had happened which is important to bring up. A few years before it had been growing and then we just grew it more was our overall multi-specialty model. We were basically building our own multi-specialty medical group. And we had already bought in urologists, [00:05:30] GYN oncology, medical oncology, vascular surgery. We were looking…we were bringing in specialties that were one way or another related to something in imaging either because they were heavy users of radiation oncology. Like people who treat prostate cancer or vascular surgeons that are connected to IR and overall oncology. So that was something that was already underway and we just kind of were moving a little further on that as we approach 2010.
Geoff: And [00:06:00] what were the group's goals in that expansion? And do you think that that was ultimately a help or a hindrance?
Jonathan: So the goals were in effect to move upstream up to the referral source to own some of the referral sources so that would be protected. It was sort of a, yeah, it was like protecting your flank, so to speak. And so of course if radiation oncology was at risk, well, let's bring in the doctors to our group who refer [00:06:30] to radiation oncology. So that was, that was the general strategy.
Now, in the short and medium term it was actually totally fine but there were two things wrong with it. One is it really pissed off Sutter, big time. The other thing is that that kind of a strategy really, the full-on strategy requires you to acquire a very large number of primary care doctors. [00:07:00] That's what you're…that's your ultimate goal if you really think about it. Because even the urologist need someone to send them patients or medical oncologist and if all the people who are sending patients are sending them somewhere else, it doesn't matter that the oncologists are in your group. For that strategy to be successful, we really needed to seriously consider how to acquire several hundred primary care doctors to start buying up primary care practices. [00:07:30] And I think there is no way to do that without a very, very serious strategic partner with deep pockets.
Geoff: Now this is a lot of complex management clearly in the practice. Can you describe a little bit about the relative role of physician leadership versus management…you know, folks that didn't have medical degrees in this process?
Jonathan: Well, I think that [00:08:00] the best thing is executives who are physicians, but you don't have that many of them to choose from, you know, Cleveland Clinic and Mayo Clinic, Emory, they have that. But it's hard to find that really well. And I think that the executives, for the most part, aren't going to be physicians. And a lot of ways that's totally fine. And there's a lot of executives that aren't physicians that have a lot of good experience, whether they've [00:08:30] been running imaging businesses. We had a great run with some executives in our growing our imaging business. Or they come from larger entities like over outside from health systems or from for-profit health companies. And then also just executives with the right kind of background that might not have very specific experience.
Geoff: Do you think that during these difficult times, though, that you know, you are getting the right support and that, you know, you seem to be [00:09:00] aligned, or, you know, was there a little bit of a tug and a pull between the different constituencies?
Jonathan: Right. So that's a good question. And I think that the most important thing at the very top is someone who values the relationships and can continue to nurture the relationships even through very tough and contentious times. So I would call it, you know, emotional intelligence, but with a real track record behind it so [00:09:30] that really focuses the doctor on we have to keep the health system happy. What do we do to keep them happy? We may have to make some compromises to keep them happy. And how do we start to develop trust across the table?
Geoff: So in retrospect, could the relationship between RAS and Sutter have been saved?
Jonathan: Yes, definitely. And I think that on the doctor side, we would have needed somebody to really kind of [00:10:00] paint a picture of where things are going in the future. And that there is a real possibility that Sutter might look to a divorce and find another partner that that's something we need to take seriously. And that our goal is to make sure they never think about it, that it's just so much easier keeping us around. And that there's compromises, things we'll have to not do that we would like to do just so they're just calm and keeping the peace between the two parties. [00:10:30]
I don't think we took seriously the idea that we were very small and they could just roll over and crush us. I think that coming to our partners and saying those things takes the right person. First of all, they had to be very brave because the first time it comes up they'll probably be threatened with death or at least a very painful outcome. But they have to be trusted and they have to come with really good facts and really good understanding of where things are going. But there… I think that that's a [00:11:00] great sort of leadership challenge that would have resulted in a different outcome.
I also would say the exact same thing on the opposite side. I think that at the Sutter executives at the time made some serious errors and things had gotten personal and I think people needed to take a step back and say, “If I can't handle this I need to get someone [crosstalk 00:11:21].”
Geoff: It's a great point. You know, you brought it up and I wanted to follow up on the question of what did Sutter lose in instigating [00:11:30] this separation and how long did it take them to figure out that they had really lost something important?
Jonathan: One thing they lost was not needing to know much about imaging, they lost that. Right? So it was like some bus drivers walking into the kitchen of a fancy French restaurant and holding all these recipes and like, “Oh, oh, what are we gonna do? The food was so good here but we don't know how to cook.” So that happened and the continuity of care [00:12:00] was really thrown off. The ability to get things done quickly was thrown off. But again, I keep going back to this. They didn't know what they didn't know and that was a totally fine thing until they suddenly had to figure it out. And the time frame there was maybe two years when they started to say, “Let's see if we can try something else here.” I will say this, they were quickly able to find a lot of radiologists [00:12:30] some of whom are outstanding and are great members of our practice today and some of them joined because they wanted specifically to be part of a multi-specialty medical group. They really liked the idea that they were working side by side with primary care, neurology and what have you. That was very appealing to them and in some ways, they get that better than we did…
Geoff: That's…yeah, that's a great message that you know, in the end, some of these folks that came [00:13:00] in to fill your spot have not only become your partners but have helped to educate the group as to the merits of an alternative way of practicing.
Jonathan: Yeah, absolutely. And that was a good lesson for me. I mean, I really thought we knew everything there needed to be known. And we were ignorant of a few things.
Geoff: So approximately as best as I can tell, a year after RAS's contract with Sutter was terminated, there was a leadership transition in the partnership. What [00:13:30] prompted that change in leadership at that time?
Jonathan: We have three-year terms for president and that was the three-year term was up.
Geoff: I see. And you became the new president and board chair of RAS. Can you describe a little bit about what that process was like?
Jonathan: Well, the way it went is at first there's kind of people sort of low-level sort of a whisper campaign about who might be interested and what do they think, you know, and that kind of thing. And again, we were radiation oncology [00:14:00] and diagnostic. And so there's sort of different interests there and, you know, who can sort of bridge the two parts. And I really felt that we needed to go directly to all the major… There's four big players in our medical in the marketplace here, that we need to go to the top of all of them and try to develop relationships, and really tell them what we value most of all is relationships. And I was talking to the [00:14:30] colleagues about that and that that we really need to turn things around and quickly, and that there really was an existential question. And the status quo wasn't sustainable and standing still is the new failing and they had elections for president and I… Well, slightly more complicated than that, but they had elections and I was elected.
Geoff: And it seems like it was a good thing. You know, entering into the separation, I think I read somewhere that the CEO of the group at the time publicly touted [00:15:00] RAS's strategically developed and robust business model, suggesting that the majority of the business was in outpatient centers that the loss of the contract would not hurt the group substantially. What did you and the group come to realize about the logic of that business model over time?
Jonathan: That there was, I'm trying to remember precisely but let's say three or four years, and then the bottom was gonna fall out.
Geoff: Yeah. And so how would you characterize this [00:15:30] period of time between the loss of the contract and the opening of the new negotiations with Sutter several years later?
Jonathan: What's really interesting and not surprising is that a lot of people can read the writing on the wall. You know, the doctors own the practice and we weren't losing doctors. But we had almost enough, almost 1,000 employees that we thought was our strength and it was, but the employees… We're starting to lose good employees that were going to UC Davis [00:16:00] or going to Sutter because they could read the writing on the wall. And they are loyal to RAS but they're more loyal to having stability in their family and, you know, being able to sleep at night. And so we started to have some attrition of good employees going to similar jobs at Sutter because they felt, you know, my kids are, you know, three and five years old but I'll be able to put them through college with this job I'm taking and I don't know what's gonna happen at [00:16:30] RAS. And there were some of these things that I described that were some additional projects we were working up to make up revenue. But as you started to look, it was getting a little bit more and a little bit more uncertain as I really thought about it deeply and that if we didn't get some new big connection with some of the larger players in our community, I didn't know. Again, I think it still takes a few years but I didn't know what would happen in three to four years. Sorry, I did know what would happen [00:17:00] in three to four years. A lot less volume.
Geoff: And so, what were the discussions like in the group? I mean, as you sort of saw this future potentially unfolding, you know, can you…are there any vignettes that you might recall that typified the mood at the time?
Jonathan: Well, I don't wanna paint it the wrong way. People were pretty okay for the time…you know, for a while there. People weren't panicking. The doctors weren't panicking at all. Our financial performance was very solid [00:17:30] and in some ways, it made it more challenging to convince people to look at another path because some of the… Initially, the response was like, “Why? We're doing great. What's the problem?” You know. And they didn't see the brick wall that was quickly headed toward us. Wait, do brick walls move? Anyway, I'm having some metaphorical challenges here. But the time frame a lot of people operated on was very close to the present, there wasn't kind of projection over multiple years.
Another thing that's a challenge [00:18:00] that's a problem in most of these professional groups is the buy-sell agreements or whatever corporate documents they have that are…govern the buying and selling and the ownership and so on, are not designed to perform in a downturn. They're only designed for a permanent bull market. And they're sort of automatic buyout of people as they retire or as they leave at whatever the current valuation is [00:18:30] and there's no ability for the remaining partners to say, “Well, we can't afford that right now. Sorry.” There's no… It doesn't exist. And so there was definitely an understanding that over time if some doctors started to feel like it was time to go, the people left behind own all the debt and have to pay off these people at the full evaluation. And that we probably would have had to do this without completely rewriting our buy-sell agreements, there is definitely [00:19:00] a foreseeable problem in the future. And I think that's fairly common in the way these groups are structured.
Geoff: Yeah, clearly ownership has its responsibility and it makes a lot of sense that in declining environments that concern over how to manage those transitions. So when did the possibility of a reconciliation with Sutter emerge and what steps were required in order to have that happen?
Jonathan: Two years. Yeah, two years after the separation, one of the Sutter [00:19:30] executives approached me and said, “Would you consider having your practice bought by Sutter?” And brought it back to the board, and we signed non-disclosure agreements and talked about it. And at the time, we were saying, “Geez, we have no idea if this is gonna work but who wants to look at it?” And everybody said, “Yeah, let's look at it.”
Geoff: So what were the aspects of the negotiations for the group to sell to Sutter that stand out the most in your mind?
Jonathan: I guess it's things that ended up resulting in the major documents that resulted in the [00:20:00] consummation of the deal. And the two biggest were the employment agreement with the medical group and the asset purchase. There's a sort of forced lack of controversialness on the asset purchase because you're selling to a not for profit. So it's very regulated and you have to have a special kind of fair market valuation. And there isn't much-negotiating ability. You can't just say, “Well, I want 10X. No, how about 8X?” You know, it's a number that's set. It was on the one hand [00:20:30] probably lower than a, whatever the market would produce but on the other hand, it wasn't…there wasn't a way to have sort of discord among the doctors in our practice about whether it should be higher or lower, who is a better negotiator, who get the best price because it was pretty much set in a very narrow band. So you either said okay, or I don't wanna sell. So it was a lower number but it made it simpler. The discussion was simpler. And the employment [00:21:00] agreement is something obviously very important to the doctors and that we couldn't start at the beginning for a number of reasons because at first, the medical group didn't know we were having the discussion. But once that got underway, it was pretty straightforward and we got a shortened term to ownership. And it was as things go relatively uncontroversial.
So those were the things that were the issues is about that stuff, certain kind of loss of autonomy, the idea of the income being [00:21:30] sort of capped a little bit more than it was. That you're selling, that all the employees and all the equipment goes to the medical foundation and we just work there now, we don't own any of it. On the other hand, it was a liquidity moment that probably where things were and where we were headed would never come up again as an option.
Geoff: So that kind of helped to make what otherwise was a difficult transition perhaps just a little bit more comfortable?
Jonathan: Yeah. But again, I don't think everybody appreciated that what [00:22:00] was listed as the value of their equity in the company was something that they could get their hands on easily. I don't think everyone appreciated that it would be hard without this deal to actually get that money. And once you start looking at it, it's an unbelievably illiquid investment.
Geoff: You know, you famously managed to keep the entire radiology practice intact through this entire transition. Was that a driving priority or a byproduct of the group's culture? [00:22:30]
Jonathan: Both. People had a lot of loyalty, they liked being part of the group. But I think also, I tried very hard to have a communication as open and transparent as possible when we had decision points at board meetings. On the board meeting before I would try to get everybody the information and have the attorneys there and they would already be able to see a document and then really pick over it for a month and we'll say, “Okay, we're gonna look at it today, [00:23:00] next month, we're gonna vote on it,” things like that. And whatever anybody brought up, sometimes that was very, very frustrating. But whatever people brought up, “Yes, we'll do that. Yes, we'll look at that. Yes, we'll ask that question.” Because people are used to having 60 board members and the board members wanted to still be board members. And so I basically, you know, “yes, what do you wanna know? Yeah, great, no problem.” Even down to the very end where we had conference calls with an attorney in Los Angeles in the waning hours. [00:23:30] You know, all kinds of stuff. Whatever was necessary to sit down and talk to people.
Geoff: Communication is clearly, you know, fundamental to the success of navigating virtually any leadership challenge and when considering that you also had over 800 employees that were undergoing termination from RAS and then hiring by Sutter, how did RAS manage communications and avoid disruption amongst such a large workforce?
Jonathan: Right. So, [00:24:00] at the very beginning and every month probably we stressed to the doctors, the owners, the need for confidentiality. And we were much more careful about how documents were distributed then recollected and they were all numbered and we knew who had each copy and so on. And we didn't want people to take things out of the meetings. But there was a SharePoint site with password protection where they could review them if they wanted to, but it couldn't be printed and so on. And part of the negotiation was that [00:24:30] one of our deal points was Sutter had to take everybody. And our employees basically, what happened to them was, they changed their name tags from RAS name tags to Sutter name tags and their paycheck was written differently. And I think in some cases, if not a lot of cases it was higher. But they didn't have to, like, interview for jobs, you know, they weren't fired, and then I hope I get a job. It was basically a very smooth transition for the vast majority of our employees like [00:25:00] 95% of our employees. And with other people, we've made a lot of effort to try to match them up with HR, and job openings very quickly to be able to make the transition.
Geoff: Yeah, I mean, when you consider all the moving parts it was really done very impressively. Can you describe any particular or sort of highest highs and lowest lows that you might have experienced during all of this? I mean, I know you're a pretty even guy, you know, that's probably a key element of your success [00:25:30] honestly in this. So as high and as low as you go.
Jonathan: I think the very beginning was very exciting to me and scary at the same time. But I very quickly felt that this was a lifeline because there are a lot of different paths. We talked to venture capital, we talk to private equity, we talked to publicly traded companies. And the only path that was fundamentally [00:26:00] focused on continuing to provide health care in Sacramento for the rest of our careers was going with Sutter. All the others had uncertainty in five years, it could go public, you get sold out, bought etc., etc., closed down, you know. And this was the only thing that allowed us to kinda make our own career decisions about if we wanted to stay in the area and continue to practice medicine the way we like. So the initial thing was very exciting to me. And then at the very end, when we realized we were gonna get [00:26:30] everybody to come across the line was very exciting.
I think there were low points along the way where things started to leak out and individuals decided…we had individuals that would decide to go talk to this person or that person and we started to wonder if it was ever gonna be possible because it just too much entropy in the system. And there was some things in the middle where I started to get mildly despondent that it was just too hard. You know, I thought the odds were against it from the beginning. Actually, the lowest part was just, [00:27:00] you know, being in the hospital and planning for my funeral. That was the lowest. Help…you know, helping them make sure that the replacement group was gonna be able to take care of business. You know, that was really hard. I realized I made a decision that that was my job and I didn't question it. But it was not easy.
Geoff: Sounds like that was in particular very stressful time.
Jonathan: I lost my cool a couple of times, but only [00:27:30] at the hospital.
Geoff: Understandable. What sorts of things did you do at that time to try to preserve some balance in your life?
Jonathan: One word, running. I would leave medical executive committee meetings and go out for a six-mile run and practically scream the whole time. And then I felt great.
Geoff: Marvelous. It's great, it's great that you had that release.
Jonathan: I highly recommend that.
Geoff: As long as the knees hold out. So looking back over the past four years now under a completely new structure, [00:28:00] how long did it take and what steps were involved for the group to reach a sense of equilibrium?
Jonathan: I think that there's been a couple sort of phases, a couple equilibria. Punctuated equilibrium. Isn't that an evolutionary term? There's been a couple of spots because, you know, people are individually going through various thought processes. Because I think right now four years out, you know, [00:28:30] part of our deal was we had a four-year non-compete and that's gone, ended in February of this year. And nobody left as a result of the non-compete going away. But I think some of the people that were originally with RAS are still sort of mourning the lack of control and ability to make quick decisions and act on them. And I think that's bugging people a lot right now. And so maybe a year ago that was quieter, so that might have been an equilibrium. [00:29:00]
I think that there's a lot of blending now in terms of the leadership of the group and the day to day work of both the original RAS people and the original Sutter Medical Group radiologists. Like I said, we're getting great contributions from both sides and that… I think that that part of it is very smooth. I definitely think the people are still feeling like the communication isn't what it needs to be and including me are still [00:29:30] sorting out who's in charge of what. There's sort of…you know, I'm the chairman of the department but then there's a doctor above me that's overall the specialist then there's the Chief Medical Officer and then there's a medical group president, and then there's the whole health system. And it's still, I'm still puzzled from day to day about whom I'm supposed to talk to about what.
The other thing is just that everything's much, much slower in terms of execution and that's challenging. [00:30:00] The stability…I mean, we went over night from worrying about where we were gonna get patients to worrying about how we were gonna get all the work done. And no one is worried about finding work from the first day we became part of the medical group to today. And volume's still been growing. Our recruitment's gotten really good. Pretty much, anybody we put out a job offer to accepts and I'm just blown away about the caliber of people we're hiring. I think we're the job to get in Sacramento area, and broader even, anybody that wants to be near the Bay Area. [00:30:30] So, I'm really…I think, in terms of general stability, we're very much in equilibrium now. Again, I think there's some things below the surface that are really bothering people that are harder to tackle, but we're working on as much as we can.
Geoff: Earlier you described, you know, what manifests is a very entrepreneurial spirit within the group. Are there outlets for that entrepreneurial spirit today?
Jonathan: Not [00:31:00] adequate.
Geoff: You see a pathway?
Jonathan: Yes, but it's very different. It's kind of like, first of all, if you got 10 things, you got to pick one. And then there's a lot of people that you have to deal with and talk to. And I'm paired with an executive that's over the imaging service line, who his previous job was Chief Operating Officer for a national publicly traded imaging company. And without him, I don't think I would get anything done except agreeing [00:31:30] to hire people or something.
And he and I sit down and work through, “Okay, so you're gonna call so and so. I'm gonna call them and then we're gonna have a meeting.” And we're both used to things going much faster. So what's… For me personally, the entrepreneurial zeal is replaced by slicing through the bureaucracy zeal to get things done. So it's different.
Geoff: There's definitely rewards in that.
Jonathan: Yeah. And so I actually [00:32:00] I am very… I very much enjoy trying to navigate the maze. I like figuring out who to talk to in this one and that one and somebody says no and I talked to their boss and say, “They said no. No, we can do that,” you know, things like that. I enjoy that but it's a very different… I think there's something still entrepreneurial about it but it's very different.
Geoff: Yeah. So what would you say are some of the greatest benefits of being integrated as employees [00:32:30] of a multi-specialty medical group within Sutter health?
Jonathan: Yeah, so the biggest of all, and it's not, it's not something that's in front of your face, but the biggest of all is safety and security, first of all. But then I feel like I understand what primary care doctors are doing and what their challenges are much better than I ever did in independent practice. And same with specialists. I feel like I am much more a direct, and all of us are much more direct part of all the different health care [00:33:00] and I think that that's very important, not just, it's not just sort of an intellectual stimulation sort of thing. But I think for radiology, we have functioned, you know, for a long time effectively by just being in an office and receiving things and sending out information and not necessarily need to understand much about what the person who sent us the thing, what they really need. It varies from place to place but it hasn't been an essential thing. [00:33:30] And I think where healthcare is going with much more integration, perhaps, you know, much more value and much less pay for volume is that radiology has to be integrated into all the parts of healthcare and the radiologist needs to know what the doctor in the office sitting across the table from the patient, what they're thinking, what their challenges are. And then what the Chief Medical Officer is looking at in terms of big size, population management questions. And [00:34:00] imaging needs to serve both at macro and both…and micro in a way that we didn't have to before. It was nice if we did but I think going forward, it's more of an existential question.
And so being in the multi-specialty medical group, I feel like we're much more positioned to understand what it is they need from us.
Geoff: Has your approach to leading within the group changed as a result of the transition to the role that you have currently in the [00:34:30] medical group and in the health system versus when you were a private practice?
Jonathan: Yeah, I think that there's much more repetitive explanation of things like how we get paid, what the chances are for differences in our salary, what is happening in healthcare on a consistent basis to help people understand where things are going. And it seems like it's a much more kind of repetitive communication of the landscape describing the landscape and [00:35:00] making sure that people understand that I'm accessible and I have information for them. It's a challenge to make sure I'm… And I'm not saying I'm fully successful at this, by the way. It's a challenge to make sure I'm always kind of visible. So because one of the things that happened, and this was I think certain bit of naivete on my part. One of the things that happened was, okay, we have a big department, I'm not gonna just do everything myself. I'm gonna have section heads, and we're gonna have leadership team meetings and the section heads are gonna communicate. [00:35:30]
Well, the individual doctors didn't really feel the love and the section heads were committed to doing this in varying degrees. And the result was that I thought it was effective and it wasn't very effective. And people thought they weren't being told about decisions, they weren't being told how decisions were made. And they weren't being told about what decisions were coming up. So we've had to…I had kind of a big town hall meeting with all the radiologists and we talked a lot about all these things. [00:36:00] And so we've had to make some changes. And just the fact that I thought there was a good structure to put in place didn't mean they would actually function properly. So I learned that…
Geoff: Absolutely. You know, listening, adaptability all traits of a strong leader. And, you know, it's great to hear how, you know, you've manifest those. You know, we talked about your approach to leading within the group, how about your approach to leading on behalf of the group in this larger health system? Has there been some evolution or lessons learned in that [00:36:30] domain?
Jonathan: Yes, a lot of it is starting up by listening and what are their challenges? And trying to kinda prompt that by saying, “Here's some kinds of things I think that we need to be doing, but, you know, what do you guys need? Where are things going? What are the challenges that you have?” I'm also leading a diagnostic imaging standards committee that's across the entire health system. So I meet with the chairs of the big, Sutter Hospitals [00:37:00] in Palo Alto and in…I mean sorry, that's a medical group. The big hospital in San Francisco and the East Bay, Modesto and Sacramento. And we work on some things that are standard imaging across…you know, it's a health system with about 3 million exams a year. And that's very interesting and there's a lot of politics there because each site believes that they know things best. And especially San Francisco and Palo Alto they think in Sacramento we're a bunch of Yahoos and, you know, [00:37:30] just fell off the radiology truck, or whatever it is.
And so there's a lot of putting topics up and seeing how people…what people say, and helping guide the decision-making process that not just people think they might have ownership of, but they really do have ownership of. And, for me, my gratification isn't that I had the idea, my gratification is that I guided a process that people [00:38:00] agreed upon. And that's not always easy. You like to kinda jump in and say, “Well, here's what I would do. Here's what I suggest. They're like this…,” you know, and you have to say, “We need this. Let's start talking about this general topic. What do you guys… What are you guys doing? What do you,…how do you think we should do it?” And have individual people work on sharing up individual subcommittees, things like that.
Geoff: Sounds collaborative.
Jonathan: You need to be.
Geoff: Is there anything that in retrospect you wish that you had done [00:38:30] differently?
Jonathan: There's a couple of things. One is what I referred to first, which is just how to set up the structure of my department to kind of spend more time asking people for their opinions and making sure that that was very visible and not having a focus on specific outcomes. You know, as long as I got this general idea accomplished, not really feeling like it was important for me to come up with what the specifics were that other people should be doing [00:39:00] that more collaborative process of just deciding the leadership structure. I think that's…And then also, I think just being more consistent communicating, although I do a lot.
One of the things that I'm constantly fooled by is, I constantly think that sending an email to a lot of people works. And it never works. It might be a way to bring up a topic but you have to…it's just a start. [00:39:30] And a month later, two-thirds of the people will insist that you never told them. So I constantly forget that rule but the rule, email by itself doesn't work. You have to do other things.
Geoff: That is a great lesson not only to learn but to impart to our listeners. One last question. And that is looking ahead now, what excites you the most?
Jonathan: Some of it is what I was talking about, about the role of radiology in how health systems have to provide care [00:40:00] and organized care. And I believe very much that radiology is at a crossroads where we can be passive and kind of move down the food chain or we can really be active at trying to support individual care decisions and population level care decisions. It requires a seamless partnership with IT, IS, whatever you wanna call it. More than most other parts of health care, because we need the [00:40:30] data science, there's a plug for ACR. We need the data science to support decision making but I think that that's something that should be integral part of what is considered radiology service over time. And I think it's…that's very exciting. I think it makes the job much more fun. I also wanna bring patients into the department more in terms of talking to them and having patient consults on imaging and I think that makes the job more fun.
Geoff: Fantastic. Well, [00:41:00] Jonathan Breslau, you have had an amazing journey and I can't thank you enough for sharing it with us with such candor and openness. Thank you very much for joining us on “Taking the Lead.”
Jonathan: Well, thank you, Geoff. It's a real pleasure talking to you and good luck with the whole series.
Geoff: Please join me next month when I speak with Jonathan [00:41:30] Lewin, Executive Vice President for Health Affairs for Emory University, Executive Director of the Woodruffs Health Sciences Center, and President, CEO, and Chairman of the Board of Emory Healthcare, the largest health care system in the state of Georgia. Prior to Emory while serving as chair of radiology at Johns Hopkins University, John co-chaired a strategic planning initiative for Johns Hopkins Medicine, which led to a formal role outside of radiology as Senior Vice President [00:42:00] for Integrated Healthcare Delivery for Johns Hopkins Medicine. We'll explore the evolution of his leadership approach and strategies as he has transitioned from heading one of the nation's top radiology departments to one of its top health systems, and how his perspective as a radiologist shapes his priorities and tactics for Emory Healthcare.
“Taking the Lead” is a production of the Radiology Leadership Institute and the American College of Radiology. Special thanks [00:42:30] go to Anne Marie Pascoe, Senior Director of the RLI and co-producer of this podcast, to Brian [SP] Russell for technical support, Megan Giampapa for our marketing, Peg Helminski for production support and Shane Yoder for our theme music.
Finally, thank you, our audience for listening and for your interest in radiology leadership. I'm your host, Geoff Rubin from Duke University. We welcome your feedback, questions, and ideas for future [00:43:00] conversations. You can reach me on Twitter at G-E-O-F-F-R-U-B-I-N or the RLI at rli_acr. Alternatively, send us an email at email@example.com. I look forward to you joining me next time on “Taking the Lead.”
Jonathan Breslau, MD, FACR, Chief of Sutter Imaging
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