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In July 2022, Kirsten Bibbins-Domingo, PhD, MD, MAS, took on a new role as the 17th editor in chief of JAMA and the JAMA Network. In conversation with Nobel laureate Harold Varmus, MD, Bibbins-Domingo discusses her research background, approaches to leadership in health care, and the critical role that journals play in communication about public health and science.
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[Dr Harold E Varmus:] Welcome to everybody in the audience. It's my immense pleasure today to introduce you to the new editor in chief of JAMA and its affiliated journals, Kirsten Bibbins-Domingo. She is currently, just to get some facts out of the way, the Lee Goldman, MD Professor of Medicine and at University of California, San Francisco. She's also a practicing internist, Professor of Epidemiology and Biostatistics, the outgoing chair of that department at UCSF, an NIH funded researcher who works on the prevention of cardiovascular disease and has other attributes that we'll get to in the course of the interview today. My own credentials today are that I'm the Louis Thomas University Professor at Weill Cornell Medical School doing cancer research at the Mayo Cancer Center. I'm also a senior associate at the New York Genome Center. Previously, I served as the head of the NIH, the National Cancer Institute, and Memorial Sloan-Kettering Cancer Center. And importantly and in full disclosure, here I was, Kirsten's thesis advisor when she was an M.D., Ph.D. student at UCSF a few years ago. So, Kirsten, congratulations on this new position. And let's talk about some things that introduce you to this audience in a way that's both personal and professional. I've known you for a long time, and I know you grew up in Bowie, Maryland, went on to Princeton University and then spent some time doing chemistry in Nigeria after college. Then, came to UCSF and the M.D., Ph.D. program and did some work on molecular attributes of a oncogenic protein and then went on to further medical training and finally joined the UCSF a faculty in the various capacities that I mentioned earlier. Tell us something about that life trajectory and how that has made you interested in this job and shaped your career.
[Dr Kirsten Bibbins-Domingo:] Thanks so much, Harold, and thanks for being with me here today. I really appreciate it. Yes, you're describing something that either sounds like I haven't been able to stay focused or for me is a journey about my interest in many things. I'm broadly curious. That has always been the case. I have always, though, been interested in science and I have been interested in science and how science can help us both to understand the world better, and help to make the world and health in the world a better place. And so I think that my love of science started very early on in high school and Princeton. It took me to Nigeria, actually, my love of science, and then to all of the things that I did at UCSF. But all the way through I've been always seeking to understand how we can both communicate our science more effectively, how we can communicate it more broadly. In order for it to have the most impact, either to advance more questions in science or its translation to to human health. And so in that way, although it is not obvious why the several steps that you've mentioned would have led me to this new position, in some ways it's perfectly obvious to me because, ultimately, scientific and medical journals are the way in which our scientific discoveries really reach the broadest audience. And there really is this position, as the Editor in Chief of JAMA and the network of journals that are in the JAMA Network is an extraordinary opportunity to think about that piece of this scientific ecosystem.
[Dr Harold E Varmus:] Well, I can remember quite clearly, even when you were a student in my lab, that while you were laboring away on some abstruse aspects of the SRC onco protein, you were also concerned about how what you were doing would ultimately have some effect on public health and even on individual health care. And, you know, you spent a lot of time in the interim years thinking about prevention and epidemiology as well as practice in cardiology. You've served on the US Preventive Services Task Force. You've been interested in global health. And I'd be curious to know what your current appraisal is of the US health system. And, you know, a lot of things have changed since you were in my lab. We have Obamacare. We have better treatments for many things, but we still have inequity. And I know you're passionate about that topic. And I'd like to know what your current assessment is of the health system. How would you like to see the health system in this country evolve in some major way? And how can you use your new job to try to foster movement in the right direction?
[Dr Kirsten Bibbins-Domingo:] We have in many ways, a fabulous health care system. We have a fabulous health care system that benefits from the translation of our enormous biomedical research enterprise into new scientific discoveries, translating into better health for many who have access to our health care system, even for those who have access to our health care system, where we have an extraordinarily fragmented system that doesn't operate quite as efficiently or as effectively as we might like. We spend an enormous amount in health care, but don't often have the health outcomes that we would expect for the amount of money that we spend. A large part of that has to do with the fragmentation within our system, as well as the fact that many don't even have access to the high quality health care that we have. And we all have a broad appreciation of both the inequities that happen within the health care system, the inequities that are caused by the lack of access, and then the fact that as much as health care is important for ultimate health, the broad context in which we all live, the social factors, the structural factors, the environmental factors, that influence the life around us all have an influence on our health and are important as well. And we have an appreciation of that. But unfortunately, that, too, sits in another aspect of the way we think about policy, about the way we think about the sectors that are involved in health. And so if we in the U.S. or globally were to think about how we would want to improve health, we have to have a far broader understanding. It begins because we are talking here about medical care and the scientific underpinnings for improving health within the context of medical care. But the broader understanding of those things that influence health are also going to be important. It means bringing more people to the table to talk about those factors that impact health. It means being more conscious about the types of science that are important at the times when we're thinking about the health that we're trying to improve. And that is one role that I think journals have a particular opportunity to play is both to shape that discussion, to shape that context, to shape the types of science and highlight the types of science that are important as we're all trying to improve both health and the inequities in health that we observe.
[Dr Harold E Varmus:] I'd like to follow up on a couple of aspects of what you just said. I asked about the U.S. health system. You focused perhaps based on your own experience, particularly on health care delivery. But I consider within the health care system to be I think to accord to public health a major role. And what our system is and, you know, the pandemic in particular has unleashed a tremendous amount of criticism from me and many others about how we deal with public health in this country and the fragmented nature of our efforts to control, for example, the pandemic, which has revealed major schisms. In the way we try to teach people about health practices that are preventive rather than curative. And so I'd like to hear a little bit more about your view of the public health system, but I'd also like to know how you think JAMA and its affiliated journals can make a difference here by enlarging the already enormous audiences you have, bringing in more people. What can be done to both make the message that JAMA and its affiliated journals deliver about the shortcomings of our system, both preventive and therapeutic?
[Dr Kirsten Bibbins-Domingo:] Yes, I would totally agree. And I think that you're bringing up a topic that's really near and dear to my heart, actually. You know, I'm a physician that works in a health care system that is part of the Department of Public Health. So I've always had a very close tie to public health and a broad appreciation of public health. I think when I think about the pandemic and the early days of the pandemic, what for me really crystallized the power when we think across what in the U.S. is far too siloed. Medical care is fragmented in and of itself. It's certainly completely fractured from public health, which is both underfunded. And then we criticize when public health doesn't operate in the way it should or as fast enough as it should, because we've had really far too long a period of time of underfunding and ignoring public health. So not surprisingly, when we're in this period of time of the crisis, public health has had really brilliant moments, but not functioned the way we would expect, especially in the U.S., it should and should in partnership with medical care delivery in order to achieve some of the things that should happen in an ideal world more seamlessly. When I think about what was really an extraordinary period for us at UCSF in the early days of the pandemic were really about the partnerships within our academic institutions. Our medical care systems are public cares systems, thinking with communities about how we could bring testing early on into the communities and scale up that type of testing to address issues of equity, issues of the types of functions that normally sit in public health about education and surveillance and identifying disease, where it is in the community, linking to health care delivery, and then actually partnering with virologists at UCSF to think about how we were testing for new strains that we were just discovering at the time and how that could work so seamlessly across sectors that hardly ever work together, unfortunately. So when you see what's possible, I think you can see the power of a system working together in a way that addresses so many aspects that we even address in a siloed fashion. What you see now is unfortunately, I fear, is still a retrenching of those, let's go back to focusing on health care. Let's criticize public health, even though it's not working as fast as we would like, even though it continues to be underfunded. And let's not really acknowledge that all of these things have to work together in order for us to achieve the goals we need to together. I think the role that a journal can play at this time is really to be the way in which those conversations are happening, to curate those conversations, to highlight the types of science that really need to be in place for us to think about a particular set of health conditions we're trying to address in a from a different angle, the way many different scientific communities might be approaching a particular problem, as well as to think about from the types of discourse that we'd like to promote with our viewpoints and special issues around a particular issue from a variety of different perspectives or people who are really thinking at the forefront about how we might think across these sectors to really work together to solve the problems we're trying to solve.
[Dr Harold E Varmus:] Six years ago, you founded an organization called the UCSF Center for Vulnerable Populations at the Zuckerberg General Hospital. And I'd like to know a little bit about what things you were addressing then and how the things that you're thinking about now were affected by the pandemic and perhaps possibly affected by your ascendancy to the editorship, JAMA.
[Dr Kirsten Bibbins-Domingo:] So we founded the Center for Vulnerable Populations at San Francisco General Hospital. It's a research center. So, the investigators there, they're NIH funded investigators, they are doing research, but their research is focused really on communities, on populations that have long suffered from poor health because of social and structural factors that are unequal in our society. And I think what makes the research done at the Center for Vulnerable Populations unique and important and interesting is people are focused, the investigators are focused on clinical problems, but they usually are also focused on policy interventions that address clinical problems. So they tend to have expertize, both in policy and clinical care or in policy and community care or in community and clinical care. Almost all of the work that's done there tends to have a focus in two types of methodologies or two types of sectors. And it's sort of what makes it, I think, the most interesting and the most impactful. There's a strong component on communication. We talk a lot about strategic science and how we communicate about our science to policymakers. To broad clinical audiences. I think as scientists, we don't want to be scientists as just learning to finish our experiment. The best way possible or learning to finish our clinical trial in the best way possible. Everything about science to me is always about how we then communicate it to the next person who needs to hear about it in order to do the next thing. And I think the work in the Center for Vulnerable Populations has always had a strong communications mode, and I think that's why this role, as I talked with my colleagues in CVP, it made sense from a lot of the things that we've been talking about and wanting to use communication in a way that really can use science to actually try to move the things that we want to move.
[Dr Harold E Varmus:] I know from following your career from a distance that you're not a novice with respect to public service, and I've certainly heard you on the radio several times talking about how we've handled COVID. And I was watching pretty carefully as you were serving as a member of the U.S. Preventive Services Task Force and making pronouncements about everything from mammography to HPV vaccination, to other things that I wonder what you've learned from those public experiences.
[Dr Kirsten Bibbins-Domingo:] I never quite anticipated who all the audiences are that we're always communicating with. And so I think the Task Force in I joined the Task Force at a time when the Task Force was making guidelines and we thought we were communicating them to primary care providers. Well, we're always communicating. We're communicating to patients, we're communicating to patient advocacy groups, we're communicating to other researchers, thinking about the next scientific discovery. We're communicating to industry. We're communicating to policymakers. We're communicating to insurers. And we have to be thoughtful and mindful. I don't want to use the word we have to be "cautious," because the other thing I learned in doing this is that we have to build relationships with these various types of stakeholders. It's actually really helpful to understand how other people think about about an issue. One of the things I learned on the on the Task Force where we graded recommendations and when I talked to a patient advocacy group and she said, "well, why do you give that a 'C.' You know, I don't like when my son comes with a 'C' on his report card, A 'C' is a terrible grade." And little things like that are things that we communicate and, you know, I can say, well, this is just a grading system, but if you're communicating more broadly, a grading system that most people think about as a bad grade on their report card, is actually not that effective means of communication. But I think more importantly, building bridges, building relationships, engaging with various stakeholders is both an important thing. It helps you in any job you're trying to have. But it's also very powerful from building coalitions that try to bring about change in many of the things that we're trying to change in health and health care. And I think it was a very positive thing that I learned both the need to communicate broadly and the need to build relationships with a broad base of stakeholders that I think is just–they're very good life lessons and very positive ones in my view.
[Dr Harold E Varmus:] One of the things that I'm reminded of by what you just said is a passage in your really, very, terrific editorial that's launching your career at JAMA about trust and trust is an incredibly important thing that I think is a source of concern to me as a scientist/politician and administrator, because I think a great deal of trust has been sacrificed in some sectors during the pandemic. And I wonder how you're imagining your work at JAMA to be directed toward trying to reestablish some of that trust between the health care system, such as it is public health practices and other things, and the large and complex patient and patient advocacy groups that we have. What kind of specific things do you imagine doing to try to reinforce the positive elements that exist in the relationship that we have with the broader public?
[Dr Kirsten Bibbins-Domingo:] Right. I do think that that trust is one of those things that is so important. We think about it in in health care and building trust with patients, the doctor-patient relationship. And we think about it as something that has, as you suggest, has during the pandemic been lost in so many of the arenas that are so important for achieving the types of population goals that we had during the pandemic. I think for journals to be effective, they have to ultimately operate on a basis of trust. And, that is, trust that our primary readership are clinicians. People who use the material that we publish have to trust that it is vetted by the processes that we have. So we have an importance to maintaining the high integrity in those processes. Authors have to trust this. Authors are part of what makes medical journalism possible, that authors trust us to do our job well. And to disseminate their work well. And the general public–that the name JAMA and the JAMA Network means something in that process. So we have a responsibility to do this well, and I think we have a responsibility to actually do more. So for us, that means who we hire, how we think about the voices that are in the room helping us to set our priorities, decide what's important. It has to do with the types of science that we think is important. And we really want to engage with the various scientific communities to really understand how our processes serve them well and how we can do that better. We embrace, as I say, in the the editorial, and we can talk more about the principles of open science. I think those are such important principles and for us as a network of journals, we think about that in many ways, but also in particular in the areas of open access, which I think has been an issue for us in publishing for a while, but will continue to be going forward. I think that we, I think, continue to reinforce trust when we can deliver to our audience the types of things that in the way that they are interested in consuming their media. I think we're living in an age of lots of feeds that influence our minds and when we can deliver our content in the way that somebody wants to receive it. I think that's important. And as we're staying on the forefront of the issues that are important for science, medicine, and public health, I think that is important, that we're not lagging but that we're leading in those areas. And those things continue to establish trust. And in all ways, we want to make sure that we have as many voices in the room being able to inform us as to what's important and also that we are as transparent as possible and as free of conflict of interest as possible, because I think that is the way that others can judge what's important about and judge for themselves the type of material that that we're presenting to our readers and our viewers.
[Dr Harold E Varmus:] Of course, judging for oneself is difficult. But you are living, as we all are, in a world in which and reviewed social media messages are often more dominant than what appears in traditionally sound journals. And, Kirsten, I've really enjoyed talking to you as always, and we're proud of what you've done as a UCSF M.D., Ph.D. student, going on to the greatest possible things and trying to improve the health of the nation. So thanks for talking with us today.
[Dr Kirsten Bibbins-Domingo:] Thanks so much, Harold. Really enjoyed it. And thanks. Thanks for joining me today and being such an important mentor to me for so many years.
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