A Conversation with UH Alumnus, Jonathan Lewin, MD

Mukesh Jain, MD: Hello everyone, my name is Mukesh Jain, and I'm the Chief Academic Officer for University Hospitals, and it's a real pleasure for me to be with a very special guest today, Dr. Jon Lewin. Dr. Lewin is the Executive Vice President of Health Affairs at Emory University; he is the executive director of the Woodruff Health Sciences Center, CEO, and Chairman of the Board of Emory Healthcare. Dr. Lewin is also an alumnus of University Hospitals, and over the years, has made enormous contributions to science and medicine, both as an investigator and as a healthcare leader.

And we're very honored that he accepted our invitation to visit University Hospitals on September 30th to deliver the inaugural lecture, which we've entitled The UH Alumni Healthcare Leadership Lecture.

So with that as a way of background welcome, Dr. Lewin.

Jon Lewin, MD: Well, thank you, and it's really it's a pleasure and an honor to be able to join you today and your alumni who hear this podcast. So thank you so much for the invitation. And I'm very much looking forward to coming and visiting my old alma mater at the end of September. It's been too long since I've been there.

Mukesh Jain, MD: Yeah, well, the feeling's mutual. There's a lot of excitement and a number of colleagues that you trained with Jon that are still here, and they have all been reaching out saying I want, I want a few minutes with Jon when he visits; so it'll be great.

So, let me get started. You trained here, but actually, you grew up in Cleveland. And can you tell us a little bit about your family, your childhood, growing up here? And as I understand it, you still have family in the area.

Jon Lewin, MD: I grew up in the east side of Cleveland and my father was, as we used to call it, a general practitioner. He had an office down around 101st and Chester where he took care of people from the neighborhood.

After medical school at Western Reserve, he did an internship at Mt. Sinai Hospital, which as many people will know was a Cleveland landmark until not that long ago, then did residency in Boston and went off to the army in World War II, stationed in Europe. After World War II, he came back to set up a practice in Cleveland, and as I was growing up he was out maybe three nights a week delivering babies or making house calls. He literally would run into people for whom he'd delivered two generations of their families.

At one point, some of his office mates were moving out to the suburbs, saying, “Hey, let's get out to where there are wealthier patients.” And his answer was, “well, if I leave this neighborhood, who's going to take care of these people?’ He stayed there, taking care of the East Cleveland and city of Cleveland patient base, and I grew up with him as a role model.

My mother had a master's degree from Western Reserve University in library sciences, and ended up working in his office and helping him out. I had two older siblings and really enjoyed Cleveland and learning the city and spending time at Case Western Reserve University/University Hospitals area, something well known to me as I grew up.

Mukesh Jain, MD: That's beautiful, and you know your comments about your father that is the classic practitioner. They could do it all, which medicine has changed a great deal since that is very inspiring. And in addition, undoubtedly, your father was an inspiration for your interest in medicine. Were there other mentors or inspirational figures for you growing up in Cleveland?

Jon Lewin, MD: Well, I never thought I would be a doctor when I was younger. And part of it was every time I saw somebody, they always said, “are you going to be a doctor like your dad?” And the answer, of course, was “well no, I'm going to do something different.” I was very interested in science, and was a real nerd.

The summer between seventh and eighth grade there was a program being run by a Case Western Reserve University professor teaching middle school kids about computers and computer science. I don't know why he did it; I think now, as a faculty member, how selfless that was. There were three or four of us; we rode our bicycles down from the east side on Sunday mornings to sit with him, and he would teach us the basic underlying computer science concepts, and we then we would work on coding on the old PDP10 that was sitting on campus. And so I learned how to program in between seventh and eighth grade, and even got a paying job at a place called Chi Corporation, which was a Case Western Reserve University subsidiary that did large mainframe computer analysis. My job working there was writing machine code for their operating system, and it was a great experience and got me into technology and science.

I grew up thinking I was going to be a scientist, either a physicist or engineer. It really wasn't until I was in college, where I was a physical chemistry major working in the lab, when I started to think that maybe there were things I could do that would merge my interest in discovery with medicine, understanding that having a bigger impact might be something I'd be interested in one day.

As I started to think a little bit more about medicine, I got a summer job at Mount Sinai Hospital working as a scrub tech in surgery. Things were a little different back then. I don't think a college summer student now could be working scrubbed in an operating room. At least, I hope that it would be a little bit less likely. But I worked in an orthopedic surgery operating room and really started to think that if I went to medical school, I could do research in biomechanics as an orthopedic surgeon. That was really what changed my mind, the idea that I could have a bigger impact as a physician-scientist than as a physical scientist. In fact, I had not taken any biology in college up through my junior year, so I had to quickly take an intro bio course at Cleveland State University during the summer and then took what I needed in terms of biochemistry and the other bio prerequisites my senior year of college.

Mukesh Jain, MD: Well, well, I'm in awe of anyone that majors in physical chemistry. That’s remarkable. That was the hardest class I remember for me, at least in college. That's amazing. So you finished college, you go to medical school, and you came back to UH for residency in radiology. And what influenced your decision to come back to UH at that time, and what stands out to you about your experiences as a trainee here.

Jon Lewin, MD: In deciding, I looked in two locations. I looked in New England, which is where I was in medical school, mostly Boston and New Haven, and then I looked at Cleveland because my parents and in-laws were living there and I liked the program so thought that would be also a good opportunity. What was interesting was that at the time not all of the diagnostic radiology programs were in the match. I was offered positions up in New England early, but University Hospitals was already in the match which wasn’t going to happen for several months.

Dr. Pat Bryan, who was the Chief of ultrasound at UH and was the program director, essentially said, “you have a really good chance of getting in here.” So I had to turn down the positions on the east coast to put myself in the match, and sure enough, he was true to his word. Even though you were not allowed to say “you're in” he came as close as he could to doing so, and so I waited to match at UH.

At that time, the real difference between the other programs I was looking at and UH was that at many of the other programs I found residents sitting in libraries reading. At UH the residents were actually doing things. They were doing biopsies. They were doing their own ultrasounds in the ultrasound suite. They were really much more hands-on and involved and much more responsible for the diagnoses than I found at most other programs. So really, it was the hands- on aspects that drew me to UH. When I got there, I found it was truly the right decision.

Mukesh Jain, MD: That's great. And where their mentors or colleagues as you reflect back that you were particularly influenced by?

Jon Lewin, MD: There were some really great faculty. It was the days of big personalities, and I think any of the radiology alumni that hear this will also agree. There were many great people there, people who were dedicated to teaching. Barry Yulish and Stuart Morrison in Pediatric Radiology, people like Pat Bryan and Alan Cohen, and others who just really enjoyed teaching the residents. And then there were some real inspirational folks, like John Haaga, who I understand just recently retired.

I have to say if I had to pick one person who was a role model at UH during those days, it would have been John because he was, and probably still is, working and moving at 150 miles an hour and always thinking of creative things. What I really enjoyed was he was always thinking of crazy ideas that people would listen to and say, “that is impossible, that would never work.” And then he would take all the time it took to prove that in fact, yes it would. Things like CT-guided core needle biopsies that people thought were dangerous when he started a few years before I got there. And we became proficient in doing those based on John's real mentorship and modeling.

Mukesh Jain, MD: Yes, you're absolutely right, and he's continued to remain very active, as you have alluded to. So you finished up at UH, went off for additional training in Germany, I believe , and then returned to the (Cleveland) Clinic for an initial faculty position. And then you came back to UH, and that was, if I recall, sort of an interesting time because there was strengths in the MR, but a group had moved around that time, and you had come in and build an MR program essentially from scratch. Tell us a little bit about that process and the lessons that you learned from that and how they might have impacted how you thought about leadership, moving to other aspects of your career.

Jon Lewin, MD: During my residency, the other really impactful group that I worked with was the MRI research group. At the time, there was a very prolific group of both neuroradiologist physician scientists as well as PhD scientists, and did a lot of research with them during my residency and really got the academic bug during that time.

Also during residency I went off to do a year’s research fellowship in Erlangen, Germany at the Siemens MRI Research and Development Center in a program that University Hospitals had developed with Siemens. While I was in Germany, the neuroradiology physician group with whom I'd worked moved over to the Cleveland Clinic, part of the back and forth which seemed to be common in radiology those days.

And shortly after I returned, just before I came back to UH on faculty, the MRI PhD group departed and went to Washington University (St. Louis). And all the postdocs and PhD students also left. So when I got to UH again, I had a nice space in the basement of Bolwell, a couple of MR scanners that I was responsible for from an administrative perspective, a great clinical MRI tech staff, but essentially no scientists. I didn't know that I should have asked for start-up funds back then, but I was able to scrape up enough to hire a programmer and to start doing some MR research and programming as I learned in my research fellowship.

One of the best things that ever happened was that when I spoke to Mark Haacke, the lead PhD who had left and had taken the group with him, about rebuilding, he told me about a young MR scientist who was working over at another institution in town. He told me I ought to talk to him about coming over to UH, and so I did. His name is Jeff Duerk and he came and joined me and together we went out and got grant support. Just before Jeff, I hired another programmer, and when Jeff joined that programmer went to get his PhD with us and stayed on. And by the time I left, there were about 25 people working in the MR group.

When I left, Jeff continued to move the group forward. And, as you probably know, he went on to then become the Chair of biomedical engineering then the Dean of Engineering at Case, and now he's Provost at the University of Miami. But really, the opportunity to build a research group from scratch and to recruit people that not only were smart but also shared commitments to mutual respect, to excellence, and to communications - to really build a culture - was an incredible opportunity that Jeff and I never would have had if there had been an existing research group.

The other thing about UH in those days was there was also a group of great collaborators. At the time, Mark had left a group of psychiatrists and neurologists interested in brain functional imaging, which was very new, and that was an area that I had helped start-up at the (Cleveland) Clinic. So I was able to sort of slip myself into that clinical research group and to provide the technical side of that work. It was a fertile blue ocean for really building what ended up being a very fulfilling research career.

Mukesh Jain, MD: That's great. So you built a remarkable program that continues to this day, and along the way, trainees, etc, great contributions to science, and as I understand that there were also light-hearted aspects of your engagement in Cleveland. I'm told that you were part of a band or some sort of musical group. Maybe you can share with our audience a little bit about those experiences.

Jon Lewin, MD: Oh sure. Those were fun days. I started while I was still a resident. But actually, your very own famous Dr. Warren Selman was the core; he was the key to the band. He was the lead vocalist and lead guitarist; we used to rehearse at his house. And it was really a UH-based band. We had a neuroradiology fellow who had trained at UH who played rhythm guitar. We had a colorectal surgeon on drums. We had an oncologist on bass and I joined on saxophone. And typically, we would also have vocalists – I think our vocalists at the time was an ED nurse. We just had a lot of fun. We would play, I would say, not the highest classes of establishments, but we had a lot of fun playing.

I can't give you the band’s name because we used to change it frequently. We used to say it was so people would come again to hear us. We went through several names, LD50, The Specimens, and The Retractors. The Retractors continued on after I was gone for a while with that name. We had a lot of fun. And I believe Warren is still playing his guitar. I moved on to jazz, which I enjoyed for a while before I left, playing with a small jazz group in the atrium during lunchtimes at UH. I continued to play jazz with a quartet in Baltimore for my whole 12 years there, and now I've gotten a little group together here in Atlanta, as well.

Mukesh Jain, MD: Wow, well, that's fascinating. So music has remained a thread throughout your career that's really wonderful.

Jon Lewin, MD: It is one of the more fulfilling things for me.

Mukesh Jain, MD: So you mentioned Hopkins, and so I was going to transition forward. After building the program here, you left to take on major leadership roles, chair of the department of Radiology at (Johns) Hopkins and, then eventually CEO of Emory health some years later. Can you share with us your leadership style? What are the principles that have allowed you to be so successful in these major leadership roles?

Jon Lewin, MD: Well, first I want to emphasize the success we had at UH with our research program was really Jeff Duerk and I working together. It was really the team-building of that program, and we had a fantastic time recruiting really great postdocs from Germany, from Egypt, from Iran; it was like the UN down in the lab with our research fellows, our graduate students from China and India. It was just a fantastic time.

As a physician scientist, the opportunity to build a culture in the lab was really helpful in figuring out what were the most important aspects of a successful endeavor. I think the lessons from my research career translate to being CEO and Executive Vice President for Health Affairs here at Emory; it's really the same fundamental concepts. The first of them is that there are a lot more smart people in the world than good people. So the key is to find a good person who is really smart, as opposed to just finding a really smart person. And we used to say the productivity of the group was essentially divided by the number of negative or nasty people you had in the group. So if you had none, you had infinite productivity. The minute you had one you brought it down, and if you got more than one you were really in trouble.

Jeff and I spent a lot of time looking for people who were not self-centered, who were team players. It was in the days before the term was in vogue, but, in fact, that's what we did - assemble a group of team players. At Hopkins, it was really the same idea. It was trying to create a culture where people looked at what was best for the organization, what was best for the department, and who thought about how to maximize the impact and productivity, in particular, of the research. The reason I think I was recruited there was because of my vision around how to build and maintain a research culture of success.

I had the unenviable task of following Elias Zerhouni as the chair of that department. As I was going, people essentially said, “What are you doing? There's only down to go after him”. But in fact, over the ensuing years, building on his base we doubled our research programs, we more than doubled clinical volumes, and we built a very successful outpatient imaging business that helped fund the research mission. It really was a great opportunity.

There are many things that I learned there. I learned from one of the hospital CEOs, words to something I'd been doing but a framework that helped me understand. That is, calling my leadership style “tight, loose, tight.” The “tight” part at the beginning is sitting down with a direct report, whoever it is that’s going to be doing the work, and spending the time to very tightly define why we are trying to get that work done. Why are we developing this program? Why are we moving in this direction? To make sure that the folks who are doing the work understand the “why” very clearly. And then, secondly, to work together to make sure that what needs to be done is clear; clarity is really the one of the biggest keys. The third component in that first part is to define metrics together. How are we going to know whether we succeed or fail? It’s important be very clear and work together to co-produce a set of clear metrics.

And then, assuming we’ve hired the right people, I would say okay, go do it. And the “how” it gets done is really up to that person: the Dean, the Chief Operating Officer, whatever level it is. So that's the loose part, go ahead and do it. Then when they're done, come back and sit down for the second “tight” part and say okay, where are we relative to the goals we set, and if we've succeeded, that's great. If we failed, why is it? Is it because our goals were incorrectly set? Is it because the resources weren't provided to do it right? Is it because the person who was doing it didn't have the right skill set and needed to further develop? Failure is a reason to sit down and decide what do we learn and how do we move forward from here. If every project is a success, we're not trying hard enough. We want to have some failures to be able to say we're really stretching and making a difference. That's become the way that I've looked at the world and leadership positions.

The other part is the willingness to really delegate, especially as the organizations that I've led have gotten bigger and bigger. It's become key to know how to delegate. That's another place that “tight loose tight” helps because you need to fight the initial urge to micromanage since we all get to our leadership positions because we're good managers and we know “how” we would do it. The key is to let that go, to let the person develop their own “how” and don’t micromanage. To micromanage would be impossible; I have about 35,000 employees in the health sciences right now, and if I tried to micromanage almost anything, we would grind to a halt. It's really all about getting the right people on the team, giving them the resources they need, and letting them fly.

Mukesh Jain, MD: You know, this, I think, dovetails well with where I wanted to go with the conversation, and it reminds me your comments of something that I've heard you emphasize in other venues, and some of this might have been, maybe annual addresses that you've done at Emory that are available, and I've had the pleasure of viewing. And you talk about three critical areas, strategic clarity, effective architecture, and constructive culture. You just spoke in the last little segment about clarity and culture. I want to expand on the culture because that's something that I think, as I've understood, you care very deeply about, and you have emphasized. So tell us about the importance of culture in an organization and how you've been able to impact that be at Hopkins and certainly now at Emory.

Jon Lewin, MD: Peter Drucker, a venerated business voice over many years, once said that “culture eats strategy for lunch every time,” and it's really true. Culture is probably the most important part of an organization, and it's the most difficult to change. It’s all about communications. So I started my first year at Emory sitting down thinking about one of my first addresses, and came up with three ways to crystallize what I thought were the most important parts moving forward: strategic clarity, effective architecture, and constructive culture. Every annual address I gave and every CEO forum I presented at one of our hospitals, I hit on those three things and reinforced them until I heard our teams using those same words; it became part of the lexicon.

At Emory Healthcare, creating the strategic clarity was the first step, and restructuring the organization to be effective was the second. But really, enabling a constructive culture has been the quest I've been on. It was the quest I was on at Hopkins, where I feel good about the culture that we built as an academic department, and here, it's really been even more a conscious effort to move the culture in a positive direction.

I think one of the important things about creating constructive culture is to never say that the culture wherever you are is not good, because every organization is embedded in its culture; the culture is the organization. What you have to do is look at the culture of the organization and say what are the best parts of this culture and how do we emphasize and grow those pieces? What areas do you need to introduce to continue to move the organization forward?

So, we've made real progress here, again based on the really collaborative group and very friendly culture that I inherited, but we did a few things to try to really move forward. One of them was to go headfirst into culture transformation using Lean process improvement measures. Not just the toolset of doing waste reduction through value stream analysis and other specific Lean tools, but to create a culture of inclusiveness where the employee on the front line can have an idea implemented or can identify a problem and that goes all the way up to the C suite quickly. We created daily huddles, and currently have about 1000 daily huddles across every work group, and by 9:45 am every morning any problem that has been identified that hasn’t been resolved at one of the lower levels is brought to the Tier Five Huddle in the C suite. That way we can help figure out what resources are needed at what level to solve those problems. It has created a feeling of inclusiveness, where our front-line staff know that if they come up with a good idea it's going to be listened to, and that makes a huge difference.

It comes down to creating a culture of valuing every opinion, of valuing every employee, of empathy and compassion for everyone at the organization, that helps move things forward. Creating, emphasizing, and reinforcing respect across the board. And really, to create a culture where people realize that before you make a decision about a business plan, a strategic investment, or anything else, you ask two questions: first, is it what's right for the patient and their family? Second, is it the right idea for our people? For the team? And only if the answer to those two questions is “yes”, do you say, does it make sense from a business plan perspective? Is there a margin in it? Is there a strategic imperative to get this done? Making sure that people always put those first two questions first is another piece of building, what I believe, has been a really constructive culture.

However, it's a journey, and there's still a long way to go. In particular, we have an emphasis now on diversity, equity, inclusion, and justice that we've been working on with focus. We started it my first year here, but it has really accelerated; we're doing an honest introspection as an organization and moving forward in that respect, as well. That's something that's much needed; it's been a journey that also is worthwhile, but certainly not easy.

Mukesh Jain, MD: Well, thank you, those are really fabulous remarks, and I certainly think our audience and the leaders who listened to it will benefit greatly from your experience and what you've done at Emory. I was thinking as you were speaking that you know you've, despite all the leadership experiences that you had and remarkable success that leadership skill set had to have been tested in a way that even you could not have anticipated over the past year. So we've all been dealing with pandemic, incredible challenges at a personal level, at an institutional level, at a societal level. What leadership skills did you draw on to deal with the challenges overseeing just 36,000 employees of a huge academic medical center?

Jon Lewin, MD: I think my approach in the pandemic was in large part predicated on my underlying philosophy, best stated by Winston Churchill who said, “While a pessimist sees every opportunity as a problem, an optimist sees every problem as an opportunity.” And I'm fortunate that I've always been on the glasses three-quarters full end of things. So seeing the pandemic arise and watching it very carefully and closely, and then working to mitigate the incredible challenges that it's caused in metro Atlanta and in our organization, coming to it with the optimism to say we can make a difference has made it easier. We understood that we could really make a difference as an organization, and we're going to help beat this thing.

I don't think anyone on our core leadership team had a day off in the first six months. We reorganized as most major centers did; we opened up an Incident Command Center, which in the past had been open for maybe three days at a time during a snowstorm in Atlanta - which means more than an inch and a half, and everything stops – but never intended to be a long term organizational structure. We opened up our ICC and put together a really effective and efficient infrastructure in terms of working groups with the right people in each group.

Along with five of my colleagues, our System President & Chief Operating Officer, Hospital Group President, Physician Group President, Chief Medical/Quality Officer and Chief Nurse Executive, we became what was called the Team Six, the ICC command group. We met two hours every day with just the six of us, initially, seven days a week, and in between had another three hours or so with the different working groups and broader organizational leadership. So we were spending about five hours a day together working on pandemic response. We still have eight hours of the six of us getting together per week, now five days a week, not seven. But we still sit down and work together, and I think the key to facing the challenges was, again, optimism.

A second key was resilience because when we found ourselves, as I'm sure you did as well, running out of N95 masks, what do we do? We can’t get gowns, what do we do? Unbelievable workforce challenges, and we had to have the resilience to say, okay, this is just something else we’ve got to solve. Let's sit down and do it together. What was really fascinating to watch was - we're an academic center as you are - and whenever you're dealing with faculty and the kinds of curiosity, inquisitiveness, and skepticism one has in good academics, it tends to grind things to a halt from a decision making process. Not just because you have the “thousand points of no,” of veto power in an academic matrixed organization, but oftentimes because of the truly great questions people ask, questioning decisions. What the pandemic did was to cause us to redesign our decision processes. So, something that would have taken us a year pre-pandemic, would take us two weeks. Something that would have taken us three months would take us three days, and a decision that would have taken us, three days or a week, we made in our meeting, right there. We had to develop the willingness to work with less clarity of data. These actions, together, made it a pleasure working with my team to deal with the pandemic, and I couldn't be prouder of the outcomes.

At Emory, we are fortunate for our expertise in infectious disease; it's a top-five infectious disease academic organization. During the pandemic, we have participated in almost every major trial in therapeutics, and many of the vaccine trials were either organized through or performed at Emory. We have an Emory-created oral anti-viral that's in phase three trials now being manufactured at generic factories in India, awaiting approval - an oral anti-viral that's been shown in phase two trials to markedly decrease the time of infection and shedding, which for Delta variant I think is going to be really important.

So the work has been fulfilling but it's been tiring. Dealing with both the physical exhaustion of the number of hours of meetings and work per day, and the emotional exhaustion of having, thousands of our coworkers come down with the disease. Fortunately, the number we lost was less than a handful, but each and every one of those was a punch to the gut.

Mukesh Jain, MD: Well, that’s remarkable, and you're right. We had a very similar approach to dealing with it with incident command, and it was an exhausting experience, but it was remarkable to see people come together with a singular focus. That we're working together, and that's really what I appreciate it in our communities; is how disparate parts of the organization all came round with a singular focus that we had a common challenge that we had to meet, and we all had to pitch in.

Jon Lewin, MD: Yes, it is interesting; part of the cultural work that I emphasized in coming to Emory was employee engagement. It’s something I really dug into wholeheartedly at Hopkins, in my department and in my senior vice president role there. We had our latest employee engagement survey scheduled about two months ago. I am proud that after people have been working short-staffed and worried about supplies and everything else, our employee engagement went up. I think it's actually not that surprising because we're fighting a common enemy, we have a common purpose, and we're listening to every voice at every level more quickly, more efficiently, and more effectively than we ever did before. I think the employees feel that and see that. Having said that, work-life balance scores went down. And, some of the staffing scores, “do you feel you have adequate staff,” not surprisingly went down, as well.

Mukesh Jain, MD: Well, maybe, as we start to wind down, I wanted to finish off with a broader perspective if you could share for our audience, which is healthcare. We've been through an enormous challenge. There will be great opportunities and challenges in the future. What

do you think are the biggest two or three that we as a society, as a nation, will have to deal with over the next decade, and what is your best advice to current and future healthcare leaders to help meet those challenges?

Jon Lewin, MD: Well, I think there are three major challenges both to society but also, in particular, to healthcare delivery organizations. Whether it's an academic medical center or community system, or whoever is providing care, there are three major issues that I worry about.

The first is cost. Healthcare costs too much in the United States. The issue we have is that health systems’ response to their rising internal costs of providing quality care has had to rely on negotiating with the insurance companies so that commercial insurance revenues are sufficient

to cross-subsidize Medicare, Medicaid as well as the uninsured. As an industry, we can't continually increase the burden on the commercial insurance because, ultimately, those costs fall on the employers, and the employers can't continually increase how much they're paying for their employees’ healthcare. So as a nation, I think we've got to deal with cost, and as healthcare systems, we have to get ahead of that. That is one of the reasons I put so much emphasis on Lean and waste reduction when I first got to Emory, and why we continue to invest heavily in making it a Lean culture where waste is discovered and eliminated. So, cost is the first major challenge.

The second is something where the band-aid was ripped off the wound with the pandemic, and that's workforce. We've been heading towards a workforce crisis for a number of years, and now there are even more retirements and folks just deciding that maybe healthcare isn’t for them. The pandemic has really shown the workforce challenges; certainly in the southeast, and I suspect it's not that different where you are, workforce challenges amongst nursing, respiratory therapists, radiology technologists and any highly trained member of the team, are just incredible.

And now, toward the end of the pandemic, it's even challenging to staff our call center. We continue to raise incentives and push up wages, just to staff our call center. The challenge is, again, cost; we can’t continually increase wages and not have to look towards increasing costs to society. Interestingly, the sort of remote work environment that was so successful for our COVID responses, where we went close to 100% remote for anyone who wasn't seeing a patient, created a challenge. Now we have organizations who are in high-cost markets like New York, Seattle and, the Bay Area, that are hiring our people to be remote workers at San Francisco rates and wages - people can live in Georgia, Cleveland, and other less expensive places and work wherever.

The third challenge we've seen the acceleration of disruptive business practices and disruptive business initiatives, which for legacy healthcare systems, academic healthcare systems in particular, are a major threat. When Amazon can provide the well-compensated care that that has helped subsidize both our non-compensated and poorly-reimbursed care and has helped us invest in our academic mission, what we're left with is an unsustainable business model. We have to figure out how to disrupt our own legacy business. We have to figure out how to create our own digital front doors, how we create our differential competencies to keep patients wanting to come to us and not to simply go online to a doc in a box. I think the keys to that are to remember why we went into medicine in the first place; our care is built on empathy, it's built on compassion, and the more we can ensure we and all of our physicians and other clinicians and staff keep empathy and compassion at the top of their list of competencies, the better we will be able to succeed.

Mukesh Jain, MD: Yeah. Thank you, Jon. Those were sage advice for all of us and the challenges that we will collectively face, not unique to Emory or Atlanta or Cleveland; it's really a national challenge. And it's something that leaders like yourself and leaders around the nation will have to help us overcome, so thank you for those thoughts. Any concluding remarks, this has been for me an incredibly enjoyable hour, but any final remarks, before we sign off.

Jon Lewin, MD: It's been a pleasure; I always enjoy these types of conversations. But I do have to end by saying that free advice is worth what you pay for it, so everyone should take this with a grain of salt. This is what's worked for me; it may not work for everyone. But this is a formula

that has been very successful for me over the years. I look to my education during my residency at UH as such an important foundation to my career growth and my success. The humility that I found, and the commitment of so many of our faculty and my colleagues to taking care of patients and putting our patients first; those really are the foundation of any success that I have had. So I want to thank you and thank the University Hospitals community for inviting me to come out and talk to you this fall and for asking me to make some comments today. And again, I appreciate everything that you all are doing, keeping Cleveland safe and healthy, and look forward to seeing you in the fall. Stay well everyone, and thanks for your attention.

Mukesh Jain, MD: Thank you, Dr. Lewin, and we look forward to your visit as well.