Training Healthcare Professionals: Addressing Health Disparities from the Battlefield to the City Streets and Countryside
Q&A with Jonathan Woodson, MD, MSS, FACS
Dr. Jonathan Woodson is the seventh President of the Uniformed Services University of the Health Sciences (USU). He oversees the academic, research, and leadership missions of the university, including over 2,500 students across various schools and programs, more than 15 research centers, and the Armed Forces Radiobiology Research Institute (AFRRI). Prior to this, Dr. Woodson was a Lars Anderson Professor in Management and Professor of the Practice at Boston University’s Questrom School of Business, where he established and led the Institute for Health System Innovation and Policy.
From 2010-2016, Dr. Woodson served as Assistant Secretary of Defense for Health Affairs and Director of the Tricare Management Activity in the U.S. Department of Defense, advising the Secretary of Defense on health-related issues and overseeing several key health agencies. A retired Major General in the U.S. Army Reserve, Dr. Woodson has extensive experience in military medicine, including deployments in Operation Desert Storm, Kosovo, and Operations Enduring Freedom and Iraqi Freedom. He holds degrees from the City College of New York, New York University School of Medicine, and the United States Army War College, and is board-certified in multiple medical specialties.
Martin Goldstein/Matthew Nathan: What influenced you and set you on a trajectory towards healthcare and service to the country, in the military, as a senior decision maker in the Pentagon, and now in medical education leading the nation's Uniform Services University of the Health Sciences?
Jonathan Woodson: I grew up in New York City in a family of limited means. Initially, I wanted to be a marine biologist. However, I went to a healthcare career day and said, “Boy, I wish I could do that. That's exciting.” An opportunity presented itself with a six-year B.S. M.D. program at NYU.
New York City played a crucial role because there was affirmative education in the neighborhood health centers early on at the intersection of health, medicine, and society. We talk about social determinants of health now, but back in those days, this term wasn't coined. It was about health, medicine, and society, and the interactions that either positively or negatively influenced population health. So, I was grounded in that early on.
My first mentor was an internist. I specialized in internal medicine, which gave me a great background in treating disease. When I recognized my real calling, which was in surgery, that internal medicine training made me a better surgeon.
Goldstein/Nathan: Where are we as a nation in addressing the challenges in obtaining, accessing, and achieving wellness and responsive healthcare? Are we educating healthcare providers today in the physician, nursing, and allied sciences to meet the demand and address disparities related to cost and access, especially in underserved populations?
Woodson: As I mentioned, my formative experience at neighborhood health centers was grounded at the intersection of health, medicine, and society, which was the beginning of the discussion on the social determinants of health. We need to educate health providers in that intersection, so they understand what drives outcomes. Some statistics indicate that 30% to 55% of health outcomes are based upon social determinants of health. This may translate into estimates that 30% of healthcare spending is wasted because it doesn't address those important factors, as well as redundancy in testing or the inefficiency in the system that leads to procedures and encounters that don't add value to the outcome.
We need to rethink our health system. For example, in European and other developed countries, there are social support systems that positively impact healthcare. Some of the dollars we spend on healthcare could be spent on those social support systems – the social determinants of health. We must determine how to spend our money wisely. We must spend some of the dollars upstream on prevention and eliminate excess healthcare spending that doesn't produce value. There must be a retooling of how we address economic development, educational development, access to food, and other aspects such as the environment that all influence health.
Michael Porter at Harvard derived an equation about the value of outcomes over cost. I have always believed that value includes access. We must serve the entire population to achieve better outcomes and cost savings. Currently, we are narrowly focused. We must create greater access utilizing evolving technologies for on-demand care and provide access to populations that previously did not have it.
Goldstein/Nathan: Dr. Woodson, you mentioned your formative education and neighborhood health centers leading to a better understanding of what is now called social determinants of health. How did those neighborhood health centers serve their communities? What made them effective?
Woodson: These were federally funded health centers, the first of which was in the South Bronx of New York. They were community-based health centers that provided primary care and some specialty care to indigent and immigrant populations throughout the city of New York. They were expanded in a more limited fashion throughout the nation. It was in those neighborhood health centers that all these issues came together. We saw firsthand the impact on health due to lack of access to care, poor nutrition, education, poverty, and their focus was simply on survival. All these factors impacted their health and care. Sometimes issues relating to health and disease prevention would take a backseat to mental health issues.
These neighborhood health centers were really the cauldron of social issues and their connection to healthcare. As a provider and as a student, we were confronted with someone not having childcare or facing eviction, and we worked with social workers to address those problems. So, at a very early stage, we were exposed to the complexity of delivering care in America, where the social determinants of health were prominent and consequential.
Goldstein/Nathan: As Associate Dean for Students, Diversity, and Multicultural Affairs at Boston University, you've leaned into one acknowledged problem: the lack of diverse providers who understand, treat, and empathize with people of their ethnicity. How are we doing in creating a collection of healthcare providers that represent the diversity of the population they serve? As an educator, how do you instill in someone embarking on a career in healthcare the tools and emotional awareness to address health disparities and failing social determinants of health? How does one teach empathy and care? How does one determine whether a candidate will be a compassionate healthcare provider?
Woodson: Number one, in terms of empathy, you must model those behaviors and emphasize the intersection between social determinants and outcomes with the care being provided. Case studies are important. Storytelling helps students and trainees get the message. As to the diversity of the workforce, emerging data suggests that outcomes are better when there is culturally appropriate care. We are not doing as well as we hoped. We certainly have made progress with respect to gender; now, 50% of students in medical school are female. However, we are not doing so well in terms of underrepresented minorities, particularly Black Americans. While we’ve made some progress with Black females, we're in a dismal place with Black matriculating males in medical and professional schools. That is an upstream problem with respect to the education of Black males in primary and secondary school and accession to college. That is the defining platform bottleneck that one needs to get through to get to a professional school. So, we've got a lot to do in terms of diversity of the healthcare workforce.
In meeting that need, we need to think about additional pathways that can bring folks to the profession. When I was the Assistant Secretary, working with Chip Rice, then President of Uniform Services University (USU), we created the “Enlisted to M.D. Preparatory Program.” For USU, the program has provided more diversity in the medical school because many of those enlisted who have come through the program have been minorities. The results have been magnificent, as evidenced by the graduation rates of these dedicated individuals who want to be part of military medicine. That is an example of a different way of thinking and providing a different pathway. Some minority students may develop their interest or focus later and would benefit if an alternative pathway was available to enter the profession. We've got to think differently, and we've got to create innovative pathways.
Goldstein/Nathan: Are the selection criteria the right criteria? You describe these young people who pursue a different path as having the intelligence and empathy, but the MCAT is not measuring those qualities. Are we failing to select the people who are committed and passionate about healthcare?
Woodson: That is right. We have learned a lot about the structural barriers – such as certain standardized tests – we have put into play that prevent people from successfully entering medicine, nursing, and similar fields. But that is not the only issue. We do need to address those structural barriers. However, the barrier begins much earlier. It is the lack of exposure – what is possible? I use myself as an example. Again, I was thinking about being a marine biologist. I never thought about being a doctor because I had not been exposed to medicine in my earliest experiences.
We've got to create opportunities for young people to visualize careers in medicine or in other health professions. It starts there. If you can imagine it, then it becomes a possibility. We then have to understand that some of the more traditional rigid pathways may not be the only pathways to a successful career in medicine. The Enlisted to M.D. Preparatory Program is such a pathway. We must be thinking more creatively in today's world. It's self-serving because we have some real challenges in producing the workforce that we need now and in the future. We have to look at opening the aperture in terms of recruiting and retaining people – who are currently excluded – in the field. It's a social imperative.
Goldstein/Nathan: There seems to be an explosion of disinformation in healthcare being provided through various social media outlets, and in many cases, that disinformation is being accepted. The United States Surgeon General has said that misinformation is one of the greatest threats to health in our country and possibly to security. Are there any formal or informal efforts being made to help physicians navigate disinformation and intervene in the spreading of information not based on science or experience?
Woodson: Another great challenge. Recognizing there is a lot of disinformation out there; that's the first step. We need to understand the difference between factual advice and influence. There was a study done by one of these survey groups that asked 18- to 24-year-olds what they wanted to be in the future. The number one occupation was influencer. What does that mean? Basically, it means that you're trying to get people to do something. But influence doesn’t necessarily need to be based on fact or what's best.
So, it is imperative we develop young people, and particularly young health professionals, to be critical thinkers and equip them with the tools, the skill sets, and the understanding of statistics and how information is presented, so they can have their antennas up for dis- or mis-information that is presented as factual but doesn't meet the rigorous test of being statistically relevant or accurate.
Finally, I think aligned with critical thinking is being able to ensure that the students understand the difference between opinion and politics versus what the data supports. Added to that is that students must be ready to engage in critical dialogues and discussion not based upon emotion. Right now, we engage in emotional discussions; we get into our camps; and we demonize the other side. That doesn't help with communication.
So, one of the things we're doing here is coaching students and mentoring students on how to have difficult conversations and how to discuss difficult subjects with people they may not agree with. Addressing these issues goes a long way in meeting the challenge of disinformation. It begins in the formative stage by ensuring that our students are critical thinkers equipped with the tools to assess the factual basis of any argument being put forth.
Goldstein/Nathan: Critical thinking and the ability to engage in difficult conversations are important tools for healthcare providers. As an educator, given the current cultural and political polarity, how do you ensure that students of differing ethnicity and political allegiances have the skillset to engage in difficult conversations?
Woodson: Yes, that gets back to the educational process of ensuring we don't shy away from difficult or challenging topics – we bring them to the students and then examine them. We look at what information is being presented, how it’s being presented, and how is it being supported. We then dissect it to understand the true value of what's being said.
There's a caveat that as healthcare providers, health professionals, and scientists, we must be careful when presenting new data or evidence that it is not overstated. We know in medicine and research that what we do in the laboratory does not always translate to what happens in the real world, where it affects different populations under a variety of conditions.
Coming out of the pandemic, we’ve learned about virology, how infections are transmitted, and the benefits of certain vaccines. We know that in broad populations, there will be a small number of people who will experience side effects. We know that for some, the vaccine will not be effective. Therefore, one of the things we must do when communicating with the public is to acknowledge what we don't know and what the potential downsides are, while also discussing the broad benefit of, for example, a vaccine or a drug treatment.
We cannot speak over-authoritatively about some treatment when we do not have comprehensive data on its outcomes of treatment in all cases. Sometimes over-stating the efficacy of a vaccine or drug gets us into trouble. So, we must present a balanced view. Again, for students, it's about coaching them on how to evaluate scientific information and ensuring they know how to construct arguments that support the evidence for a newly developed therapy. It's more challenging today in this digital age, but we must dedicate time and a portion of the curriculum to preparing students for the future.
Goldstein/Nathan: During the pandemic, there was guidance and healthcare polarity between people with reputable pedigrees and backgrounds. For example, the Surgeon General of Florida, a Harvard-educated physician, implemented a vaccination policy that was antithetical to CDC guidance and the views of leading national experts. The average healthcare provider observed this tennis match, trying to figure out how to treat and advise patients who may have political allegiances shaping their beliefs.
Woodson: Exactly.
Goldstein/Nathan: People are bombarded with information without the means to tell what's reliable. This can lead to confusion, fear, and uncertainty. Social media algorithms trap people in silos of like-minded information, where false claims spread unchecked. Misinformation can lead people to doubt the credibility of public health recommendations. Our political leaders take positions that are politically supportive regarding COVID vaccines, resulting in vaccine hesitancy, while 1,500 people are dying every week with only a small number of people getting vaccinated. As an educator, how do you propose to address this broad, complex problem?
Woodson: At USU, we have fully accepted that we have moved into a digital age where people obtain information over digital platforms, which can be misused. This gets into the issue of educating students in a formative way to be critical thinkers and evaluators of information. There action to be taken in the realm of policy and policing these platforms, especially those using AI, to ensure they do not reinforce misinformation. If I'm investigating a topic and the articles are negative or reinforce my intuitive way of thinking, we must not reinforce that misinformation simply because it aligns with the data that supports assumptions.
There is work to be done in terms of policy programs using AI to fact-check and flag misleading content, as well as clearly labeling AI-generated content to prevent readers from mistaking it for fact. Addressing this issue should start in grade school. We must teach users to identify AI-generated content and to evaluate its veracity. We should educate users to critically evaluate all online information regardless of the source, or they will be susceptible to reinforcement of erroneous ideas. There is work to be done in both the policy realm and the education realm, beginning in elementary school.
This is a brave new world. We are now in the fourth industrial revolution driven by data and the digitization of society. We must adjust all these information and educational systems and strategies to ensure we have a much better-informed population that can utilize these platforms correctly.
Goldstein/Nathan: You returned to public health leadership, chairing an institute in healthcare policy and innovation at Boston University. What was the genesis of that, and what did you give or take away from that role?
Woodson: After serving in government, I established the Institute for Health System Innovation and Policy at Boston University. The idea was to create an interdisciplinary institute bringing together engineers, social scientists, healthcare professionals to innovate new healthcare delivery systems that optimize various pathways to care. Early on, we recognized the opportunities presented by the fourth industrial revolution. By bringing together individuals from diverse backgrounds outside traditional medicine who approach things differently than we do, it offers great potential for improving healthcare. We approached this challenge through four main initiatives:
First, evaluating emerging health and biotechnologies for their true value in enhancing patient outcomes, experiences, access, etc.
Second, re-engineering healthcare delivery systems to effectively utilize digital technologies. The current model, rooted in twentieth century practices of paternalistic care and knowledge dissemination, needs modernization to match today’s information democratization. That is a challenge.
Third, advancing the healthcare workforce’s digital skills. Professional schools have lagged in integrating these crucial skills into their curricula, despite society’s rapid digital transformation. How can we produce the leaders that could manage this change? An entirely different set of competencies is needed.
Fourth, assessing and reforming policies and statutes to leverage technology for expanded access, improved outcomes and sustainable healthcare systems. For instance, outdated state-based licensing laws hinder telehealth’s potential to connect providers and patients across state lines, particularly benefiting rural and underserved communities.
Does that make sense to you?
Goldstein/Nathan: That change makes perfect sense. Our experience in federal healthcare, specifically the Department of Defense (DoD), which uses an electronic medical record accessible by any provider to treat a DoD patient anywhere, is an example of virtual healthcare providing global support.
The DoD provides continuity of care to veterans using telehealth, achieving outcomes comparable to those on the battlefield. How do you translate the excellence and efficiency of care on the battlefield to improving healthcare effectiveness in rural and underserved communities?
Woodson: So, the history of military medicine starts with a certain approach to treating casualties, which evolves through necessity and advancement to improve battlefield care. This experience and knowledge then migrates into the civilian sector. Major examples include advancements in blood and blood banking during World War I and II, as well as the deployment of specialty surgical teams. In the Vietnam War, helicopter evacuation and the training of Allied personnel had a profound impact, shaping civilian helicopter transport systems and EMT training.
Throughout history, there has been a continuous transfer of knowledge and experience, aiming to prevent the loss of expertise during the interwar periods and maintaining a sense of urgency and preparedness for future conflicts. This readiness ensures that we do not revert to previous starting points in times of volatility. As conditions and expectations change and evolve, we must continually advance and develop new strategies for care, advancing novel methods, to stay ahead of the curve in improving healthcare.
So, how do we leverage military advancements to benefit civilian medicine? During the interwar periods, it is crucial to form strategic partnerships with engineers, scientists, social science experts, and selected institutions and academic health centers. These collaborations are essential for enhancing proficiency, advancing disease science, and developing novel treatments. Aligning these strategic partnerships is very important in improving healthcare outcomes.
Goldstein/Nathan: You touched on the idea of addressing state licensure, especially when regulations and restrictions imposed by state laws conflict with a physician’s judgment of what is in the best interests of the patient. The current hyperpolarization contributes to that challenging environment for physicians. How do you address that conundrum confronting physicians as a senior educator?
Woodson: I was on a teleconference with several presidents of universities in the D.C. area discussing what may be occurring is a fundamental failure in how we educate young students. This failure translates into how they function later in life. The issue is this: we've got to be able to engage in dialogue on difficult subjects. The context for that dialogue is to understand that individuals have different values. The default can't be to demonize the other side because that creates barriers for dialogue, discussion and new levels of understanding. The moment the other side is demonized is the moment people stop listening. We have to emphasize and develop critical thinkers. We've got to teach and develop leaders better, with a vision of a better tomorrow, who have the skills to motivate people to work toward those common goals. We must develop leaders who can understand and help people to embrace and emphasize what is in the common good, even though we may have certain differences. Whether it is big government or small, we must create opportunities for people to succeed economically and provide a pathway for their kids to get educated and have a better future. I think that's something, no matter what your beliefs, you can rally around.
There are not enough people who are willing to take on the challenges of true leadership. They want power. They want money. But at a formative stage, we've got to educate differently to produce people who can assume those leadership positions in the future. If we don't do that, we're going to get more of the same. It's a tough job, and I don't mean to be Pollyannaish about this, but that is the issue for educators. It becomes an onerous job for senior leaders to create the environment in which we can develop those skills in our young people. How do we prepare leaders to better negotiate what is going to always be a complex and rapidly evolving set of conditions and then how do they prepare the communities they lead to engage in those discussions? The world is so partisan. It is the important job of our universities, our colleges, our high schools, and even down to the elementary school to start developing the skills that are needed for critical thinkers in an age of complexity. Issues are not simple. We must do a better job of educating and preparing our youth.
About the Authors:
Martin H. Goldstein is a 2020 Harvard ALI Senior Fellow and Senior Editor for the Social Impact Review. Martin has thirty plus years in biopharma, initially at Hoffmann-La Roche, followed by Genentech. Subsequently, as the founder and CEO of ViroLogic, Inc., a clinical laboratory guiding therapy of HIV-infected patients. More recently, he has been working with venture to build biotech companies pursuing cutting-edge science to develop therapeutics to treat disease.
Matthew Nathan, M.D., is a 2020 Harvard ALI Senior Fellow and Senior Editor for the Social Impact Review. Matt was previously the 37th Surgeon General of the Navy and most recently a Senior Vice President for a large tertiary care healthcare system.
This Q&A has been edited for length and clarity.