Forging a Path to Better Healthcare: Dr. Robert McArtor Maine's First Chief Medical Officer

We are celebrating the creative and human spirit In our many interviews today, we're interviewing Dr. Robert Mcartor, Bob who is a longtime Maine resident and also a Maine based and national leader. Really I would say in medicine and many other things. Thanks for coming in today. Thank you. Pleasure to be here. I don't even think I can say enough how thrilled I am that you are willing to come in and have this conversation, but I will say that my dad was equally thrilled because as a longtime family doctor who worked with you in the family medicine department at May Medical Center, he also looked to you as a leader and a mentor the way that I did. I happened to be a couple of decades behind my dad, but I think what dad was describing and continues to talk about is just sort of the immediate impact that you had on the department and many people around you, but then also the long lasting legacy and that's not something that everybody has the ability to claim. Did you realize that you had made such an impact in your work? I'm not sure I did. It was such a joy to be doing what I did. We saw results and we saw evolution, both of the family medicine department and the medical center and then the privilege I had of working with Maine Health, but I'm not sure I did until I reflected and I think what helped me reflect, I would meet my former colleagues or residents, faculty members, and they would tell stories about working together and what we accomplished together and I reflected and said, gee, we made a difference. But I think it was them, my former colleagues and friends helping me realize the journey we'd be on. We kind of go through with blinders on sometimes and we don't do a lot of reflection, maybe not as much as we should, but yeah, I think in the long run it was quite satisfying. Well, and even the words that you're using now, the fact that you use we that's really very telling of the approach that you always took when I was working with you, the sense that you're working with and building a team and you're working with and building a team of people that may go on and impact other teams and other patients and other practitioners in the future. And that's really important. Yeah, Very important. I remember when I made my transition from private practice, I practiced in Ohio for about 10 years, small town family medicine. I made the transition from practice into medical education and then administration where I gave up my practice. And it was a little difficult giving up, taking care of patients because I loved it, but to gain the perspective that even sort of one step removed, I was able to make a difference in patients' lives and in trainees and helping trainees to realize that some of them were leaders just waiting to happen and help them, encourage them to take those roles. So yeah, healthcare is a team sport always has been, but it's become more so and I think realizing that made it all the more important to provide opportunities for others to get into, stick their toe in the pond of leadership roles and encourage their development. And what you're describing is really interesting because I think there's a sense that if you're a physician, let's just say although physicians are just one part of the healthcare team, that by virtue of the degree that you've attained, that you are automatically a leader, which people may look to physicians to be leaders, but that one doesn't translate into the other. Just because you have earned a medical degree, it does not necessarily qualify you in any way to actually lead other people. I would say. What do you think? I agree. I agree. Physicians and many providers in healthcare and the healthcare team are really bright, dedicated people and expert in their area of healthcare delivery, but just because you have a nursing degree or a medical degree doesn't translate into being a leader. I agree with that. And Lisa, early on after I joined the Maine Health team, and by the way, I think I was the third or fourth person hired by Don McDowell, the original CEO. So I have a long institutional memory, but one of the things that we realized early on and I help our management team come to grips with was that as we began to build and think about building a healthcare system, there were a lot of key players, physicians among them, but not exclusively physicians. But I encourage the senior management team to think about putting in place a physician leadership training program to take the skills and the passion that physicians have to lead and help channel that energy into a formal program of learning skills and knowledge and to develop leadership skills. So yeah, we didn't assume two things. We didn't assume that they were automatically going to be great leaders because they were physicians or nurses or nurse practitioners, and we didn't assume that they would just emerge if we waited long enough. So we decided we needed to grow our own and we started the physician leadership training fellowship probably about 97 or 98, and it's still going. It's been around a while. You were one of the first, if not the first chief medical officer. I believe in the entire state of Maine, at least this is what I'm told. I don't think anybody predated you and being a chief medical officer, even that I think is relatively new as a role. And by relatively, I mean within the last 30, 40 years, something like that, and even that role has evolved over the last decades that it's been in existence. What does it mean to be a Chief medical officer? What does that entail? So it might help to think about a little bit about the evolution of physician leaders in hospitals, medical groups and so forth. So originally the physician leaders had titles like director of medical affairs or vice President of Medical Affairs. And most of their focus, in fact, all their focus was on the medical staff credentialing, privileging committees, monitoring quality and so forth. But it was a narrow focus on that group of players in the system or an organization in particular, the development of the main health system. I came on as initially a consultant and then was hired as the first CMO, and it became clear that one of the important tasks I could play was an expanded role since I wasn't leading a medical staff, but still was focusing on the delivery of care. It expanded the role, and I think of it as sort of having been the clinical conscience on the senior management team for Maine Health, and when we would sit and talk about making financial deals and bringing new members into the system and so forth, I would gently remind my colleagues that our core business is really clinical care and it's taking care of patients and important to put into place information systems and insurance systems. But when it comes down to the end of the day, we're doing all of that to take care of patients. So I think the role of the chief medical officer evolved because of the need to think more broadly beyond the medical staff and how we can coordinate healthcare services across a community and across, in this case, southern One of the things that I know you spent a lot of time focusing on is quality, which I'm guessing many people don't realize that we're probably assuming that we walk into a hospital on any given day that we're going to have a certain level of quality. We assume that we're going to go in, we'll have the right body part altered or removed, or the baby will be delivered correctly or we'll get primary care in the right way. But quality was not always a focus, and it is one of the reasons why I believe you thought it was so important and you wanted to spend time on it at the point in your career where that became a focus for you. Yes, and 40 years ago, quality was mentioned and it was assumed, but it was never measured in a meaningful way. It was sort of anecdotal, gee, main med is a great place. They have high quality care. How do you know? Because I say so that's no longer, it may be true, but it's no longer acceptable. Probably 30, 40 years ago, some leaders around the country, physician and medical care leaders began to think about the importance of measuring quality and looking at outcomes with data and information to compare. So when we started thinking about how are we going to do that in the main health system and include quality metrics and ensuring quality care and know that we were doing it and not just say we were doing it led to the development of focused programs to improved care of specific populations. One of our very first programs in improving quality of care was among children with asthma, and it was a real need. Maine had one of the highest rates of childhood asthma, and in order to get our arms around that, we set up some programs and tools and information for providers, for schools, for parents, for emergency rooms, and we measured outcome. And that evolved into programs for improving care of adults with heart failure and so forth, chronic pulmonary disease among others. So quality, it became important to not only measure it, but to share that information with the public and share it whether we thought our numbers were really great or not. And it gave the patients and consumers, if you will, in healthcare some information to make choices. And our goal was not only to say we were the best, but to prove we were by here's the data and we have improved care of our population of diabetics from here was the threshold we intervened, here's what we did to improve care. Now this is how they're doing, measuring their blood tests and glucose levels, et cetera. So it became a very important part of what we were doing and how we defined ourselves. In some markets, it became important as a marketing information. So our data in hospital system A is better than some other hospitals, and so you should come to us. But the real reason was to have a healthier population. Of the things that you're describing actually is this idea of health being a population-wide measure. And I think even that is a bit of an evolution. I mean, we've had public health and I know you have a master's in public health, but that more people have that now. But back when you got your master's in public health, I don't think that many physicians had gone in that direction yet, but to think about the patient as being part of a larger entity and how do we approach things from the macro level, that was a relatively new concept when you were beginning and moving through your career. It was, I developed my interest in public health when I was practicing in Ohio and seeing one patient at a time and knowing what I was doing with that patient, but not really knowing how the community as a whole was fairing health wise. And I got interested in how are we going to know that? How can we determine if we have a healthier population? Being in family medicine, thinking more broadly about those issues, I think helped me think about that. I was about 20 years into my career when I went back and got my master's in public health, which helped me a lot because one of the things that, and I'll tell you a funny story, but one of the things that helped with that kind of a background was when we were developing the health system, we said from the very beginning that we were going to focus on population health and groups of patients, not just individuals who happened to show up at the emergency room or in a physician's office. And that was important from the beginning, and it's not accident, and it wasn't just trying to find words that would shine in the public, but when we established our mission, we said our mission long-term in Maine Health is to continually improve the health of the population and the communities we serve. And we meant it. The funny story is that Don McDowell, who was the visionary, who was an originally A CEO at Maine Med and had a vision to develop a health system where we could achieve the kind of things we've been talking about. And Don was a finance guy and he worked forever in hospital systems and had never thought a lot about outside the walls of a hospital. He was very good at what he did, but when he decided to develop the health system, he called me one day and he said, Bob, there was a consultant here who is helping me think through about how do you put together a system of healthcare providers and hospitals? And he said, he made a chart and put up a chart and it said, there are five key components. One is a group of hospitals, a group of physicians, human resources, managing the folks information system finance. And then he put up a box that said health of the population. And he said, I get all the others, but what the hell is health of the population and how are we going to deal with that? And I said, Don, I think I can help you with that. So that's when I started going down and spending some time with him and which evolved into my role as the CMO. But I was one of the things that encouraged me to take a bit of a personal risk to jump from a very comfortable position as chairing the family medicine department at Main Med and moving into a new organization, which had a bit of a roadmap, but we weren't sure where it was going and weren't sure how I was going to succeed. But we knew, I knew I felt, and from conversations with Don and some other folks who were coming on board that, yeah, we really are going to care about the population we serve, and it isn't just going to be combining hospitals for the sake of improving purchasing or being more effective financially. We really want to put our resources into the population. And we did. And they have. Looking back early on, you said, have you reflected on what you've done? Looking back and thinking about how we've affected and improved the health of groups of patients and whole communities is probably one of the more satisfying things we did. And that is an interesting leap because I think when you look at least the way we used to get paid in medicine, it's less and less so now with value-based care. And it used to be that everything was, you have a patient, they come in, you charge their insurance company or you charge them. It's all fee for service. So if you look at each individual patient, then there's going to be a gain for having dealt with that patient. Population health seems a lot more amorphous. So for a finance guy to say, oh, I think we should look at this and try to understand it, I can see where there might be some concerns. You can't easily define what sort of financial gain you may get from working with a more global question. Right, Right. Yeah. And it was a risk, but Don was a courageous visionary and he said, we'll figure it out. What eventually evolved, of course, was not only individual pay for a hospital visit or an office visit, but over time, the insurers and others who support the healthcare system said, quality is important. We want our clients, our insured to have the highest quality care, and by the way, we'll build in some financial incentives, and if you can show us that you're improving care of your diabetic population or your children with asthma or whatever group it is and the population in general, we'll use those metrics to help improve and enhance your financial performance as well. So the two kind of came together over time, but it wasn't obvious 30 years ago that that's the way it was going to go, but it did evolve that way. So one thing that I haven't really talked about that much is your really pretty amazing career as an athlete, which is, I remember when I was a resident, you had run some marathons and this was, I think marathons were starting to become popular, but they weren't quite where they are now. And I vividly remember you walking upstairs backwards at one point because you had just run a marathon and your quads were bothering you. And I was like, wow, that's, here's a guy that is the head of our family medicine department. He's out running marathons. I have no idea how old he is, but you went and did that, and then you're 80 years old and you went to the world championships as a triathlete. That was a few years ago now. Yeah, A few. But did you ever consciously think to yourself, well, I'm a family medicine doctor and I'm the head of a family medicine department and eventually Maine Health, I need to model health. Did you ever consciously make that decision or did you just say, well, this is what I just need to do for myself? I think it's the latter. That's the way it started. I'd been an athlete all my life and I ran track and did that in high school and college, but I was always a sprinter. I never ran farther than 400 yards as a matter of principle. I thought it was crazy to run farther than that, but I always enjoyed running and just athletics in general, and it was part of my escape from the stress, especially when I was in practice. I would go out and run and being alone in nature and on a road by myself and all I could hear was my feet hitting the ground rhythmically. I hoped that it was for me. But as it evolved, I think people sort of said, gee, here's a guy that pays attention to his health and he's a healthcare leader. So I encouraged others to do so sometimes by intimidation, sometimes by invitation. But yeah, it became an important part of who I was and what I did, and I loved it, just loved it. I ran my first marathon when I was 54 years old. It was the first year I was at Maine Med and I had announced my wife in Ohio before we moved just one day. I said, I've made a decision. I've decided that I need to run a marathon before I die, and the corollary is I don't want to die running my first marathon, so I need a coach. So I hired a coach and someone to help me learn how to do it, and it went from there and I got interested in triathlons, A guy named Bill Dexter who was sports medicine, family medicine extraordinaire in our department at Main Med. He took care of my injuries when I was running marathons and he would say, Bob, I have several groups of athletes that I take care of, long distance runners, triathletes and others, and he said, I see you long distance runners a lot more than I see triathletes because they do more cross training and it's better and easier on their body. He encouraged me to try it, and I took a beginner's class and introduction to triathlon at the Booth Bay Harbor y, and it evolved from there. If you competed in the world championships for your age when you were 80, how long did it take you to train up to that point? I had been doing triathlons for about 10 years before I got to that point, and when I fully retired, I was able to devote more time to training. So I decided to push the limit from short distance, triathlete triathlons to medium, and then half Ironman, and I actually did one Ironman in my life, but it evolved over time. But when I retired, I had more time to train and I trained leading up to the national championships, which qualified me for the world championships. I was able to train four or five, six hours a day and loved it. Just loved it. So it was a great journey. Also, my friends would say, why are you doing that? And gee, you're doing pretty well. How does that happen? I say, well, one of the rules is you keep showing up and you keep training and doing your best. And the other thing is that sooner or later people in your age group when you're 75 or 80 are going to die off or quit and then you'll advance. But it was mostly the encouragement of family and friends that kept me going. It was very exciting time. It is true that there is a natural attrition over time, however, the people in your age group, but if they're still in your age group, they're pretty tough. They are. I mean, the people who are still doing that sort of athletic work when they're 80 years old, those are strong people, strong, determined, lots of persistence and perseverance, so I don't think you should understate that Well, it was like a brotherhood sisterhood when we got to the 75 or 80. It became a smaller group when I competed in the national championships, which led to the world championship and National Championships, made the USA age group team to compete internationally. I remember I went there not knowing what to expect. I'd never been to an event like that, and there were actually between the men and women in the 80 to 84 age group, there were 23 of us, which I was impressed with, and they were vital active people, made it extra fun being with them As we're talking, one of the things I'm really struck by is the idea that I went into medical leadership because I kept seeing people who were older than me stop practicing and I wasn't that old. And so the average age of physicians I think we're going to see over time is going to go down because it's turned out to be a career that's really not sustainable for most people over multiple decades. And somehow you created longevity with your career and I want to hope that that's not just because of when you went through, I want to hope that there is a way that we can help clinicians of any sort, physicians in particular, but also any other types of clinicians have longer careers in medicine, and maybe they're not seeing patients 32 hours a week, but maybe they're doing something with teaching or maybe they're doing something with leadership. How can we look at medicine or clinical care as more of a professional trajectory over the course of a lifetime? Really great question, and I've thought about that and saw the beginning of that when I was still working full-time with earlier and earlier retirements, and we went through the period of time when my generation of physicians were beginning to make noises about retiring early because the way healthcare had changed and evolved in a variety of complicated ways, their usual statement was, this is not what I signed up for and I can't live this way. It's impinging on what my view of my world was going to be when I went into medicine. And we went through that phase, and I think one of the ways to overcome that is to do what we were talking about earlier, and that is to actively encourage and support physicians who want to take on other roles, not only physicians, but providers of all types. We're not talking just about physicians who are getting burned out or this isn't what I signed up for. It goes to a whole raft of health professionals, nurses, and others. So we need to think about providing opportunities for them to do other things so that it isn't, it's not just for lack of a better term, the daily grind in an environment that I didn't expect to be working in. Now, I think we've passed through that generation of this isn't what I signed up for, and people going into medicine now are with their eyes wide open about it's different, it's change. What's the constant in our lives. It's change, and so we need to encourage and support them to do that. Health professionals of all types look at the shortages, people who are leaving healthcare, some of it pandemic driven, but some of it's the factors that you've talked about, And I would like to believe that we're through that. This isn't what I signed up for. I think you're largely right, most of the people now, it's not, I think when I hear that it's actually maybe people who are maybe in their sixties say, and they made it through covid and that was what they did not sign up for. They made it sort of that far, and it's like, absolutely. Did anybody sign up for covid? No. So I get that. I think what I worry a little bit about is even the younger people who are coming in and they're enthusiastic and they're passionate and they want to make a difference and they want to care for patients, I think that what we have set up currently, the model is work, work, work, work, work until you just can't do it anymore. So how do we create a financially and fiscally reasonable healthcare system that enables people to build in those other things that they may want to do? Because whenever I talk with somebody about how can we pull a leader in a medical leader away from clinical duties, what I hear is, well, how are we going to replace the revenue that they've generated on that side? I mean, that is an important question because as they always say, no margin no mission if you can't actually bring the money and you can't keep the lights on. I wish I had a really bad answer for that. I don't, but I think it's one of the things that among many challenges that leaders have now is what you're talking about. It's sort of the, I've gone as far as I want to go. I feel like I'm burning out and I'd like to do X, but how are we going to fill in? I think it becomes time. The times are providing opportunities to be creative about how we define a health provider's job and what the expectations are. I was talking with a colleague of mine who I practiced with back in Ohio in the seventies, and he wasn't complaining, but he was observing that he had just met physician who, younger physician who's a hospitalist, and the hospitalist was explaining to my friend that one of the ways they're coping is that in their group, they work seven days on, seven days off. And that kind of approach I think helps decompress some of the stress. It's easier to do with somebody, but it doesn't mean it couldn't be done in practice settings. Job sharing has been around for some time and maybe that needs to be expanded and revisited and look for opportunities on how to do that in a way that gives physicians opportunities to do other things, serve their community, volunteer, be a physician leader, whatever it is, but it's rethinking the role and embracing the opportunity to experiment and try something new. I absolutely agree with what you're saying, and I also know that there are some people who look at, I'm going to get my medical degree, it's a terminal degree. This is going to educate me for the thing I'm going to do for 50 years. Now, clearly this is not the way you looked at your career nor you, nor do I, and I actually am not sure that that's a very, given how long we now live as humans, I'm not sure that's a completely realistic way of looking at one's life. Some people will want to do medical practice for 40, 50 years and they'll be very happy doing that, and I support that. Other people will not. How do we open up this possibility of lifelong learning for people who have earned what's essentially been considered a terminal degree? How do we suggest you're not finished beyond your continuing medical education credits that are required? Maybe there are other things that you'd like to actually look into. Maybe there are other things that you can bring back into the practice of medicine to keep you feeling passionate and joyful. Yeah, again, I think it's thinking, it's looking for disruptive change. So take a currently traditional practicing provider, whoever it's, and the way they define their day and their week, and provide some opportunities and resources to modify that, to allow them time to explore other interests and encourage that and do it. We have hundreds of physicians now in the main health system who have been through physician leadership training and they've taken on other roles. These folks can be change agents and they can say, in my organization, we want to be able, whether it's a hospital or a physician group in the system, let's reallocate some resources to support broadening physician's horizons beyond the terminal degree, whether it's another degree or a leadership opportunity or organizing whatever in the health system that isn't traditional is a way to do it. And I think that health systems who might begin to look at it that way may realize that longevity of the success and the quality and the contentment of their providers, variety of disciplines may depend on how creative we can be to help them broaden their horizons. They're bright, energetic people, passionate about what they do, but we shouldn't keep them just in the box. And it's that finding resources. We did that early on in a small way when we started the physician leadership training. Every hospital was willing to put up several thousand dollars per physician to help pay for the consultants and teachers we brought in, and it paid dividends over time. The physician leadership training evolved in not too long ago, recent years to be renamed provider leadership training, and they now include nurses and advanced practitioners and others mental health workers, and that's going to help provide those opportunities across the whole spectrum of providers and care. But it's willing to take that first step and say, maybe it'll be a bump in our bottom line, but it should pay dividends. So going to ask kind of a parallel question, and it's about longevity, but this time it's about longevity as humans. I mean, during covid, we saw the life expectancy decrease, but overall we've seen the life expectancy increase. And you're clearly somebody who decided at 54 to run a marathon, and by the time you were 80, you were doing this world championship triathlete triathlon. Not everybody will want to do that. We're not suggesting anybody needs to do that. That was a personal choice that you made and we celebrate you for that. How do we help human beings? And you and I as doctors, how do we help other humans kind of come to a place where they understand that life is long and that living inside one's body is going to require some care and creativity that may evolve over time in order to maintain some sort of semblance of health? I think that there are many parts to that and many points at which you could have an intervention or provide an opportunity to help people as they live longer, live happily and more healthy. One of them is Maine Health's focus on health of the population. And if we're continue to be successful in dealing particularly with chronic illness and alleviating some of that burden, then it allows opportunities for people to do other things. And so I think the basic, I think, Lisa, is to optimize health even as our bodies age. And some of us are more fortunate than others. We control what we can, and otherwise, it's who did you choose as your parents? But you can control a lot. It's not just on the margin. You can control a lot. I think keeping focus on healthy living and dealing with illnesses we know that are going to come along, but knowing that people may have more energy and be able to do more, providing those additional opportunities. My wife and I live in a retirement community and I characterize it as a retirement community where my neighbors and friends there, and they're about 250 homes in this retirement community. It's where people came who are our age to continue living and try new things and not to choose a place to go and die. And that's an attitude. And the group that we've come in contact with are astounding. I mean, their backgrounds and interests are unbelievable. For example, we said when we move to the community and we're anticipating it moving, we said, what do people do here? What kind of interest groups do you have? And the woman who was dealing with us in buying the home we bought, pulled out a list, two page list, single typed of 30 some interest groups that exist within the