The “triple aim” and beyond

May 21, 2013 —

Capital1E Pluribus Unum, “out of many, one.” These Latin words can be found inscribed in several locations in our nation’s capital, including the Capitol Building itself. Its meaning is simple: Our country is comprised of many individual states, diverse individual persons, and vastly different viewpoints; yet out of the many, we are one. One country. The United States of America. Indeed, it is a powerful statement and one that truly captures the essence of our great country. Walking outside of the U.S. Capitol Building on my way to the National Library of Congress, I took a moment to visually absorb the magnificent buildings and sun-baked landscape to further reflect on this truth. I began to think about my own winding path to becoming a physician, and all of the collective experiences that have been woven together over time, each contributing to one tangible goal and one evolving vision for the future.

The tail-end of medical school provides a perfect opportunity for students to really slow down and appreciate their accomplishments, reflect on their values and future aspirations, and prepare for the next phase of their careers. It is a time to be with family and friends, to recharge from the many months and years of hard work and personal sacrifice. As we wrap up the final chapters of our medical school years, it is important for us to make time for this process. Life is short, and while we all still have many years of training and countless opportunities that await us, we should try not to lose sight of how far we have come. We should remind ourselves frequently of the reasons we wanted to become physicians or other health professionals.  We should thank those around us who have supported our seemingly endless educational pursuits; they too have sacrificed! Completing medical school is a significant life milestone. And yet, it represents only one out of many.

Capital2As the sun began to set over the Capitol dome, I snapped a quick shot with my camera phone and headed back to the D.C. Metro. It occurred to me that like many of my colleagues who are about to graduate in a couple short weeks, I too have come full circle, and it is an extraordinary feeling. I have been fortunate in medical school at Des Moines University to have had the opportunity to pursue several unique educational experiences. From working in Geneva at the World Health Organization, to spending time rotating in Uganda, to my last two months as a health policy intern with the American Association of Colleges of Osteopathic Medicine in Washington, D.C.; each experience has complemented the next. Full circle. So what’s on the horizon?

One of the best parts about becoming a health professional is the opportunity to collaborate with colleagues on developing innovative solutions to critical health care issues facing society. Our health care system is actively transitioning from a “sickness” model to a “wellness” model that emphasizes prevention, care coordination, high quality care, accountability, affordability and cost-effectiveness. We will be increasingly expected to think about population health and patient- and community-centered care. The so-called “triple aim” of moving toward a system that provides better quality care, better health outcomes, and all at lower costs is becoming the new business model. In my opinion, health professionals need to stay engaged and actively involved in the implementation of new models of health care delivery such as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMH). Our expertise and knowledge ought to help guide, inform and facilitate these transformative changes as they unfold.

As mentioned in my last blog entry, this is indeed an exciting time to be entering the medical profession. Arguably at no other time in recent history have physicians had the opportunity to make such a significant impact on our evolving health care system. We (students and residents) will be working independently within this system soon. Let us take part in shaping health policy!

Capital3It has been nearly five years since I completed my graduate training in public health, and so many of the ideas and concepts we learned then are being actively discussed at the national and international levels today. It must be true that it often takes five to 10 years before new innovations in health care delivery and medicine are broadly accepted and generalized. Well, it’s finally happening. I could not believe my ears when I heard mention of the need to focus on the social determinants of health and community-based care, or discussion of global aging, long-term care, and the life-course approach to health. These ideas would have been dismissed as radical only a few years ago; now they are dropped routinely at high-level meetings and Congressional briefings. Furthermore, in medical education circles there is increasing attention to developing competency-based curricula, diversifying the physician workforce, and attention to interprofessional education and collaborative practice. I applaud these progressive developments and ongoing efforts— truly fantastic!

Recently, I had the pleasure of meeting one of my public health heroes at an Annual Symposium on Social Determinants of Health at Johns Hopkins University, Sir Michael Marmot. Dr. Marmot was one of the original authors of the Whitehall papers, and he is chair of the WHO Commission on Social Determinants. His work is nothing short of exemplary. After his keynote address, I introduced myself and asked him one question: “Dr. Marmot, as I begin the next phase of my training in internal medicine, what advice could you share on how to maintain my passion for the broader issues, the social determinants of health, and how to stay engaged and promote these issues to my colleagues without getting bogged down by the demands of residency?” His response could not have been more appropriate. He said to always remind yourself of the reasons you went into medicine to begin with. The rest will fall into place.

And so, colleagues, it is my personal hope that as we all don our caps and gowns, we do not forget why we signed up for this. I hope we continually remind ourselves of the changes happening all around us, and that we feel compelled to voice our opinions and offer our skills and expertise for a broader cause. I hope we think about the bigger picture and move beyond the exam room and into our communities — our GLOBAL communities. Let us work toward the triple aim and enhance our health care systems of the world. But let us not stop there; collectively we can work toward a common vision for health in the future. We are many, diverse, opinionated, multi-talented, creative individual physicians. We can harness that energy, and together make a greater impact. E Pluribus Unum – out of many, one.

Congratulations, D.O. Class of 2013 and all DMU graduates!


Roberto J. Fernandez, MPH, is a fourth-year D.O. student in the Class of 2013 at DMU. He is currently serving as an Osteopathic Health Policy Intern (OHPI) for the Government Relations Department of the American Association of Colleges of Osteopathic Medicine (AACOM) in Washington, DC. Following his upcoming graduation in May, Rob will begin training as a Resident in Internal Medicine at Genesys Hospital in Grand Blanc, MI. Ultimately Rob hopes to pursue his various interests in physician-leadership, health policy, global health, health systems research and academic medicine and is considering future specialization in hematology/oncology and palliative medicine. Contact Rob at Roberto.j.fernandez@dmu.edu.