MedicalPhysician Q&A

Finding the Joy in Medicine: A Conversation with Dr. David A. Fleming

Despite being the current President of the American College of Physicians (ACP), David A. Fleming, MD, MA, FACP thinks of himself as a “simple country doc”. The native Missourian’s roots were indeed in rural, community-based medicine, but his distinguished career has earned him impressive accolades from the academic, professional and medical arenas. Yet at the heart of his success lies a deep commitment to patient care and a respect for the human side of medicine.
Home-grown wisdom
Medicine was a family tradition for Fleming, but when SDN spoke to him at the 2014 UC Davis Pre-Health Conference (UCDPHC), he couldn’t pinpoint the exact moment he knew he wanted to be a physician. “Its hard to know exactly when it locked in that this was what I wanted to do, but I remember sitting at our dinner table on Sundays – we used to have these massive dinners at my grandma’s house – and typically there’d be all types of discussions going on, about politics, news, but my great uncle and I would be talking about heart disease. He really instilled the hunger for knowledge, the quest for knowing more. I still read his books and notes that he gave me. It stayed with me as I went through high school and college.”
After graduating from medical school at the University of Missouri, Fleming set up an internal medicine and geriatrics practice in his hometown. For almost 20 years, he “worked 12-15 hour days, 5-7 days a week, and took care of very sick patients.” Then, in 1999, he made the decision to go back into academic medicine, accepting a fellowship in biomedical ethics at Georgetown University. He returned to the University of Missouri, where he was already on faculty, and began doing bioethics work at the new institution’s recently-opened Center for Ethics.
“Eventually, I became faculty in the department of internal medicine, and moved up the ranks, if you will, becoming vice-chair and then chair of medicine about 7 years ago,” Fleming explains. “About a year and a half ago, I threw my hat in the ring for leadership of the American College of Physicians and became President this year.”
Performing three diverse roles in three diverse environments “has made life interesting,” Fleming says. “As a Chair of Medicine, my role is highly administrative. I’m in charge of the academic activities, the research, training and also the clinical activities of a faculty of about 120, and about 120 residents and fellows. As co-director of the Center for Ethics, my role is essentially to run and participate in the academic offerings that the Center has in teaching, writing, publishing and providing clinical ethics consultation for our healthcare system.”
His responsibilities for the ACP are what’s taking up the “lion’s share” of Fleming’s time at the moment, as he finds himself traveling 70% of the time to both international and national locales, representing the College. “I attend all of the committee meetings of the college, and I’m involved with policy activities. So I find myself coming and going quite a lot,” he laughs. “We have 141 chapters – about 65 domestic chapters, and soon to be 16 international chapters – so we have not only an national impact and obligations, but an international impact and obligations.” These obligations include answering the needs of ACP members who are asking about “education, lifelong learning, access to care, end of life care – these issues that are very common in the medical community. We try to explain (our policies and opinions) in a unified way, but we have a very diverse membership – about half are primary care physicians, the other half are sub-speciality providers, and each of these has diverse interests, diverse needs, and we must try and provide a unified voice. Sometimes you don’t always meet the needs of everyone, as they see it. We find ourselves at odds with some of our policy statements with our membership who have strong beliefs in one direction or another. We try and bring the discussion back to the core principles of what we are about at the ACP.” Despite these challenges, says Fleming, “the vast majority (of membership) respond, even if they disagree, thanking us for our efforts.”
The New Frontier
For obvious reasons, healthcare reform has been an integral focus of Fleming’s tenure as ACP President. “Healthcare is in a huge state of flux right now,” he states. “And there’s (reasonably so) a lot of anxiety around what is going to happen to healthcare, and how healthcare providers are going to position themselves in the care of patients in years to come.”
In Fleming’s opinion, the biggest impact of the Affordable Care Act can be seen in how healthcare is being provided: “The cost of healthcare becomes a dramatic concern, and there’s a dramatic shift in deploying means and mechanisms by which to control healthcare costs while sustaining quality in healthcare and high-value care.” This has led the AFP to start operating with a new mantra. “Our new mantra is that we must find ways to train students, residents and fellows, as well as our physicians, in how to provide high-value care while still being mindful of the tests, treatments and imaging studies we’re doing while we’re caring for the patients; while we’re trying to seek the best outcomes for these patients. Which is challenging, because physicians and other healthcare providers have been used to doing whatever they felt was needed… They were less concerned about cost, and more concerned about patient outcomes, trying to serve the patient’s needs. That’s put a lot of stress (on care providers): a lot of accountability, a lot of reporting.”
Fleming is especially concerned about the “meaningful use” process of using of electronic medical records (EMRs). “EMRs have had a huge impact on how we provide healthcare, not all of it in a positive way. Because much of what is part of being a physician now is using electronic medical records, which has added to our daily work. So what we’re trying to do right now is to guide policies regarding how EMRs are deployed, developed and utilized in a healthcare setting.”
“Finding joy in medicine is something so very, very important, and we’re trying to help our physicians by providing them support and services to do that,” he explains. “The ACP is very supportive of the Affordable Care Act, and we are very supportive of universal healthcare and what we’re pursuing in that regard. The challenge that we have is that we have millions- upwards of 30-35 million individuals, ultimately, with health insurance – many of whom who won’t have access to primary care doctors, because we have not deployed our healthcare providers and our health care teams in a way that everyone can be served fairly. And that’s something we’re trying to address right now: team care, multidisciplinary teams where everyone on the team- physicians, nurses, doctors of pharmacy, therapists, behavioral health, social workers, administrators – that is now the standard of care in many areas, in terms of not only how we do primary care, but speciality care in an integrated world- and will soon be the standard of care everywhere – and that will provide high value care that will optimize access, because we’ll have better means of contacting patients, especially those that have chronic conditions that need monitoring. We are hoping this will have the impact we think it will, as we look at the needs of primary care and speciality care in the years to come.”
Nurturing a future workforce
As an educator, physician, and leader, Fleming is uniquely poised to understand how today’s medical students can become tomorrow’s most effective doctors. “I think a problem-based curriculum is going to be increasingly important, in teaching not just the science of medicine, but how to utilize knowledge effectively to solve problems in health care. Those are curricula that really have a positive impact in how students evolve, and do well in training,” he muses. “I also think we need to incorporate more in our curriculum of high value care, utilization of sources, multidisciplinary care, disciplines training together – so that when these student graduate, its already natural that they communicate with each other effectively.”
Perhaps most importantly, though, Fleming stresses that “we don’t want to forget about humanism in healthcare.” “[We need to know] how to effectively communicate with patients; we need compassion, empathy…all of those very important bedside skills cannot get lost in this mass of technology – all of the technological, administrative, meaningful-use kinds of activities that are occurring. And that’s one of the dangers I see – we’re going to be de-emphasizing the humanism and over-emphasizing how we use our technologies meaningfully, so we can get paid and control costs. We’ve become so technologically-driven that we forget how to talk to each other- and our patients want to be able to talk to us. They still need us to pay attention, to touch them.”
Opportunities like the UC Davis Pre-Health Conference are a great start to instilling these values of connection and community. Fleming, who gave the Keynote Address on the Sunday morning of the conference weekend, encouraged pre-health students to make the most of the networking and educational opportunities UCDPHC offers. “I think that having individuals of like mind together in the same room, even if it’s a very large room, sharing a rich dialogue about the profession, is profoundly important.”
David A. Fleming, MD, MA, FACP, is the 2014-2015 President of the American College of Physicians (ACP), the nation’s largest medical specialty organization. He has served on the Ethics, Professionalism and Human Rights Committee and the Health and Public Policy Committee, and received the ACP Evergreen Award for member outreach in 2009 and the Laureate Award for outstanding service to medicine and ACP from the Missouri Chapter of ACP in 2012. Dr. Fleming earned his bachelor’s degree from the University of Missouri and his medical degree from the University of Missouri School Of Medicine. He completed his internship, residency, and chief residency training in the Department of Medicine at the University of Missouri School of Medicine, where he is currently a Professor of Medicine and serves as Chairman of the Department of Medicine and Director of the MU Center for Health Ethics. From 1999-2001, Dr. Fleming was an Associate Professor of Medicine at Georgetown University in Washington, DC while completing a two year Health and Human Services Research Fellowship in Primary Care focusing on bioethics. He is currently a member of the Boone County Medical Society, the American Medical Association, the Association of Professors of Medicine, the Southern Society of Clinical Investigators, and the Southern Medical Society. Dr. Fleming has authored and co-authored over 60 peer reviewed journal publications and book chapters, and is editor and author of the book, Care of the Dying Patient.

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Suzanne Barston is a Chicago-based writer and journalist specializing in the areas of healthcare and science.