Sculpting Better Care for People in the Safety Net: A Q&A with Seiji Hayashi, M.D., M.P.H.
Since 1996, the Commonwealth Fund has offered a yearlong fellowship for physicians committed to transforming health care delivery systems for vulnerable populations, including people of color and economically disadvantaged groups. Under the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University (formerly the Mongan Commonwealth Fund Fellowship in Minority Health Policy), fellows complete academic work leading to a master of public health degree at the Harvard School of Public Health, or a master of public administration degree at the Harvard Kennedy School of Government. Fellows also participate in forums and seminars with nationally recognized leaders in health care delivery systems, minority health, and public policy. This year, the Commonwealth Fund has added a second fellowship, the Commonwealth Fund Fellowship in Minority Health Leadership at Yale University, which is open to clinicians applying to the university’s MBA for Executives (EMBA) program.
We spoke with Seiji Hayashi, M.D., M.P.H., a 2000–01 Fellow, about how the fellowship has shaped his career.
You earned an undergraduate degree in studio art as a sculptor. How did you find your way from there to medicine?
I was always interested in art, and in college I took one art class, took another, and eventually I became a studio art major. After graduation I took a year off to pursue another passion — fencing — and explore my art. I started training at fencing clubs with an Olympic coach and working to support myself. After eight months, between work and fencing, I hadn’t made any art. I remembered that one of my sculpture professors had sat me down near the end of college and said, ‘You’re a talented sculptor, but it’s obvious you have a lot of other interests. Being an artist is hard; you have to want to sleep, eat, and drink art.’ I realized I had other passions and decided to go to medical school.
How did you become interested in public health?
I was introduced to social justice issues in medical school, at the Albert Einstein College of Medicine in the Bronx, where I got involved with Physicians for Social Responsibility. I had some incredible mentors there, including H. Jack Geiger and Victor Sidel, who taught me about the interactions between poverty and health and about community-oriented primary care, which is a way of integrating primary care and public health to take care of all of a community’s needs, not just health care.
This prompted me to take a year off from medical school. I moved to a village in El Salvador to do public health work, very broadly conceived. I was building kindergartens and bridges in addition to building clinics and training community health workers.
What got you interested in applying for the Mongan Fellowship?
When I moved to the University of California, San Francisco, to pursue a residency in family and community medicine, I began to realize that the U.S. health care system was really dysfunctional. Even in the most progressive city in the nation, people had problems accessing care and affording their medications. I wanted to figure out if I could help change that, and that’s how I came across the Commonwealth Fund and the Mongan Fellowship.
While in San Francisco, I was part of a group of residents who “adopted” the neighborhood of Visitación Valley. We went to that community and combed through all the demographic and health data we could gather. Then we met with community members and said, ‘OK, it looks like teen pregnancy and violence are issues here; maybe we can help you work on them.’ And the community members said ‘No, we need jobs.’
We didn’t know anything about that. But we wound up creating a job training program for health professions like lab and EKG techs, in partnership with the City College of San Francisco. San Francisco General Hospital made a commitment that they’d hire people from our program. So this was my first experience of how community-oriented primary care could work in the U.S.
What was most valuable part of the Commonwealth Fund Fellowship to you?
I really didn’t know what to expect; I just knew that I could get further training in public health and understood I would have exposure to national thinkers and get to visit places like the National Institutes of Health and the Centers for Disease Control and Prevention. But the mentoring and leadership development parts of the program blew my mind. I never thought certain jobs were possible for me. Hearing from national leaders about how they started their careers — this opened up a world for me I didn’t even know existed.
Since your Commonwealth Fund Fellowship, you’ve worked in academia [as assistant research professor of public health and assistant clinical professor of medicine at the George Washington University Medical Center] and government [as chief medical officer for the Bureau of Primary Health Care]. In both roles, you focused on strengthening the quality of care at community health centers. What did you learn about how academic research and government policy can affect care for patients on the frontlines?
The most important thing I learned was that health care is so big and complicated that it takes everyone to make it better. My work in academia focused on implementing community-oriented primary care initiatives in the U.S. and improving the quality of care delivered to Medicaid beneficiaries. My work in government as part of the $5 billion federal community health center program brought care to 26 million underserved individuals and families.
For six years, you’ve also worked as a family physician at Mary’s Center, a Washington, D.C., community health center. Tell us about this clinic.
The vast majority of my patients are Latino, but we also see immigrants from Africa as well as other underserved families from the D.C. area. Many are uninsured, have low incomes, and/or limited English proficiency, so trying to get care for this population is incredibly difficult. Even prescribing a $5 or $10 medication is difficult — many of them can’t afford even that much. And patients have to wait months and months for specialty care. I work with a team of social workers, behavioral health clinicians, and care coordinators who can help, but it’s still very challenging. But I love it.
And for the past year and a half you’ve served as director of medicine at the Human Diagnosis Project. What’s the goal of this project?
The Human Diagnosis Project was founded in 2013 to build the first open medical intelligence system to map the steps to help any patient. Right now, thousands of physicians and students are using it for medical education and to learn from each other; clinicians are able to submit a question about a particular patient and get advice from clinicians around the world.
I know nothing about technology, but when the founders approached me I thought it was a very interesting way to help people in the safety net and elsewhere access world-class care. It’s different from e-consult and other tools first because it’s in the public domain, and also because like Wikipedia it uses crowdsourcing techniques to make sure the opinions we get are accurate, robust, and balanced. There’s also a machine-learning system running in the background that studies how diagnoses are made, and we hope that this will someday help clinicians make better care decisions.
With Commonwealth Fund support, we’re running a pilot involving nine federally qualified health centers to see how their clinicians can use the Human Dx system to collaborate on tough cases and educate their new clinicians. We’ve also started an opiate crisis line, where physicians can ask a group of experts how to treat someone struggling with opioid use disorder or how to handle prescribing for someone with chronic pain.
The next steps for Human Dx is to leverage our work for use in systemwide quality improvement. Expanding medical knowledge and improving clinical decision-making should lead to fewer medical errors and less waste — ultimately improving the value of care.