INTERVIEW SCMA President Walt Mills, MD

Born to a doctor and nurse in Texas in 1953, Dr. Walt Mills moved to the South Bay when he was 8 years old. He attended college at Notre Dame and medical school at UC San Diego, graduating in 1980. While in medical school, he spent an extra year studying medicine in India, ultimately publishing a paper in the American Journal of Psychology on the effects of meditation on pain.

Dr. Mills completed his residency in family medicine at UCLA/Santa Monica Hospital in 1983. He and his wife Elizabeth, a nurse practitioner, then traveled for two years, working at a mission hospital in Nepal and living in a meditation center in Iowa. Returning to the United States, Dr. Mills practiced at South Lake Tahoe with Tahoe Family Physicians for one year and then moved to Sonoma County.

Recruited by two Sonoma family physicians, Drs. Gary Greensweig and Jim Lowy, Dr. Mills helped start Primary Care Associates of the Redwood Empire, for which Walt and Elizabeth opened a new office in Rohnert Park in July 1986. The practice grew rapidly. Dr. Mills became a certified practitioner of Ayurvedic medicine, which attracted patients interested in alternative therapies. Primary Care Associates grew eventually to 70 providers in 14 offices serving 100,000 patients. Dr. Mills served as president and CEO when the group merged with St. Joseph Medical Foundation. In 2002, he obtained an MBA in Medical Management from USC.

In 2003, the Mills family, which by then included daughter Victoria and son Christopher, moved to Elizabeth’s home town in Massachusetts, where Dr. Mills served as a medical director for Fallon Medical Group. The family decided to return to California in 2005, and Dr. Mills joined Kaiser Santa Rosa, where he is currently an assistant chief of family medicine services. For the past few years he has also been deputy director for the Santa Rosa Family Medicine Residency. In May, Kaiser announced he will become program director of the new Kaiser Family Medicine Residency, which will open in 2014.

This interview was conducted at Kaiser Santa Rosa on May 2.

At what point did you decide to become a physician?

My mother was a nurse, and my dad was a physician, which I know influenced me. In elementary school I remember wanting to be a doctor. When I was 14, my 37-year-old mother died of breast cancer. My father was a hematologist/oncologist. I remember making a promise to my mother, somehow or another I was going to become a doctor.

Why did you decide to specialize in family medicine?

In college I learned transcendental meditation, and I wanted to integrate what I was learning about spirituality into my career in medicine. Family medicine was conceived around a biopsychosocial model and thus was a good fit. I actually was torn between internal medicine and family medicine when I was deciding on my residency, but eventually chose family medicine as it seemed to be a holistic specialty attending to the mind, body and spirit.

In medical school I had good role models--doctors who seemed to be really excited about taking care of patients and families, the whole continuum. Being there when people are born, at the end of life, and everything in between was attractive. I have always been a people person, and being a family doc taking care of patients as friends seemed like a wonderful way to aim my career.

The last piece that sealed it for me was the people I met in family medicine. They were kind, compassionate and, for the most part, idealistic and mission-driven--wanting to make a difference in the world. During my 30 years learning to be a family doc, I’ve increasingly appreciated that family medicine is my calling.

In 2009, you received the Outstanding Contribution to the Community Award from SCMA for your work with the Santa Rosa Family Medicine Residency, the Southwest Community Health Center, and the Northern California Center for Well-Being. Let’s start at the end. Could you describe how the Center for Well-Being began?

In the early 1990s, I was given a small grant by the Sisters of St. Joseph’s of Orange to look at community health. We pulled together the meditation programs that I had been developing, along with the cardiac rehab programs at NCMA and Cardiology Associates. We brought nutritionists, yoga instructors, and a variety of other instructors together to start providing health education that included attention to the mind, body and spirit.

In 1994, Dr. Jim Price, at that time the president of NCMA, Memorial Hospital leadership, and Primary Care Associates formed a new 501(c)3 nonprofit called the Northern California Center for Well-Being. We ended up contracting with all the local health plans, including Kaiser, to provide educational programs that otherwise were not getting done. I had the pleasure of serving as president until 2003, when I moved out of state. The Center has an amazing dedicated board and staff that continues, despite a small budget, to sponsor many wonderful health education programs. In fact, our residency refers many of our safety net patients there currently.

You were also recognized for your work with the Southwest Community Health Center, which was one of the first health centers in the county. Where do you think the health centers are going? Do you think they will continue to expand?

With health reform, the good news is that access to primary care services will continue to improve as we are incented to build effective “patient-centered medical homes” for all our citizens, especially the underserved, who traditionally have had their primary care done in emergency rooms. I think the health centers will cover a good portion of the people who are going to be insured with health reform. Most important, they will continue to serve a role for the uninsured. We are still going to end up with a significant number of people who, for various reasons, are not going to qualify for coverage. The only place they will have reliable access to primary care is through the community health centers.

You were honored as well for your contributions to the Sutter family medicine residency. Now Kaiser plans to establish its own family medicine residency. Could you explain how you reached that decision? What were the factors?

In 2006, Sutter was considering closing its hospital in Santa Rosa, which would have meant that the residency that has been in our community for over 60 years would have had to find a new sponsoring hospital, or close. Sutter reached out to Kaiser, Southwest Community Health Centers, and other stakeholders, including SCMA. As a result, I got involved with the residency and was asked to be the Kaiser liaison. Over time I became the deputy program director. One of the many delights to my job is that I work with Dr. Jeff Haney, who is our extremely talented program director.

 Under Dr. Haney’s leadership, the residency has had a successful turnaround and continues to be one of the most successful in the country. Last year, we had over 600 applicants for our 12 intern spots. Wonderful residents continue to train here, and many stay in our community. Last year, 10 of the 12 graduates went to local community health centers.

Given our success and the predicted shortage of primary care physicians, Kaiser, Sutter, Santa Rosa Community Health Centers and our other community partners have spent the past few years in dialog about how to ensure an adequate workforce to meet the needs of our community. Last year SCMA partnered with the Department of Public Health and came out with an elegant workforce analysis which predicted that Sonoma County will soon be critically short of primary care doctors. After much due diligence, we agreed the best model for expanding our residency training in Sonoma County was to have a new Kaiser-sponsored residency program. As an educational collaborative, we will share current didactics, curriculum, faculty, clinical rotations, and other resources. Between both programs, we will go from 12 residents per year to 18 residents per year, each spending three years in training. Thus by 2016 we will have 54 physicians in training in Sonoma County, once the new program is fully up and running.

Will the residents who come through Kaiser do the same rotations as the Sutter residents? Will they be going to the community health centers, or are they going to be restricted to Kaiser?

We are currently designing the new program so it’s not clear, but we are going to collaborate across curriculum and rotations. Likely the Kaiser residents of the future will spend some time at community health centers, and perhaps at Sutter Hospital, just as the current Sutter residents spend time at Kaiser. Our residents will spend most of their time at Kaiser because they have to have continuity with patients for training purposes. That said, it will be enriching for those residents to spend time in a wide variety of community experiences, like the mobile health van, homeless shelter, school-based clinics, and the Jewish Community Free Clinic. We want the graduates to feel comfortable practicing not only at Kaiser, but also anywhere else they might want to go around the world.

Will you continue as the deputy director of the Sutter residency?

I am going to be the program director for the Kaiser residency. Dr. Jamie Weinstein, a Kaiser faculty member, is going to become the deputy program director of the Sutter program and will work with Dr. Haney to ensure that we continue to support the current residency.

The Affordable Care Act envisions several new types of medical models, the most prominent of which is the Accountable Care Organization. What is your view of ACOs?

Regardless of what happens with the individual mandate, we are now on a path that will eventuate in the rest of the Affordable Care Act, meaning there will be patient-centered medical homes providing primary care within larger medical neighborhoods called Accountable Care Organizations. I think there is a moral and financial imperative for us to do that because we know that the quality of care is better and the cost is less in such integrated delivery systems. We know that lives are saved and there is less preventable disease when we are taking care of prevention and chronic care, and leveraging advanced technology and information systems as is intended for ACOs. For now the ACO is a good way to be thinking about how we can best meet the challenge of providing high quality, affordable health care for our community.

Are there other reforms that you think are needed beyond the Affordable Care Act? Is a public option still on the table? What about single payer?

Those are just payment methodologies and, while necessary, remain insufficient. Real health reform is about redesigning the entire delivery system, including payment models that align incentives to provide the exceptional care we are capable of in the 21st century. I am much more certain that we are going to reorganize the way we provide care. I think the payment mechanism is going to continue to change depending on economic and political forces, but eventually the competitive market forces will arrive at new payment models that will do more than bend the cost curve. We spend 16% of our gross domestic product on health care, with predictions of 20% in a few years, which is totally unsustainable. If we continue to do things as we are now, we may be out of business by the end of this decade.

Do you have any particular interest in clinical medicine?

Family medicine is great for me because I find I’m interested in a broad range of clinical medicine. During my career I’ve enjoyed delivering lots of babies, assisting at surgery, doing in-office procedures--basically the full scope of family medicine. I have an added qualification in geriatrics and am certified by the American Board of Holistic and Integrative Medicine.

Now that I’m teaching medical students and residents on a daily basis, I have a new excitement about clinical medicine, with continual discoveries of how to better provide a therapeutic alliance with patients in need. Clearly, for me it’s the people part of clinical medicine that interests me the most. I probably get a hug from most of my patients, and at the end of the day that is what it’s all about.

I would like to understand the importance that love and compassion have in being a good doctor. That is probably my keenest interest at this stage of my career--how does one be a true healing presence? Our residents and fellows have taught me a lot the past few years, the biggest learnings being around such areas of energy medicine like acupuncture, Reiki or Tai Chi. Somehow spirituality and healing are woven into my appreciation of clinical medicine as well.

Americans have many lifestyle-related chronic conditions that you probably have to deal with every day. Where does your responsibility begin and end? How involved do you think doctors should be with their patients’ lives?

I have seen studies showing the majority of illness is lifestyle related. I believe the doctor-patient relationship is a sacred and critical part of the solution to “lifestyle medicine.” The behavioral change tools and skills we have are far better then when I was trained. Motivational interviewing, shared decision making, mind-body medicine, integrated behavioral health, group visits, and other innovative care models are blossoming in our training programs and are supported by solid science.

I think as physicians, scientists, leaders and community members, our responsibility is to ensure that our systems are aligned with good health practices. For instance, we should never serve food in a school that isn’t healthy food. We should structure things so that smoking is more difficult. We should build environments so that exercise is a norm. For example, support healthy ways to get to school with paths for people to ride their bikes or walk safely.

You ask how involved should physicians be in their patients’ lives. I guess I believe we should seek that sweet spot of involved enough to make a difference. The evidence that a doctor’s caring attitude is a potent influence of a patient’s ability to change behavior is strong. It also improves actual effectiveness of a medication. When a doctor performs the “ritual” of writing (or typing in the computer) a medication order, the patient experiences a better result when the patient believes the doctor cares and is their advocate.

Is community health training something you would see implementing in the local residency program?

Yes. Our academic sponsor at UCSF is actually the Department of Family and Community Medicine. Family medicine has always included community health training as a requirement. With our partnering with Santa Rosa Community Health Centers, we’ve been able to improve on our curricular offerings for our residents. Most of our residents do community health projects. Most spend time in developing countries, where there is significant experience in community medicine. Many have master’s degrees in public health. I actually hope we start to sponsor advanced fellowships in community medicine in the next few years to better train our future physicians. Countries like Spain who have done such programs have seen dramatic improvements in their communities’ health. We hope to do the same.

Speaking of community, you are a longstanding member of the medical association, which is a community of physicians. How do you think membership has benefited you?

I think part of the fun of being a doctor is having the privilege of being with the incredible community of other physicians. SCMA is an important resource for our community of physicians. Most of us are working for different organizations, but SCMA lets us reconnect with each other and often reminds us of why we went into medicine. That has really been a theme for me for the last 26 years of being in SCMA. It’s a place where it doesn’t matter where you work. We’re bonded as colleagues. We can talk to each other, share our hopes, dreams, frustrations. I think that is just so important to feel connected to other humans, and as a physician where the stress is often such a challenge to our well-being, SCMA provides a home for us to provide one another with support. At times, when things come together, we can find joy in what we do together.

Nonetheless, SCMA and other organizations face challenges in recruiting physicians.

We have one of the highest membership rates within California medical associations, which speaks to the special way our physicians feel about SCMA. That said, we are in a very crucial time for our profession. Are we going to be led and managed by MBAs and attorneys, or are we going to be in organizations that are consistent with the physician ideals of putting the patient first? I always say, SCMA is our only significant organized physician voice for advocacy in the legislature, and for being able to address common concerns like specialty and primary care access, payment reform, public health, workforce development, and so many other worthy causes. We became physicians to make the world a little better place; we can’t do it in isolation, but need to organize ourselves. SCMA supports physicians coming together, effectively using our volunteered energies to work with our talented SCMA staff to get important things done, that otherwise would not.

Do you see any particular challenges for yourself in the next few years? What are your major goals?

Health. If I have a message this year for my fellow physicians in our community, I would want them all to be taking care of themselves, seeing their doctor, following the kind of prescriptions that we give to our patients for healthy living. Staying connected with those that you love. Make sure you stay focused on your purpose and passion.

I am blessed with my dream job right now. I get to take care of patients, teach, and help build new programs that have value. Without health, I suddenly can do none of this. My specific professional goals in this final stage of my career are simple: to help build a successful new residency program at Kaiser while supporting the continued excellence of our current Sutter residency; to further the evidence-based use of integrative, whole-person medicine; and to keep the joy alive in a medical life.

Is there any particular experience you have had in your career that summarizes what you think about medicine or about being a doctor?

I know a young man who has disabling Tourette’s syndrome. As his family doctor, I have been there for him: given him medications, taught him relaxation techniques, ensured that he was seeing all the right specialists, and doing the best evidence-based whole-person care I know. Six months ago, neurosurgeons at another Kaiser hospital implanted some deep-probe electrodes in him and turned them on, just like a pacemaker. His Tourette’s syndrome, which was basically constant--he could not even sleep without heavy dose narcotics and muscle relaxers—“went away.”

Recently he walked into my office smiling, gave me a hug, said thank you--and he had his life back. To me this represents the amazing medical possibilities of 21st century medicine. I just love “miracles.”

Do you have any closing thoughts?

In the year 2020, I want us to be able to measure and say that every single citizen in Sonoma County has access to a patient-centered medical home. I hope we have the will to get to universal access, to address the immoral social injustice that health care disparities represent. For the past four years I’ve been on Sonoma Health Action, a program founded by the County Board of Supervisors. Our goal is that by 2020 every citizen really does have access to a medical home and we are the healthiest county in California. I hope this becomes a compass for all of our physician community and that along the way we find joy in our shared medical lives.

Mr. Osborn edits Sonoma Medicine.

Email for Dr. Mills: walter.w.mills@kp.org

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