Physician Spotlight Series: Andrew Saal, MD, MPH

Featured Physician: Andrew Saal, MD MPH
Dr. Saal is former Chief Medical Officer of Providence Community Health Centers and Clinical Assistant Professor of Medicine at the Warren Alpert Medical School of Brown University.

Award: RIMS “Dr. Charles L. Hill” Award
This honor is awarded to a RIMS member physician for leadership and service.

Dr. Saal has been honored with the Hill Award for the exceptional leadership and service he has demonstrated throughout his career and for his work redesigning primary care delivery at the Providence Community Health Centers (PCHC). As the Chief Medical Officer of PCHC for the last decade, Dr. Saal orchestrated the transformation of the health center from a safety net clinic to a patient-centered medical home. With the backing of “the most amazing team ever,” he created an advanced practice medical home with several specialties, integrated behavioral health, and population health teams to deliver high-quality primary care to all Rhode Islanders regardless of their cultural background or ability to pay. Dr. Saal is known for advocating relentlessly for his patients, developing innovative programs, and improving the work lives of colleagues and staff. In the words of his nominator, “Dr. Saal is a true model for how physicians should lead and how they should care for their patients and colleagues.”

Q&A with Dr. Saal:
Your career as a physician has focused on under-served populations, reducing barriers to health care, and building community health networks. What motivated you to focus on under-served populations and this model of health care?

It’s quite literally in my DNA. I am the son of a firefighter and a nurse. Community service and advocacy are my life philosophy. Empowering people to care for themselves is foundational. Primary healthcare (everyone in the community) is far more inclusive than the traditional concept of primary care (only treating those who can get to a clinic). There’s a lot of overlap, but one also needs to recognize how people interact with their community environment and public health resources.

I learned the importance of health care teams – especially community health workers – early in my medical education. On several occasions I worked in the mountains of Honduras with the Hombro a Hombro project. When you’re practicing medicine in a remote community with minimal public infrastructure, you realize that the village health worker has a far more sustainable impact than a doctor in a white coat. As physicians, we simply cannot parachute into a remote village, deliver some antibiotics, and then walk away. It’s far more important to teach members of the community how to help take care of their neighbors. The essential messages include ensuring safe drinking water, educating about the benefits of breastfeeding, developing systems to vaccinate children, and building resiliency within the village. Grassroots initiatives endure.

After medical school, you joined the US Indian Health Service on the Hopi Reservation in Arizona. What impact did that experience have on your career?

One realizes very quickly that the people in the village – be it the patient’s aunt, uncle, or the extended family – are the ones who can sustainably improve the health of their community. Not every condition requires a pill. The best care plans begin with access to health food, regular exercise, and housing. The role of the physician is to help out when things get complicated or break. But the foundation of health begins with extended families and social networks – the community itself.

How did you take that knowledge and apply it to the under-served populations served at the Providence Community Health Centers (PCHC)?
After working with the US Indian Health Service, I used the same primary healthcare principles in community health centers in Flagstaff, Arizona, and Burlington, Vermont – two very different places with very different populations. The key was to build grassroots networks, bring groups together, and emphasize sustainability. When I moved to Rhode Island to serve as the Chief Medical Officer of PCHC, I had to learn how to build systems of care within densely populated, highly diverse neighborhoods. No surprises – improving primary healthcare begins with asking families, church leaders, and civic activists what their communities need to succeed.

You served as Chief Medical Officer at Providence Community Health Centers (PCHC) for nearly a decade. What accomplishments are you most proud of?

Transforming the health centers from safety net clinics into patient-centered medical homes that are nationally recognized for delivering some of the highest quality care. When I arrived, most of our resources were spent putting out fires… now, the care teams are beginning to focus on fire prevention so to speak. The right people have always worked in the clinics but they didn’t have enough resources or adequate staffing. One of our first projects was to build the IBH (integrated behavioral health) teams. By embedding counselors directly within the primary care teams, we were able to bring culturally appropriate care to thousands of people to help them better manage their health. The most dangerous question in healthcare is “How do you feel today?” There is no separation of mind and body – and when you get down to it, all health is behavioral.

We also realigned and expanded the care teams to improve the patient experience as well as the clinical outcomes. With team care, it’s not just the doc in the white coat practicing medicine. It’s also a medical assistant who loves to teach and a supercharged RN who can order mammograms, A1Cs, and other preventative services with or without a patient visit. Team care improves staff morale, the patient experience, and healthcare outcomes. I believe that team care models can help reduce clinician burnout while helping provide higher quality care.

You’ve been recognized by staff at PCHC as being a true model of how physicians should lead and how they should care for their patients and colleagues. How would you describe your leadership style?

I am humbled by this nomination but also challenged. I could not have done any of this without the most amazing team I have ever known or the support of my extraordinary wife Karen and our daughters.

The Quintuple Aim of Health Reform reminds us that the healthcare system itself can inadvertently create an environment that leaves clinicians, staff, and patients feeling powerless – advocating relentlessly for resources in a system designed to limit access and cost. As physicians and leaders, we are challenged to not only help the person in front of us, but also our clinical teams, our colleagues, our communities, and ourselves. Leadership begins by showing up on the frontlines and never asking someone to do something that you yourself wouldn’t do. A little cultural humility is necessary. So is empathy, personal accountability, and respect for every member on the team. One needs to not only voice the mission, they also need to live by those principles. In the words of Dr. Paul Farmer, “Equity is the only acceptable goal.”

Most importantly, physician leaders need to recognize and own the pervasive nature of burnout at every level of the organization… all while promoting a vision that things don’t always have to be the way they are at the moment. We need to believe that we can create a health care system that delivers high quality care at a lower cost, brings satisfaction to patients and joy to health care staff, all while promoting health care equity for every member of our community. The innovative ideas and answers are right there in front of us – if we are humble enough to stop talking and listen.

Do you have a favorite quote or mantra?
At the turn of the 20th Century, Dr. Orison Marden commented “There is no medicine like hope, no incentive so great, and no tonic so powerful as expectation of something better tomorrow.”

Outside of your demanding job, what do you like to do in your spare time?
I have a small garden where I’m forever arguing with the local herd of deer. I’m trying to grow their favorite wild flowers and green leafy plants, and apparently I didn’t get the memo that they make a wonderful snack for our neighborhood herbivores. Outside of gardening, I enjoy kayaking around the estuaries of the Hundred Acre Cove and along the rivers of the East Bay.