For He’s a Jolly Good Fellow

University of Utah Physician Assistant Program (UPAP) clinical associate professor, Dave Keahey, MSPH, PA-C, will be headed to Washington, D.C., in September. It was recently announced that Keahey was chosen from a highly competitive field of applicants to participate in the Robert Wood Johnson Foundation Health Policy Fellowship program. He is only the second PA selected in the program’s 40-year history.

The fully funded residential program brings up to seven fellows to Washington, D.C., each year, giving them an inside look at the health policy political process and exclusive hands-on experience working with the most influential congressional and executive offices in the nation’s capital. Launched in 1973 and funded by the Robert Wood Johnson Foundation, the program is conducted by the Institute of Medicine, which recently changed its name to the National Academy of Medicine.

Keahey, active in PAEA leadership and chair of our Government Relations and External Affairs Council, talked with us about his extensive journey to reach this point in his career.

1)  What roles and events would you say lead to this fellowship appointment?

My role as a Utah PA student in 1981–1983 set the stage for my interest in health policy. My preceptorship was split between a for-profit multi-specialty clinic two days a week and a rural Idaho community health center (CHC) for three days. The contrast between the two settings was dramatic, not only from a patient population perspective, but also from a financing perspective. The incentives in the for-profit fee for service clinic were clear: the more you do, the more the practice (and you) make, regardless of patient outcomes.

The CHC had to exist within finite budgets. Leadership and clinicians sought to wring out the highest health value possible within defined financial parameters. There was never any doubt that the interest of the patient came first and generating margins, second. In the CHC, the integrated role of multiple team players was valued and relied upon to improve population health, long before the concept of the Patient-Centered Medical Home (PCMH) gained widespread traction. The dichotomy was painfully clear to me. This experience prompted me to choose graduate school, a 25-year career in CHCs, leadership in my state PA organization, a career in PA education, and ultimately service with PAEA.

I found PAEA a welcoming outlet for my health policy interests. My selection as a member of the Government Relations Committee, and later chair of the Government Relations and External Affairs Council (GREAC), provided me with a crash course in federal advocacy. The innovative and encouraging environment that I have seen evolve in our maturing professional organization has lead to a steep and enjoyable advocacy learning curve.

2) Was there something specific that prompted you to go into PA education?

Prior to entering the Army in 1977, I was a history major at Boise State University with plans to become a professor focused on 19th and 20th century American and European history. So I guess teaching, in some form, was always in my DNA. Shortly after graduating from UPAP in 1983, Don Pedersen asked me to precept a second-year student. I found that I enjoyed clinical teaching. I am now full-time faculty and volunteer 10% of my time at the Maliheh Free Clinic. At Maliheh, I am able to care for the underserved populations I’ve focused on my whole career while precepting students — so I’m constantly teaching and learning.

My mentors have had a lasting impact on my own teaching. As Dr. Perry Klass puts it in her 2008 New England Journal of Medicine essay, The Moral of the Story, “I had a peculiar sense of multiple levels of precepting — of me standing over the intern, and my preceptor standing over me, and of the ways that your medical education comes down to you partly from people you will never meet.”

3)  What surprised you most about serving as a leader?

That progress often takes considerable time. As a clinician, I was trained to make decisions with my patients, take action, and measure our shared outcomes. Outcomes in leadership often take much longer and required a shift in my temporal orientation. This shift has helped me to avoid frustration and focus on building relationships that are mutually respectful and aimed at shared benefit. I have always found it helpful to educate myself about opposing viewpoints so that I might understand perspective and motivations. Measured patience is a virtue I have grown to value.

4)  What hadn’t you anticipated about serving in leadership?

That there are so many PA role models who would take the time and expend the effort to help me down this path. Their interest and generosity of spirit has inspired me to think beyond the confines of my own experience and consider “why not?”

5)  What were your lessons learned?

Too numerous to count! However, there are two that immediately come to mind:

  • I am a learner among learners in all things. I think that we never really arrive at a space where definitive knowledge is ours. I learn from my patients, my students, and my colleagues — virtually on a daily basis. This understanding requires action on my part that is based on a willingness and openness to be guided by humility rather than self-centered personal recognition.
  • I now realize that opportunities are often not apparent the first time around. Activities that would not have interested me, or seemed possible, just a few short years ago now have grown to become a major focus. Part of this personal evolution has included a willingness to be bold and reach for opportunities that appear — at first blush — to be beyond one’s grasp.

6) What does this fellowship mean to you and your career?

At this early stage, the meaning and implications are something of a black box — one filled with opportunities and challenges. The fellowship will afford me an unprecedented “peek behind the curtain” as to how health policy is conceived, developed, vetted, implemented, and assessed within the context of a highly politicized environment influenced by multiple invested parties. It means that I will have a unique opportunity to explore the thinking and opinions of folks whom I have admired over the past three decades through studying their published articles, policy declarations, and public work.

Before I submitted my initial application, I reviewed the writings of current and past Health Policy Fellows to get a sense of the impact this experience had on their subsequent careers. The consistent message was that the experience is “life-changing.” This change accrues through accumulated knowledge, skill development, relationship building, and understanding of the policy process that is at the core of the fellowship. And  I do not take lightly the fact that current and future members of our faculty at Utah will absorb what I do now.

7) Why is advocacy work so important?

Busy clinicians and educators often experience advocacy sporadically on the receiving end of an urgent email from PAEA beseeching them to “contact their members of Congress.” But the defining nature of advocacy is that 95% of the work occurs behind the scenes. It includes strategic planning, establishment of clear goals, and the careful development of measurable mileposts to guide progress. In short, advocacy work is about developing effective, long-term trusting relationships with stakeholders.

This requires investment of treasure and human capital by organizations such as PAEA. Fortunately, our strategic aims are wholly compatible with the health care needs of our nation. This congruency is vital, and I believe that advocacy for our profession, students, and the patients they will serve is interwoven with all we do as educators. In one sense, when we graduate highly competent and compassionate PAs, we are advancing advocacy.

We have been highly successful as educators of an effective PA workforce, and we need to claim our earned place at the tables surrounded by policy and decision makers and our health profession partners.

8) What are your goals regarding this fellowship?

My response will have to be broad as the journey is just beginning, and I’m still getting my head around being selected. I do want to demonstrate, through my words and actions, that I am an active team learner with my cohort of fellows and to honorably represent our profession. This includes acceptance of the dual responsibility to effectively represent the Robert Wood Johnson Foundation.

While serving in my legislative, executive, or agency assignment, I hope to do policy work that will advance health care in the U.S., particularly for those who experience barriers to access, and provide me with the opportunity to bring a unique PA perspective to the discussion.