Y-ECCO Interview corner: Florian Rieder

 

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Florian Rieder © ECCO

What was your background like?

I grew up in a small city close to Munich as the middle of three brothers and went to school there. My childhood was mostly spent on tennis and basketball courts. I am the only physician in my family. There are three professions among my relatives – lawyers, businessmen and teachers – so I’m working in something quite different. That said, my parents were always very supportive of what I do.

What inspired you to do medicine?

I was attracted to the combination of interacting with people, the science and the dexterity needed for interventions – that combination is very exciting to me. It is a job that is for a higher good and never gets boring. I enjoy spending time with something where I can improve people’s lives.

Training across Europe can vary. Where did you train and what was it like?

I went to medical school in Munich, Germany, where I worked with Professor Siegmund and Professor Endres. My education in medicine and gastroenterology started in Regensburg with Professor Rogler and Professor Schoelmerich and then I moved to the USA, where I repeated my training in medicine and GI at the Cleveland Clinic under Professor Fiocchi. I had my fair share of training! While medicine is global and universal, the approaches in different systems vary significantly. I learned a lot at every step of the way.

How did it end up being gastroenterology and IBD?

I think this happened during my PhD thesis with Britta Siegmund and Professor Endres, who at that time had a clinical practice seeing patients with complicated IBD and was running therapy studies in the lab setting. I liked the idea of being able to learn from patients and then tackle the problems with novel approaches in the lab – a set-up that I am working in now. It is stimulating to work in IBD, a disease where patients suffer but where many aspects of the pathogenesis and the mechanisms are unexplored.

Where do you get your inspiration from?

In general, I think that one can find inspiration from anybody you interact with, regardless of job, background or income level. This includes the cleaning person who comes into my office every morning and always has an upbeat comment for me, in particular when I have had a grant application rejected. It also includes the patients with the most severe IBD when I see how they manage their daily lives. It makes me feel grateful for what I can do and lucky that my family and I are healthy. Many of my colleagues have inspired me. It is impossible to give an exhaustive list, but the largest influences on my career have been Britta Siegmund and Gerhard Rogler on account of their excellence as physician scientists and leaders. Claudio Fiocchi, my longest-term supporter, is a visionary in the field of IBD and has been a really proficient career builder and mentor. I highly admire Julián Panés, Axel Dignass, Iris Dotan, Gert van Assche, Bill Sandborn and Brian Feagan, for their honest opinions and guidance and for the fields they have created. What all of these people have in common is insatiable excitement about what they do.

Florian Rieder © ECCO

How come you ended up in the USA?

I moved to the USA ten years ago and my initial intent was to return to Germany after the end of my post-doc, but one month after I arrived in the USA I met my wife, who is a surgeon at the Cleveland Clinic. I ended up staying and so had to repeat my training in the USA. We are now settled in Cleveland with two young kids.

Was it tough to go back and repeat your training?

It was quite intense, particularly as in the USA the work load is high and people work very long hours. I was also running a lab in parallel, which is unusual in the USA during training. I had to learn a new work system and function in a different language, and we had our first son during that time. I was younger when I started it and I had lots of energy, so it was no problem, but by the end I was tired. That said, I would do it again – the training in the USA is high quality and even though I was repeating items I had learned before, you always learn something new.

Where do you work? What is it like?

Now I am a staff IBD physician scientist at the Cleveland Clinic, in Cleveland, Ohio. This is one of the largest hospital systems in the USA offering highly specialised care. One day a week I see and perform endoscopy on patients with IBD (at quaternary care level) and the rest of the time I am running a translational research programme around stricturing IBD. This includes both clinical research and basic research.

What are the best and worst things about your current job?

I do not want to sound too American, but the best things are the opportunities. If you perform well you have resources that are unmatched, which includes number of patients, personnel, funding and so on. You can build your own work environment around areas of interest. On the flip side, once someone is in trouble the system does not have much memory and the safety nets are weak. Ultimately in the USA there is more room to both the top and the bottom.

Having worked in both Europe and the USA, what do you see as the biggest difference between the European and North American systems from a doctor’s perspective?

The administrative burden for physicians in the USA is lower and there is more support from ancillary staff. The environment is highly professionalised and hospitals are run like a business enterprise. The hospital is well organised and in my case protected research time is genuinely protected. Productivity metrics are used more extensively and patient satisfaction plays a bigger role. There is more accountability of performance, both good and poor. A big difference from being a clinician in Europe is the huge disparity in the US health system depending on where you work. Salaries are significantly higher in the USA and the taxes are lower, but one has to pay more out of pocket for education, health care and so on.

What kind of productivity metrics are used and how?

In our clinical unit we get monthly updates on metrics such as number of endoscopies performed, patients seen, slots filled, overbooking, revenue generated and endoscopy quality metrics. All of this gets compared to all your colleagues in the department and your interest section. Every quarter we receive patient comments, and yearly we receive trainee comments, teaching scores and patient satisfaction scores. All metrics are accessible to all colleagues in the department through an online portal. On the research side we receive monthly updates on accounting, overheads generated and administrative metrics.

Does this system help you deliver better clinical care?

In my opinion, the use of metrics means that you have fewer outliers – particularly fewer underperforming physicians, as any arising potential situation can be addressed earlier and in a focussed manner. The system is fully transparent. If handled well by leadership this can be a powerful tool, but to stay fair one has to ensure that every physician’s personal situation and practice patterns are factored in. For me personally the use of metrics doesn’t change my general approach or motivation, but for some the system may be inhibitory due to the focus on delivery and productivity to meet indicators.

Florian Rieder © ECCO

And what about from the patients’ perspective – what are the biggest differences you see there?

The insurance status is critical for patients in the USA. To name the two extremes, if patients are well insured then they can go to expert centres and get perhaps the best medical care in the world, whereas if insurance coverage is poor or missing, not even health care prevention is covered and patients get their care through emergency room visits. There is a large heterogeneity in quality of care so the disparities in access to healthcare and quality of care can be huge. The US system is built around the patient and service to the patient is emphasised. It is to some degree like retail – the customer (in this case the patient) needs to be satisfied. Reimbursement to the hospital is partly dependent on patient satisfaction. Resource utilisation in the USA is the highest in the world, but patient outcomes and life expectancy are comparable to other countries.

What could the two health systems learn from each other?

I am not a delivery of care expert, but some European health systems may benefit from implementing more patient-centred care models and wide uptake of strict quality metrics. On the other hand, in the USA it would be valuable to ensure that health insurance is provided for everyone, independent of income. A more centralised or at least centrally funded health system may be able to make more efficient use of resources, but the notion of this is not particularly popular in the USA. 

How do you balance work and private life? Does being in the USA affect how you find this balance?

My wife is a thyroid surgeon and works full time in a busy job. We have two kids aged 3.5 years and 7 months, so work–life balance is a challenge. In general the USA is a more work-based society. A greater proportion of socialising happens in connection with the workplace. Vacations are shorter, but can be negotiated. If you have research grants your flexibility is greatly enhanced. However, with both of us working we have had to build up a support system for the daily chores at home so that we can spend more time together as a family.

What do you do when you’re not working?

Before we had kids, my wife and I were travelling a lot. We love film festivals. Also, I scuba dive and used to play a lot of basketball. But since our kids came along, everything revolves around them and their interests. So, currently when I am not working you can find me in the children’s museum, the botanical garden, the natural history museum or in a swimming class or soccer practice.

How did you get involved with ECCO and what does it mean for you?

I joined ECCO at the time Y-ECCO was founded. I participated in the Y-ECCO Committee and then became Y-ECCO Chair. I organised or participated in multiple workshops as well as clinical guidelines and I established the Topical Review category for publications. Currently I am a member of SciCom. I see ECCO as a group of friends who share the common goal of improving the lives of patients with IBD. While I live in the USA now, I still join in all ECCO Meetings and I love to meet my friends and collaborators. ECCO supported my career tremendously and I want to give something back by helping junior IBD experts to succeed. I recommend every IBD interested person to join ECCO and become part of the team.

What’s next for you?

I shall support my kids growing up, enjoy family and life and continue to build our academic programme.

Please contact the ECCO Office and tweet your ideas @Y_ECCO_IBD for other people you’d like us to interview and the questions you’d like us to ask.