Reared in the remote, high desert of Northeastern Montana, received his MD from UC San Francisco in 1980, and completed Internal Medicine Residency in 1983 at Virginia Mason Medical Center in Seattle. After two years in rural private practice in the Pacific Northwest, he returned to Virginia Mason, where he practiced General Internal Medicine for 23 years. Since 2006, he has worked primarily in hospital-based medicine. He assumed a leadership role in the VM internal medicine residency in 1993, served as Program Director from 1996 to 2007, and has been Associate Director since 2007. In 2013, he relocated to Billings Montana, to assist in establishing a new internal medicine residency program at Billings Clinic From January 2002 to June 2009 he served on Residency Review Committee for Internal Medicine, appointed by the American College of Physicians. He chaired the Educational Innovation Project subcommittee of RRC-IM, a multiyear effort to change from process-based to outcomes-based accreditation and collaboratively align educational and quality of care outcomes. Since 2011, he has served on the Board of Commissioners of the Joint Commission, where he chairs the Achieving High Reliability in Healthcare Strategic Interest Workgroup, and serves on the Standards and Survey Procedures, Performance Measurement, and Governance Committees. His core professional interest is the design and implementation of clinical microsystems around the needs and preferences of patients, with education integrated in the daily work. As a member of the physician leadership team at VM, he has been a strong proponent of waste elimination, the integral role of education in quality and safety, and of relationship-based, patient-centered care. He observed the Toyota Global Production System in practice at Hitachi air conditioning, Toyota Automotive, and at Toyota supplier factories in Japan. He led and participated in several kaizen events, using lean management tools to reward clinical faculty, reduce interruptions of clinical work, eliminate extended duty hours, and integrate resident and faculty schedules.