It's great to be back and to see to what good use
this building has been put. It's wonderful to see it's being
used with all the different students in the various venues.
And it raised a question that I asked earlier to Gordon,
I said, well what did you do before this building was built?
How did the students get taken care of?
I guess that's something to think about.
But it's a pleasure to be here. I'm not here to talk at you.
I'm not here to give a lecture. I'm here to try to raise
some issues, which I hope you will find stimulating and
provoke some discussion, about issues surrounding
the big picture as it affects the nation's academic
health centers in general, and this academic health center
in particular. I've got just a few notes that
we can go on, and so forth. A couple of years ago,
I was very happy in my position as executive vice president
and Dean in San Antonio when I got a call asking me
to look at this position at the Association of Academic
Health Centers. And I must say at the time,
that I was not familiar with that organization.
And it's possible that many of you are not familiar
with it as well as. I had, of course, been
very active and familiar with the AAHC.
The person was very persuasive on the phone, and I went
and looked at the position. And I realize there was
a whole other world out there. A world that existed beyond
the of world medical schools that may be assuming a very
important role in the future. And that organization,
the Association of Academic Health Centers,
is not a discipline-specific organization.
In other words we're not representing medicine
or physicians, we're not representing nursing,
we're not representing pharmacists.
Specifically, we're representing everyone.
It's a non-disciplinary specific organization that's an
umbrella organization for all the components
of academic health centers, which we define as an accredited
degree-granting institution of higher education that
consists of a medical school. That medical school can be
either allopathic or osteopathic.
And I must say I have learned a great deal in the last couple
of years about osteopathic medicine, as they are very
active members. Plus, one or more other
health profession schools or graduate programs.
So for example, nursing, allied health, pharmacy,
dentistry, veterinarian medicine,
public health, of course, and graduate studies
in the biological sciences. And that's one more "and"
to our definition, an owned or affiliate relationship
with a teaching hospital, health system or other
organized healthcare provider. That's sort of our definition
of what an academic health center is.
A fascinating creature. One that is undergoing
a great deal of evolution. And I had the impression when
I was interviewing for this job that there was a wave out there
that was building, a wave toward integration.
An integration of academic health centers
in a very substantive way. And that this organization
could be part of that wave and help and facilitate
some of the organizational and structural changes
that are taking place amongst academic health centers.
And not only, by the way, in the United States, but I'm
learning in various places around the world as well.
So what I'd like to do is go over that with you
a little bit today. Some of my views about
these organizational issues. You know, it may not sound
very interesting to you at first, but it really is
interesting. It's kind of fascinating,
because you need to take a step back
and look at the big picture. And I try to put these pieces
together for you. I'd like your reactions
to some of the things that I'm about to tell you.
So getting back to the AAHC, we represent all the components
of academic health centers, we have a mission statement,
a vision, etc., I'm not going to bore you with that.
But let's first look at academic health centers
in the larger societal context. We're going to do a lot
of big picture stuff right now. We're all aware that there are
a lot of forces that are driving change within our academic
health center complexes. I can pick just three of them
and we can discuss them briefly. Science and technology;
demographic, socio-cultural and political trends;
and the third would be just economics.
These three categories of forces are impacting quite dramatically
now the nation's academic health centers.
Let's look at them very briefly. Science and technology
is something I don't need to dwell on for this audience,
but there clearly is exponential growth and
discovery in everything that's going on right now in
the basic mechanisms of disease, human genetics, proteomics,
information technology, new medical devices and tests.
You know, I had a very interesting discussion.
I'm part of a group called the Blue Ridge Group, which puts
together some very interesting reports every year.
And they talked about knowledge management
and medical decision-making. We had somebody come in from
Vanderbilt, who is an expert in this area and said, you know,
an average clinician can juggle about five facts simultaneously
in making a patient decision, comfortably.
And actually, if you are a really good specialist,
you can probably do up to ten-- five to ten facts.
Well right now, we suspect in the next five to ten years,
the good clinician will need to juggle about 100 facts.
And that if this curve continues of information development,
in 20, 30, 40, 50 years, there might be a 1,000 facts
that surround a clinical decision, which is beyond
the capabilities of the human mind,
far beyond the capabilities of the human mind.
What does that mean for healthcare delivery?
And what does that mean for medical decision-making?
You begin to get into these kinds of discussions,
and you realize the power of science and technology
to change drastically the way we do things and the way
things are going to happen. So that's a force that is very
powerful and is one that we're comfortable with,
because we know about science, we know about technology.
we don't know where its taking us, we don't know where it's
leading us, but we understand the basic ethos of science
and technology. But when we get into the
second area, socio-cultural and political trends,
well you know, we get a little more uneasy.
To realize that our enterprises are vastly impacted
by socio-cultural and political trends.
You could pick, just simply, the aging of the population,
population growth, issues in chronic disease,
end of life management, and a host of socio-cultural
issues and political issues that are beyond our control.
We like to be in control of things.
And these are way beyond our control.
Yet all of these factors dramatically affect
how we do our business, how we get our work done,
how we are employed, how we take care of people,
how we run our lives. And that's a huge factor.
We're undergoing tremendous demographic changes
in the United States, and around the world.
These will impact what we do. In politics, you know,
who knows? Except that healthcare,
and I'll talk about this a little bit later, is emerging
other than the war in Iraq as a lead issue in Washington.
And I want to get into a discussion with you about that.
So, socio-cultural and political stuff, very important.
Then finally, brute economics, you know we have to pay
our bills, don't we? We want to grow and expand.
And we want to grow in development.
I got a quick look at some of the buildings going up
on the campus. And my reaction was,
okay, how are they paid for? What debt have they incurred?
How will you keep these buildings open, the electricity
going, fully populated and flourishing?
Especially in an era where NIH has lost considerable
purchasing power. An NIH dollar is not worth
very much compared to what it used to be worth.
I met with Dr. Zerhouni recently, a couple of weeks ago.
We meet on a regular basis. And he said tell your folks to
be prepared for 2-3% increases for the foreseeable future,
which you know, doesn't even keep up with inflation.
So, I look at these buildings and I think okay, how does
this great university and this great academic health center
going to keep the lights on, the researchers flourishing
and everything else happening. There are three things that
happened in the last 30 years to drastically affect the economics
of academic health centers. The one is the BiDole Act.
Is everybody familiar with the BiDole Act?
Is anybody familiar with that? It passed in,
I think it was around 1980. I don't need to go into that.
It was really very seminal in allowing universities and
other entities that receive federal funding to harness
the intellectual property that they produced.
And has spawned a revolution in tech transfer amongst
the nation's universities and academic health centers.
It had a very profound impact. It opened up avenues for
licensing and commercialization that are indeed
very, very powerful. And I predict, in an era of
constrained NIH funding, it will become even more important,
as we work in the area of tech transfer
and intellectual property, intellectual property bundling,
and things of this sort. However, the real change in
1980, we're only just beginning to see the full impact of that.
Then there's something called the anti-tax movement.
When was the last time a politician got elected
who proposed tax increases? Can anybody tell me?
Does anybody have a memory of that?
There had to be somebody, or maybe that person
wasn't elected. But can you think of anyone
who was elected on a platform of tax increases?
This is one of the most interesting sociological
phenomena in the United States. For the past 30 or so years,
we've had an anti-tax movement in this country that has been
indeed profound. And it has affected so many
aspects of our public lives, in terms of the basic
infrastructure that we have: Police, fire protection,
social services, funding of universities, education.
It goes on and on and on. But we've adopted a very, very
powerful anti-tax mentality. And that has had dramatic, and
some people would say draconian, I'm not necessarily saying that,
but they've had dramatic impacts on the way we fund things
and how we look for money and resources for things
that don't necessarily make a profit.
We don't look for a fire department
or a police department to turn a profit, do we?
And then finally, I think perhaps the most significant
economic force has been the rapid growth of the market
in healthcare. You know, the times have changed
so dramatically. You know, direct advertising
to patients by drug companies is a fairly new phenomenon.
Yet, we can't escape it on television today.
In the early 1970s, under Richard Nixon, there was
an opportunity for national health reform.
Nixon believed in HMOs. He saw an opportunity.
This was opposed by organized medicine, socialized medicine.
And a very hard fought campaign was successful in not letting
that move forward. I think what happened is that
was a very short-sighted campaign.
Because instead of having socialized medicine,
a far stronger force has come into healthcare.
And that is the force of the free market
and the free market economy. And that's been very dramatic
in the last 30 years. Extremely dramatic.
And as a result, enormous wealth has been created
in the health sector, in the trillions of dollars.
And I'm not talking wealth in the hands of rich physicians
and specialists. I'm talking about wealth in
the hands of insurance companies and medical device companies,
and spin-offs, and all the things that surround
the health market. Enormous wealth.
When you think about how changing the healthcare system,
you know, somebody's got to reach into those pockets and
take some of that money away, a very, very difficult thing
to do. Even more concerning about this
has been that the market, as efficient
and effective as it is, is a very blunt instrument.
It seeks profit. And there are many aspects
of healthcare delivery that are simply not profitable.
Certainly not in the short-term. And the market tends not to move
in those directions. It tends to move
in other directions where profit can be had.
So you see for example, more and more activity
in cosmetic surgery. There's an interesting study,
and I'm probably going to misquote it, because
I don't remember exactly the facts and figures,
in a dermatology journal within the last month or so,
in which they looked at time to schedule an appointment
with a dermatologist. And I can't remember what state
it was in or what kind of national sample or local sample
it was, but they had two things. If you had a mole
that you were concerned about, it might be changing color,
you wanted to get it evaluated, the average wait time
to an appointment was 28 days or so.
But, if you wanted to get a wrinkle taken care of,
it was much less, maybe 10, 12, 14 days.
I think there's a message there. There's a message about
the market in healthcare that's very profound.
And to me that is a substantial thing we have to consider
as we look at the landscape of healthcare reform
and the forces that are impacting on our nation's
academic health centers. So if you take these together,
socio-cultural and political, the BiDole act, economic forces
and so forth, science and technology,
and there's probably a host of other things that
I haven't mentioned. These are contributing to
a fundamental remolding of what we call the academic
health center enterprise. And the remolding, in the
broadest terms, that's taking place is from an ivory tower to
a complex business enterprise. Ivory tower.
Complex business enterprise. All in a generation, or so.
Big change. Big change.
We just need to be aware of it. But unlike business
enterprises, academic health centers have missions
that must go on regardless of profitability.
We can't tell your dean that we have a little shortfall
in the budget next year, I guess we won't educate
third-year medical students. You know,
"That's a no-go folks." We have missions
we just can't discard. So the complexity of our
business enterprises are doubled or tripled
by the fact that we can't truly run them as businesses.
I had the honor of giving a talk at the business school
at the university of Texas at Austin to some MBA candidates.
And I to convince them in the course of an hour
that running an academic health center was more difficult
than any other corporation you could think of.
And of course, they laughed a little bit when I started
with that, but they all agreed with me at the end.
Where else can you not cut product lines
that are not profitable? Where else do you deal with
things like tenure? Where else do you have
the comprehensive regulatory web that engulfs us
in almost everything that we do. We are in a transition
to a very complex business enterprise that can't
be run strictly as a business. Anybody want to make
any comments or things before I get to a little bit
more specific level of stuff? Anybody have any reactions
to things that I'm saying? Am I off base,
or is some of it resonating, or comments of any kind?
I'm sure this is not a bashful group.
( inaudible ) That's a really great question.
I've evolved so much on that issue.
I've gone through so many permutations.
And I think it's a great, great question.
What is it going to take to make a fundamental change?
First of all, I don't think that the health system
is dysfunctional. I don't think that the
health system is unsustainable. I think people who tell you that
are missing the boat. Because I come from
the school of thought that says every system is perfectly
designed for the results that it gets.
Our system is perfectly designed for the results that it gets.
Bad outcomes, expensive, etc. Beautiful.
It works fine for that. I've come around to
a philosophical point on this, my philosophical point is this.
It kind of dawned on me when I was up in Canada.
And that was before I saw the Michael Moore film, Sicko.
And I don't know if anybody's had a chance to see it.
I was up in Canada, and I was attending a meeting of the
organization that's kind of the companion organization
to ours up there. There was something going on
in Quebec at the time, some bill for more private
health insurance, or whatever. And they were having a debate
over this. Speaker after speaker after
speaker came up to the podium and said we can't have this
bill because it violates the fundamental Canadian principle
of solidarity. As a people, as a country,
solidarity. We care about each other.
We want to have a safety net that's meaningful and real.
That really made an impression on me.
Then I saw the movie Sicko, which I agree with the critics.
He takes small examples and generalizes to whole
health system in France, or wherever, you know, and does
the thing in Cuba or whatever. But he makes the same point,
which is that, you know, when are the American people
going to start to care about each other.
So I've come to the conclusion that substantive healthcare
reform in this country is only possible when there's
a change in the American psyche. A change from being rugged
individualists, who, you know, pull yourself up by the boot
straps and get the job done. And if you can't do it, tough,
kind of thing, to a change where we care about each other.
Whether that's even possible. Because I think to get
substantive change requires a change in the psyche.
And I've written a little piece where I say change the psyche
before we change the system. Whether that can happen or not,
I have no idea. But there's where I'm evolved to
at this point in time. Yes?
( inaudible ) You're getting into a lot
of important issues here. Thank you for raising
that point. First of all, there's the whole
patent law situation. There was just a patent bill
that was passed recently that you might want to look at,
I think yesterday or today. We do have a dysfunctional
patent system, which impacts everything that we do in terms
of intellectual property. But the future in intellectual
property for universities, we believe now, is more in
what we call IP bundling, intellectual property bundling,
because it turns out that for many discoveries
and particularly on the road to commercialization,
there are many, many points along the way where things
have to be joined and put together.
It's not one thing, often, that is the thing.
It's this in conjunction with this,
which puts this, and this device is made
to work with that, whatever. So we put together a group to
deal with issue of IP bundling. We think that will be a powerful
change agent for academic health centers to work together, or
amongst each other in new ways to get IP bundling done,
which will help commercialization
and which will put forward, I think, a much more doable
kind of structure for reaping some of the economic rewards.
But really what we're after is just good commercialization
of our products. So it's a complicated area,
I'm not an IP lawyer. I've talked to a lot of them.
We need reform in the patent law.
But you think we need to have this idea of working together,
bundling our intellectual property, as a way to have
a substantive change in how things are going now
in tech transfer. Right now, many offices
are doing the best they can, hoping to get a hit.
It's almost like playing a roulette.
You have a lot of things coming in,
and maybe something will happen and maybe something won't.
Sometimes, the incentives for the faculty aren't
well aligned with tech transfer. You know, not just the inventor,
but the lab, the department, the school,
all should benefit. The university should benefit.
And they're waiting for a hit to come through.
We think that by bundling things together, cross fertilization,
we may have a better chance of having
a more robust operation. But yes, there's a lot
of activity in this right now. Yes?
( inaudible ) Unless a miracle happens.
Unless you have a "Gatorade," or the equivalent.
( inaudible ) I would argue that
it's necessary for us to do this, just the way that I would
argue that the necessary for us to do clinical trials.
If you look at the clinical trials operation at this
university, I would venture that it's small potatoes
in terms of revenue, compared to your overall
research budget. A fraction,
a small fraction of that. The risks are very high.
It's a very high risk area. It's a very complicated area.
Yet, I would argue that fundamentally academic
health centers need to do that. We need to be a magnet
for clinical trials. We need to be conducting them.
We need to be developing the new knowledge that comes
from it. And the same thing
with tech transfer. I think these need to be
profitable areas for us so that we can sustain them,
not necessarily make a fortune off of them.
( inaudible ) Absolutely.
( inaudible ) And we're also very weak
in the area of legal help, in this regard.
If you come up with something, that you're going to be sued
for infringement of somebody else's--
You need really deep pockets to sustain something through.
So you're right about that. Yes?
( inaudible ) I actually have--
It's in here. Can I save that for a little bit
later, because I've got some very strong feelings about that.
It's a very important trend. Yes?
( inaudible ) Correct.
( inaudible ) I think we've made a lot
of progress. I really want to congratulate
the AAHC for doing great work in this area.
You know, it's only as good as the disclosure
in the first place, as you know. Getting a system of adequate
disclosure has proven to be a challenge in many
of the academic health centers around the country.
Is it the faculty chose not to disclose, or they're not aware
they should disclose, they're not disclosing properly,
that's one thing. Then getting it into a database
or a meaningful format that can be assessed
by somebody is another thing, and then having a process
in place to actually gauge whether this is a significant
conflict of interest or not. And then if it is, how to
manage that conflict is an enormous issue
and requires a lot of resources. As we get closer and closer
to industry, which we will do because of the changing
financial economics, and the NIH budget getting flat,
we need to figure out the best ways to manage those,
and it has to begin with the idea of integrity.
And it's got to start right at the top and go right through
the entire organization. There's no substitute for that.
It's got to be clear that this is a fundamental thing
that we're going to do at every level.
But it's a big, big issue. Yes?
( inaudible ) Yes I do.
I mean, don't misinterpret me, I think the market is doing
some great things in healthcare right now.
And you want each sector to do what it does best.
I think we're out of balance right now, that's all.
( inaudible ) Absolutely.
Yes? ( inaudible )
Well, what I see happening is changing relationships
with the university. And development--
This is my mother's doctor again, hang on a second.
Nope? Good. That's the only call I take
during lectures. She's turning 90, so I've got
to deal with that. She's a standardized patient at
Jefferson Medical College in Philadelphia.
I've written about it, it's an amazing story.
But anyway, yes, I do. I think for universities
like this one, it's in establishing new
and meaningful ties with new departments,
and other departments, that have not had good relationships
with the academic health center in the past.
Departments of Sociology, Departments of Psychology,
Departments of Humanities. All these other things that
can be blended in. There's a clear trend
toward doing that. Go ahead.
( inaudible ) Well, I've learned a lot about
nursing in the last two years, let me tell you.
As I have about pharmacy, and veterinary medicine,
and dentistry, and so forth. There's a whole world out there
that I'm just learning about. And we're just completing
a major Macy's sponsored work force project, in which
we're looking at work force shortages, particularly in
the academic sector, but in the nation as well.
I'm going to be reporting on that in October.
And it's clear that no one has really looked at the impact
of a short in "X" health profession,
impact on somebody else's health profession.
So what does a shortage of nursing really mean?
What does a shortage of radiology techs really mean?
What does a shortage of neurosurgeons really mean
for everybody else? We're trying to big picture
this and to work on that work force area.
It's very exciting. But it's one that I think
also influenced greatly by globalization and the migration
of health workers around the world.
Let me jump back. This has been great, by the way.
Let me just jump back a little bit here.
What's happening with organizational models?
You have basically two prototypical
or organizational models of academic health centers.
You have the fully integrated model.
And that's a fully integrated model where there's a single
board of some kind, under which is somebody with a title,
whatever it might be, chancellor, CEO, who knows,
whatever that title is. And that person,
everybody reports to, who reports to a single board.
Hospital, clinical, health system, research, deans
everybody, comes up through this one person,
a fully integrated model. Vanderbilt would be
a good example of a fully integrated model.
Penn State is one that's thinking about,
is pretty well integrated. University of Pennsylvania has
integrated the medical school and the health system,
but not the other health profession schools,
so there's a prototypical model. The other is a splintered
or split model, where you have the dean, for example,
reporting to somebody, the Dean of Medicine reporting
directly to not a provost, but to the president
of the university. And you have the other deans
reporting to a provost, the other deans of
the health profession schools. And there are many, many
permutations of this particular splintered model
around the country. If you ask, well why do
you have the particular model that you have, you've got to
look at your history, economics and politics.
And that will explain why things are the way they are.
Now, what is happening in terms organization
to address the challenges that I mentioned earlier?
It is clear to me, and I visited at least 40 or so academic
health centers recently-- A trend toward what I would call
corporate management. And I don't mean corporate
in a pejorative sense, but in a management sense.
What are we seeing by corporate management?
We're seeing expanded roles for existing physicians, such
as a VP for health affairs. That may be a single person
called the VP for health affairs, or it may be
the VP for health affairs and the dean title, or whatever.
What people are telling me and what I'm seeing is that
the VP role is getting bigger and bigger all the time.
So much so, that in many cases there's an executive dean, or
vice dean or something like that to help run the medical school.
VPs for research with system wide responsibilities,
not just for running the compliance office
or grants management or however, that is done, but
the brain power, collaboration bringing groups together.
Creating liaisons where there weren't before.
Creations of new roles in this corporate management structure
in compliance, and so forth. I'm seeing a lot of this happen
around the country and a lot of reorganization
along what I would call non-disciplinary lines.
So the creation of centers, and institutes and other venues
for cross fertilization of disciplines,
breaking down the silos. Markedly increased efforts
to relate to stakeholders. I know there are people here
from public affairs and development.
That is a big push right now. Why?
Because people need the money, and also because it makes sense.
It makes good sense. The stakeholders
are very broadly defined, including the public,
and grateful patients and community leaders.
But the stakeholders is a long list.
Accelerating the transition of research into practice.
That is a big push. The CTSA that you've gotten,
congratulations. That's a wonderful coup
for this institution, has been an example of that.
Trying to move the continuum more towards translational
and clinical research. The gap between basic science,
our knowledge, and what we're actually putting into practice
is getting larger and larger. It's getting increasingly
intolerable. And we need to try
to close that gap. So there's a lot of effort now
in the translational and clinical areas.
Not isolated, but linked in the continuum.
Globally minded. Somebody mentioned
globalization, thank you. I've written a piece called,
"The Multinational Academic Health Center."
I am convinced that, if we're not today, we will be
multinational organizations, in the truest sense of the word.
I've been working closely with a group from Singapore,
which is a very interesting island state, an island nation.
Duke is starting a medical school there.
Some very famous researchers from the University of
California have relocated there. They want to build
an academic health center, an integrated model.
I just met with them in New York last week.
And I'm going to see them in November.
It highlights this globalized phenomenon that's taking place
in clinical care, in research and in education.
And every place that I've been to has something going on
in the international arena, although it may not be
totally well organized, it might be decentralized, etc.
But, you know, I have a vision that we're all going to be
in this together globally, and that my organization
can play a role in bringing this together.
Academic health centers are, in a sense,
apolitical organizations. They just want to do good.
We want to improve the public's health and well-being,
whether it's the United States or around the world.
Why can't we work together with our friends who operate
centers around the world to develop programs?
Mutual programs that seek to improve the public good,
whether it's in discussing the dicey issues of the
migration of medical personnel from around the world,
from country to country; whether it's issues of public
health, which are very dramatic and important; whether
it's issues of research and education.
I mean, there's so many things that we can do
in a multinational sense. I think that your point is
so well taken, that we will see our evolution into multinational
academic health centers in the very near term.
And Asia is going to be a place that we need to pay
a great deal of attention to. If the 19th century was the
European century, or whatever. If the 20th century
was the American century, everybody's saying that
the 21st century is going to be the Asian century,
You've got to pay attention. You've got to learn what's going
on and be part of it. So those are some of the things
that I see happening, and this trend toward running it
more like a business. Remember I said the evolution
from the ivory tower to a complex business enterprise.
Very, very important. It means that the faculty
and the staff have to change fundamentally
the way they view their jobs. And not necessarily
in a negative way. The sense of entitlement
that is so important to many people in academia,
needs to be understood in the context of
doing something productive, and doing something productive
that advances the strategic plan of the academic
health center that everybody's labored on.
Basically, we're in this together as an organization.
And we all have to be moving in the same direction.
It doesn't mean we can't have new ideas, we can't go out
on promising on paths of research and investigation.
But at the end of the day everybody's got to be working
together toward the same ends. This gets to the point
that I like to make, which is that we're getting to a point
in our evolution where we cannot tolerate the degree
of internal dissidence that we've had traditionally
in many academic health centers, internal dissidence, friction
between the medical school and the teaching hospital,
friction between departments, friction between this
and friction between that, and whatever.
That's a problem for us now, because it consumes a lot of
time, a lot of emotional energy, and eats up a lot of resources,
and you don't get anything done. And I'm convinced that
those places that minimize internal dissidence
through reorganization and corporate management or
other good things, integration, are going to be the places
that clearly advance and move ahead.
Those that fall prey to the quagmire of internal dissidence
in whatever way it develops, are going to have trouble
staying where they are today. They're not going to be able
to maintain even the status quo. I think you all know what I mean
when I talk about that. So we're going to see
a continuing horizontalization of the academic health center
enterprise throughout all its mission and management areas.
We're going to see a process of accelerated change.
This is good, because I think the process of accelerated
change enables you to make the tough decisions quickly.
That will facilitate resource allocation.
If you're stymied by a rigid structure, as many places are,
you're going to figure out a creative way to get around it.
So I've been working with a couple of places that have
intolerable situations between their hospital and
their school, or their schools. It's tough because the hospital
has a separate board, maybe not unlike here,
and you need legislation to get around it, etc.,
so they're coming up with ideas, creative solutions because
they're working together. Creative solutions, maybe
a bridge board can be developed. Maybe a new position can be
created that will oversee some of these things.
People are trying to do what they can to get around rigid
structures that are preventing progress and presenting people
from moving ahead. Yes?
( inaudible ) Great point.
I saw this yesterday in Chicago. I won't tell you which
institutions I was visiting, but I visited a whole bunch.
You know, it brings to point-- There's two things going on in
all these relationships between the academic health center
and the university or the hospital there.
You've got structure, and you've got personality.
Structure and personality. Okay?
Is the structure in such a way that it's impossible
to get things done? And if it is, you've got to
change that structure somehow, and be creative to do it.
But even more importantly, are the personalities such
that the job cannot be done? Because there are often people
in leadership positions who don't have the personality
that's integrative and collaborative
in seeing the big picture. And it doesn't matter what the
structure is, it doesn't matter what the org chart shows, you've
got to have the personalities that work together.
In every hire that comes up, if I were sitting on a board
or a search committee, or whatever, looking for
somebody in an important leadership position,
the main thing I would look for, maybe personality isn't the
right word, but I would look for someone who's got the skill
of working with other people, and is not totally focused
on advancing their own career, but are looking at
the big picture for the organization as a whole
and willing to work with people and to develop new relationships
and that float new ideas, and to bask in the reflected glow
of other people around them, rather than being themselves.
Do you see what I mean? So yes, this is a big issue.
The thing that causes almost the maximum amount
of casualties in leadership positions that I've been in,
I've noticed in the last couple of years,
has been friction between-- personality clashes,
essentially. Friction between a leader here
and the leader right above that person, whether
it's a university president or somebody else,
whoever that might be. The compatibility there
is absolutely crucial for getting the job done.
Now some places have put into place, have a university
president that puts into place, a structural format
that protects the president from problems that might occur
in a health center, because it's such a high risk,
high profile, high economic driver.
And therefore, will delegate a good amount of authority,
not to a provost-- A provost generally comes
from the humanities. And they're brilliant provosts
around the country in history and whatever, but they don't
know much about how to run an academic health center,
what it means, what it's all about.
So they will delegate that to another person
who has that responsibility. And that person could have
the title of vice chancellor for health affairs, or whatever.
Some university presidents don't want to do that, because
they don't like having two reports.
And they think they're taking something away from the provost
and doing something bad with the university.
But in my experience, I was involved on a blue ribbon panel,
in a very high profile investigation,
involving a failure of a major transplant program at
an institution in the country. It was the kind of program
that just went belly up with a lot of bad publicity.
And all kinds of bad things happened.
We went out to investigate it. And what we saw was not that
anybody was doing a bad job, or criminal, or anything like that.
What was happening was that everybody in their own
narrow sphere was trying to do the best they could, and felt
that if you gave them another couple weeks or months,
they could fix the problem. So whether it was
transplant director, the hospital director, the dean,
it didn't really matter. They all were trying
to do their job. What was missing was that there
was nobody between the president and the academic health center
to point that out to anybody. And the president certainly
didn't have the time and the inclination
to be able to do that. We recommended putting somebody
in that particular position. So I'm a big advocate
of empowerment at the university level of someone to oversee
the complex enterprise of the academic health center
in a sophisticated way and in a way that harmonizes
what goes on with the university.
That's not a message that everybody likes to hear.
There are many people who feel that's not the way to go,
because it's not good for the university, etc.
That's my position right now. But you're right about that
being an important point of departure.
There are many, many examples of that.
But I think your point is exceedingly well taken.
Thank you. So in the end, I would posit
that those institutions that are more effective in integration,
or more effectively able to integrate their components,
will be the ones that will be successful.
Those that are unable to do so are stymied by either
rigid bureaucratic structures, or personality things,
or whatever, are going to struggle
to maintain the status quo. There will be an increasing gap
between the two kinds of institutions.
I was going to conclude with a couple of comments about
healthcare reform and what's coming up on the horizon
in Washington, and maybe a little bit
about the association, but I get the sense maybe
I've gone on too long. Do you think I have?
Before I move on to that, if you have the time
and patience, would anyone like to comment
about some of the thoughts up to this point, about
organization and management and things of that sort?
Yes? ( inaudible )
Correct. ( inaudible )
That's a very insightful comment.
Could everyone hear what he had to say?
That was extremely insightful. I thank you for bringing it up.
I think it's a leadership issue. I think it's a leadership issue
that is emulated from the very top.
I think it has to do with transparency of management,
and transparency of management decisions
and sharing of information. One thing I've learned about
academics throughout my career is that if you give academics
information, they will pay attention to it.
And if you give them feedback they will understand
that feedback. If you tell them why
you made a decision, whether they agreed with it or not,
and were willing to tell them, that's good.
That's transparency. So I think to develop this kind
of change, cultural change, it's a change
that starts at the top with transparency at all levels
and the sharing of information and data.
But it's a long row to hoe. ( inaudible )
Yes. No, no, I mean--
Tenure, you mention that word and you get a room
full of people very quickly. It's an interesting historical
perspective on tenure, if you read about it.
I believe it started with the church many centuries ago.
And I mean, it's a whole interesting thing.
Basically, there is a cultural difference between being part of
an academic health center and being part of a university
in say the department of English or Psychology,
or one of the other departments. There is a difference.
The fundamental difference is in how the economics works
and what the expectations are. Bridging that
is very, very difficult. I think that, again, I would
posit that discussions with the leadership of the Senate would
be a very worthwhile thing to have, to try to achieve
some level of understanding. You know, often Senates,
especially universities view the administration
as the dark side. You've crossed over the line.
You're the enemy. You're the evil, or whatever,
because they have a lot of false ideas and misunderstandings
about what it is that administration does, and
what their responsibilities are, and how complex and difficult
their jobs are. Trying to demystify
academic administration for the Senate
and for the faculty in general would be a wonderful thing
to try to do. One thing I always would have
liked to have seen is for universities
and academic health centers, in particular,
to develop leadership programs, where they train the next cadre
of academic leaders through whatever kind of program they
might set up and put together. I know Emory has tried
something in that regard, to demystify this whole thing,
because academic administration is exceedingly important.
It's not the evil part of the university.
It's something that can make things happen and make things
happen for the better. But it's a very difficult job.
And I think communicating that to the Senate and the faculty
on a regular basis is important and then engaging them to come
over and try it a little bit and see what it's like.
It would be a good idea. ( inaudible )
The answer is yes. I'm saving that for tomorrow.
( inaudible ) Is that okay?
( laughter ) ( inaudible )
Let me refine that a little bit. What the market does really well
in healthcare is it responds to what people want
and can pay for. That's what the market does.
As opposed to what people need. You know, there's
a big difference between want and need.
Market driven responds to want. You want to get something
and you have the money to pay for it,
you're going to get it. But you need a whole bunch
of other things that you may not want
or can't afford. In that case, that's where
the market falls down. So that dichotomy
is very important. But I think both of them
have a role to play in an overall healthcare system.
I think the want is an important component,
the need is more important. How are we doing time wise?
( inaudible ) Okay.
( inaudible ) I think that when you
think about it, as economics gets tighter, as the NIH
budget is level or declining, it gets more and more attractive
to take money from industry. My view is that
that money never comes with strings unattached.
There's something attached. It may be nearly invisible, but
it comes with strings attached. It doesn't mean in my view
that you should never take it, but it means that you need
understand those strings, and what they mean,
and whether they fit in with the overall guidelines of the
university and the academic health center.
I think you need to have-- It's a cultural thing
for each place to decide what level of comfort they have
with those kinds of relationships.
And, more importantly, how do you manage
those relationships. Do you have a clear plan
of managing those relationships? What does that mean?
It means that there are guidelines that people have to
follow in regards to these kinds of gifts, donations,
whatever you want to call it. And they have to be based
on some intellectualizing of some kind, so that
there's a rational for it. I can understand why
some places said, you know, we can't come up with
an intellectual rationalization for this,
and we're not going to do it. And I respect that.
I think other places can say we can come up with
a rationalization, and this is what it is,
and we can change it as needed.
But we're going to put this into place and follow it.
But inevitably, we're going to drift closer and closer
to industry, because of, not just the economics are going
to demand it, but the world of science and technology
is going to demand it. And to get certain things done,
you're going to need to have these kinds of relationships
So I think you need to decide where this place culturally
wants to fit on that continuum, and then to figure out a program
that successfully can manage those kinds of relationships.
But I don't think there's a black or white answer.
I respect places that take one extreme.
But every place has to have their own comfort zone for that,
but it's got to be clear and manageable.
( inaudible ) Yeah, well that's a big issue.
We cannot be separated from the community
in which we're embedded. And we should not
be separated from it. Community can be defined
as a very narrow radius around an academic health center,
or it can be a huge region, or whatever.
Whatever it happens to be. But we cannot be separated.
And we never should be separated from the community
that we're embedded. We are too much of an important
driver of the community's health and well-being.
Not only are we an essential economic engine
of the community, a vital economic engine
to this community, look at the jobs,
look at the payroll, look at all the stuff
that spins off from that. But in terms of the health
and well-being of the community, the public's health
and well-being, the education of the next generation
of health providers, the generation of new ideas
and so forth, and so on. It's all for our community
of some kind or another. If we lose sight of that,
we lose the public's trust, And we go down the tubes.
So we cannot be separated from our communities,
however you define them. And we must always operate
on a plane of public trust. And that public trust
can only be gotten through working with our communities
and acknowledging that they're an important part
of what we are and what we want to become.
Never, ever separate ourselves from that.
( inaudible ) I mean, there's a lot of debate
about that point. First of all, a lot
of academic health centers took the lead in developing
different tracks for tenure. I don't know if there's
a different tenure track system here, but there's been a
lot of experimentation in that. The real debate in tenure,
as I understand it-- I'm not an expert in this--
Is the relationship between tenure and salary,
more so than criteria for getting tenure, is what is
the nature of the link between tenure and salary.
And that's a highly complicated, and maybe highly variable
phenomenon from place to place. I don't want to get into
that discussion. But that seems to me the level
where it's really important, is how that is pursued.
Maybe it would be a good time to concluded with a few remarks.
You've been great. I was just going to mention
a few things. I think we all agree
that healthcare will have a much higher profile in 2008,
as we go into 2008. And there will be a lot
of debates over the uninsured and the future of
employer-based health insurance. We'll hear a lot
of pay for performance, and things like that.
I'm glad I'm not talking about pay for performance today.
I've got some views on that. The whole issue of projected
health worker shortages are going to become very,
very prominent. There will be a lot of debates
over what we mean by a nation, should we be self-sufficient
in the production of our healthcare work force,
a lot to say about that issue. We talked a little bit
about the role of the market versus regulation.
I have an opinion about the growing role of the states
in healthcare reform. As you know, a number of states
have taken some highly visible steps to change
their health system. I think they're all commendable.
Massachusetts, California, and so forth.
But you know, I don't see great things happening
on a state-by-state solution. I think you need a national
solution for this. And maybe we'll learn from
these state by state experiments of what works and what doesn't.
But in the end, it's got to be a national solution.
I think we've got to be very careful in healthcare reform,
not to lose the basic principle of insurance, which is,
cover the many for the needs of the few.
I was very concerned when the administration last year,
or a couple of years ago, was pushing a very boutique
kind of health insurance. You know, if you're under 25,
you can get it real cheap, and whatever.
And it would be attractive in the short-term.
I think you need to cover the many for the needs of the few
however you design the system. And I want to be sure that
we don't lose sight of that. Getting the message
to the faculty and your staff that things are changing
is very important. Getting them to understand
that it's not business as usual anymore is fundamental.
And taking the high road on all decisions is so important.
Sometimes, you need to sacrifice short-term gain for something
bigger in the long run. It doesn't help people's careers
necessarily, because they're often not around
for that to happen. But taking the high road
every time you have the opportunity to,
is just extremely important, and explaining to people
that's what you're doing. Anyway, why don't I break here
and thank you all for being such a great group
and dialoguing with me so much. I really appreciate it.
Thanks very much. ( applause )