Future Leaders of Academic Health Sciences Centers
Their number is small, less than 150 organizations compared to nearly 5,800 hospitals and more than 4,000 colleges and universities. Yet academic health science centers (AHCs) share with research-intensive universities the spotlight of attention and prominence that makes their names readily recognizable.
Leadership of AHCs is demanding. The tenure of a dean of medicine is just over four years, slightly more than that of a hospital CEO at 43 months. Executive turnover is the rule, continuity the exception.
Many AHC leaders are selected more because of their success in research, education and patient care, not their administrative record, leadership skills or experience in effecting significant change within an organization. Until recently, most AHC leaders learned their jobs as administrators by doing them, not as a result of training or education in management.
What’s more, the future of AHCs is mixed. On the one hand, health care organizations, including AHCs, confront an array of challenges: an economy in turmoil, demands for better care quality and safety with fewer resources, and a still-to-be-determined national health plan. Recently, Johns Hopkins University provost Lloyd Minor offered two stark judgments. Citing comparatively higher costs and worse health status indicators, he asserted, “The American health care system is broken. If we do not change it ourselves, rest assured that others will do it for us.”
And with respect to the health care “silos” that bedevil the best intentions of individual physicians to address a patient’s often multifaceted health woes, Minor cites the metaphor of a Ferrari engine connected to the brakes of a Porsche, to a BMW’s suspension, and the body of a Volvo. “’What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.’”
On the other hand, University of Southern California’s president Max Nikias contends that medical schools and biological sciences and health sciences will be assuming much more central roles in the life of the American research university. The sort of transformation wrought by physics in the 20th Century is being re-enacted now by biology and the life sciences. The best universities, he maintains, will be those with medical schools and related life sciences.
Whether the proverbial glass is half empty or partially full may matter less than the reality that governing boards will be recruiting a new generation of leaders for their institutions at a time when change seems constant and, in James Orlikoff and Mary Totten’s words, “the past is no longer the prelude to the future . . .,” and drawing on convention or “looking for solutions within is unlikely to help.”
The “Interesting” Context of Academic Medical/Health Sciences Centers
AHCs exist at the nexus of health care and higher education and are therefore home to the complexities of both sectors. AHCs provide most of the education for medical professionals; garner a disproportionate share of research funding in the life sciences; produce much of the innovation in medical care; typically pioneer new types of treatment even as they render primary and emergency care and outpatient services; host more than half of the living Nobel Prize recipients in medicine; serve as the practice settings for would-be doctors and nurses; and provide health care for the nation’s vulnerable populations.
AHCs cost and spend more than almost any other professional service and therefore attract scrutiny from an army of stakeholders.
Moreover, part of the explanation for turnover in AHC leadership is the sheer complexity of the organizations’ mission. The complexity increases with the establishment of interdisciplinary centers and line services such as those devoted to cancer, heart disease, and women’s health. These centers and services create matrix organizations by imposing lateral responsibility across a traditional administrative hierarchy with the aim of integrating treatment without disrupting the traditional disciplinary and clinical departments. The results are mixed and challenges remain, among which one is the lack of clarity about the role and expectations of the service line leader.
Ironically, much of the literature addressing the preparation of AHC leaders calls for exposure to sectors other than and in addition to medical education and the health sciences as well as more, not less, interdisciplinary activity. The search for “best practice” is not restricted to what exists within academic health and medical centers or post secondary education, but, instead, encourages aspiring leaders to examine, for example, how the use of sophisticated informatics and information and communication technologies are applied in fields as different from health care as logistics.
Orlikoff and Totten make a case for what they call “contrarian leadership for challenging times” and cite at least two reasons for thinking differently about who becomes head of AHCs. The first is that “[d]oing more of what you’ve always done is only going to get you what you’ve always gotten – a particularly painful realization when it comes to assessing progress toward improving health care quality and safety.”
A second reason for seeking contrarian leadership is that “at their best they are visionaries or even heroes, able to see what others cannot and willing to act with the courage of their convictions.” The importance of different, alternative visions of how AHCs could work increases because the sources of funding to support productive research will likely have to come from changes in clinical practice since other sources of research support – e.g., the National Institutes of Health – have had their own funding stagnate with the exception of recent, one-time federal stimulus monies. Robbing Peter – the delivery of health care – to pay for more Paul – research – while at the same time improving care quality and safety will entail major changes in clinical care that may not be viewed as possible or acceptable for some medical professionals at first glance, if at all.
It is difficult to envision anyone other than a physician serving as dean of a medical school (indeed, accreditation and licensure requirements may prohibit anyone but a physician from so serving). But it is possible to imagine how specialties other than the more prevalent ones – internal medicine and pediatrics make up, respectively, 41 and 14 per cent of current medical school deans in 2008 – could become more prominent backgrounds of future deans, particularly if health care shifts more to prevention of illness than treatment of ills.
New Paths or Well-Trod Routes?
Physicians will continue for some time to come to make up the vast majority of heads of medical schools and academic health science centers: they constitute 90 per cent today.
By contrast, physicians are only four per cent of hospital leadership, down by 90 per cent since 1935. The marriage of the life sciences to academic medicine, hospital and clinical services, and research has fostered large, complicated organizations. They are almost always not-for-profit, tax-exempt entities that house numerous formidable business enterprises involving multi-billion dollar budgets. Hence, anyone seeking a leadership role in AHCs will need to bring to the job real facility with complex budgeting driven in part by revenues seemingly always in flux and large capital expenditures. This skill is a must for any would-be AHC leader, and in increasing numbers of AHC leaders have earned a PhD, MBA, or MPH in addition to the MD degree as a way to acquire that skill.
Regardless of training and as is the case in all of American higher education, fund-raising by AHCs has become a major activity for their leaders as well as a larger presence in the centers’ non-medical operations. Aspirants to the AHC presidency who are uncomfortable with fund-raising need not apply.
Pressures for more interdisciplinary approaches and structures are likely to broaden the range of specialties doctors bring to leadership posts. The early, albeit, still nascent signs of progress in capturing and using basic operational and treatment data make it possible to imagine an AHC head whose preparation and career converge at the point of application of computer science, information technology, biology, and patient care and reflect less her/his medical specialization.
As more AHCs focus their strategic areas of expertise – typically narrowing the range of specializations offered, their boards and leaders will feel pressure to move from the current strategy of relying on medicine and treatment to one that emphasizes patient and community/public health and prevention. This will require more investment in other areas of biomedical science, including the behavioral sciences, public health-related research, informatics, management sciences, and clinical research.
For a variety of reasons, not least of which are care-related as well as financial, AHC boards may look for leadership in candidates who understand and are experienced and accomplished in “translational research.” The National Institutes of Health describe translational research as the process of applying discoveries generated during research in the laboratory and in pre-clinical studies, to the development of trials and studies in humans. The second area of translation concerns research aimed at enhancing the adoption of best practices in the community.”
The mindset able to comprehend and understand the processes and stages of translational research is more likely found in the individual who has experience in seeing the process through to its culmination, insight available for those biomedical researchers who have shepherded a discovery through to becoming an effective product or protocol, but in any case, an innovation. If the prototypical translational researcher has seen her/his work through to commercialization, then that experience is likely to be attractive to boards looking for leadership able to straddle research, discovery, testing and replication/verification, licensing or sale, and able to organize the elements of an AHC to make the process work.
One other factor may influence leadership of AHCs. Researchers from Deloitte observed that the needs of an increasingly multicultural America may well require changes in health care.
Beyond unique medical problems experienced by certain ethnic cohorts, the growing number of internationally born workforce members add pressures to incorporate Asian and ayurvedic approaches with traditional Western allopathic medicine. . . . Changing the system from a homogeneous platform focused on Western medicine methods to a heterogeneous one represents a huge paradigm shift.
As problematic as such a change may well be, there are places in America where large segments of the population constitute a sizeable portion of an AHC’s client population who prefer and will seek out the kind of health care with which they are accustomed and comfortable and which has been shown to produce good patient outcomes. Boards sensitive to the needs and preferences of those communities may therefore want to identify candidates for the presidency/CEO who are aware of, experienced in, and catholic in outlook with respect to what constitutes effective health care.
In the 1971 film “The Hospital,” the depressed, cynical chief of medicine, Dr. Bock, engages in the following dialogue with a patient:
Patient: So at 9:15 this morning I rang for my nurse...
Dr. Bock: Rang for your nurse?
Patient: To ensure one full hour of uninterrupted privacy.
Dr. Bock: Good.
In the forty years since the film appeared, health care has undergone profound changes and endured its share of challenges, including, perhaps, the repetition of “one full hour of uninterrupted privacy.” Changing the conditions that make possible indifferent care, an unsustainable business model, soaring costs and stagnant or declining health status, consumers who do not assume personal responsibility for their own health, and physicians devoting substantial time and energy to arguing with insurance companies - none of this will be easy or quick to change. But if change is to come, it will more likely come with and from leaders who see the world somewhat differently than their predecessors.
Richard (Rick) A. Skinner, PhD
Senior Consultant, Harris Search Associates
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