Deans of Medicine: Leadership in a Time of Whitewater Rapids
Twenty years ago, Peter Vail wrote: " Most managers are taught to think of themselves as paddling their canoes on calm, still lakes. . . . They’re led to believe that they should be pretty much able to go where they want, when they want, using means that are under their control. Sure there will be temporary disruptions during changes of various sorts–periods when they’ll have to shoot the rapids in their canoes–but the disruptions will be temporary, and when things settle back down, they’ll be back in the calm, still lake mode. But it has been my experience . . . that you never get out of the rapids. . . . The feeling is one of continuous upset and chaos” (p. 2).
By and large the metaphor of “working in whitewater” has held up well. Ask anyone today who is charged with leadership or management and you will hear the plight of persons who are more often than not convinced of the truth of Emerson’s conviction that “[e]vents are in the saddle and ride mankind.”
Nowhere is this more true than in the world of academic medicine. It speaks volume that increases in the costs of higher education over the past three decades are invariably compared unfavorably with those of health care, a sector often seen as “out of control”. And there is a special place in financial hell for medical students, more than 80 per cent of whom graduated in 2015 with educational debt averaging more than $200,000 (Association of American Medical Colleges, 2015).
Leading a college of medical education may actually require extending the whitewater metaphor to include the high falls many deans feel are just beyond the next bend. Confronted by a landscape in which fee-for-service is challenged and dealing with illness and injury is expected to change to preventing and avoiding both, medical colleges are tasked with finding ways to educate students in very different ways, including adding more to an already-stretched program of training. Containing costs to students thus assumes enormous importance.
Moreover, the Affordable Care Act (ACA) focuses very much on primary care physicians as opposed to specialists. But the aging of America creates medical needs that at least for the foreseeable future requires specialization or else patient wait times will grow or the elderly will have the burden of traveling greater distances to obtain care. Responding to which demand becomes problematic and influences an array of choices a dean of medicine has to make, including faculty hiring and facilities.
Some of these challenges are not entirely new. What is new is the scope and the rate of change with which the medical dean must contend. Technology has long been a source of change for medicine, but now technology is challenging the way faculty teach and students learn as well. Virtual reality, for example, could alter established pedagogy and not just didactics but also clinical experiences.
Technology is also changing patient-physician relationships, with more and more individual information available to each patient. Artificial intelligence can expedite the transfer of information from patient to physician and expand the opportunity for person-to-person engagement.
Health-care analytics made possible by electronic records and advances in computing are already beginning to identify parts of the health-care continuum that add costs without a commensurate return on the resources being invested in that aspect of care. While no one yet sees in health care or medical education what Buckminster Fuller called “ephemeralization” – technological advances that enable us to do more and more with less and less – it is possible to envision a time in which the art and science of medicine are vastly improved as a result of technology. Whether the social and economic structures of health care can adapt to such change remains to be seen.
All of this and more fall within the purview of the dean of medicine; not to the granular level but as strategic opportunities and threats not easily denied. The sorts of medical deans needed for such a brave, new world must be strategic and possess the sort of macro-level understanding of the forces at work in health care and medical education. S/he must be a change agent but never forget how hard change is on most of the people encountered in everyday life.
Deans of medicine cannot “protect” anyone from the forces of change already at work on both medicine and education any more than a kayaker can slow the rush of whitewater or soften the boulders that will be encountered. But medical colleges are not battleships (though to some deans they may well seem so) that can only be steered incrementally and they are not new and fragile institutions. Vision, very clear vision is required and yet the future is no less volatile than the recent past, so risk is, of necessity, everpresent.
Medical education needs leaders who can understand that “[t]o some extent. . ., everybody is resistant to change. . . . Leadership is about doing what you think is right and then building a constituency behind it” (Michael Bloomberg, 2012).
Albert Lee and Eric Hoyle, “Who Will Become a Successful Dean of Faculty of Medicine: Academic or Clinician or Administrator,” Medical Teacher (July 2009).
Eugene Rich, Diane Magrane and Darrell Kirch, “Qualities of the Medical School Dean: Insights from the Literature,” Academic Medicine (May 2008).