Understanding Academic Medical Centers: Simone’s Maxims¹

Academic medical centers today represent a unique fusion of traditional academia, hospital functions, several levels of education, and, above all, patients. They are complex organizations trying to discharge an often conflicting melange of responsibilities. This complexity has grown in recent years with the increasingly rapid rate of change (1), stressing both faculty and leadership (2, 3). Lamenting the toll of change is not new (4). However, the qualitative difference in recent change is underscored by the shift in focus of two articles, 15 years apart, on academic governance by Petersdorf (5, 6), especially as they have affected deans and their dramatically shrinking tenures. Economic turmoil and its consequences are blamed most often for the angst in academic medical centers (7). And yet, some blame the faculty and leadership for not changing fast enough (8) or for choosing doomed strategic pathways in response to those pressures (9). In fact, a Forum on the Future of Academic Medicine in 1997, sponsored by the Association of American Medical Colleges, reached a consensus that novel management systems are crucial to future success but blamed the unwillingness of faculty to change as a major obstacle to progress (10).

This turmoil can be perplexing to individuals working in such an environment, especially trainees and younger and mid-level faculty. They are the most vulnerable in the system and may not yet have sufficient experience to use as a reliable touchstone. Are there lessons or guidelines that can be learned and used as one proceeds through a career? Can one better understand academic institutions, their leaders, and processes? Are there some consistencies that broadly apply to help negotiate the increasingly stormy seas?

Like many colleagues, the more my career has involved administrative and leadership responsibilities, the more I have become a student of academic medical centers and how they function. During my career, I have moved through the trainee and faculty ranks and been the responsible leader at the section and department levels. I have also had senior administrative responsibilities at major academic medical centers: St. Jude Children’s Research Hospital and the University of Tennessee; Stanford University Medical Center; Memorial Sloan-Kettering Cancer Center; and the University of Utah. Throughout those positions, I have gained some wisdom and many battle scars. To make some sense of my experiences and what I learned from many others, I began years ago to establish personal rules of thumb, “maxims,” to discern some meaningful patterns in seemingly chaotic events and baffling human behavior. Thus, Simone’s Maxims gradually emerged to guide my own judgment.

These maxims concern the behavior of academic medical institutions, their leaders, and their faculty from the individual’s point of view. They were accumulated and developed from years of personal experience and many mistakes, as well as occasional revelations, both personal and borrowed from others. Although these maxims are personal, each is supported by the experience of some colleagues. I am confident that my experience is not unique, and that at least some will resonate with others in academic medicine, each of whom will have personal variations. The maxims are offered mainly to those below the full professor level, because they are less experienced and also because we full professors tend to believe we know it all. They have grown and evolved over time, and they are likely to continue to do so; these are no tablets from Moses, to be sure. The maxims are contained in five categories: institutions, leadership, recruiting, job changes, and success.

This first maxim may sound cynical, but the relationship between a trainee, faculty member, or any employee and the institution is impersonal and contractual, whether written or not. Institutional leaders must make decisions that are not personal but usually have positive or negative personal consequences. One cannot expect the same consideration as one may receive in a family. Despite overwhelming evidence to the contrary, it is surprising how often even full professors believe they deserve special consideration because of loyalty, longevity, or past productivity. A wise colleague once told me that job security was the ability to move to another job (because of professional independence). One must keep in mind that institutional relationships are really with persons, who can and sometimes do love you back. My fondest memories of places I’ve been are of coworkers and patients, not “the institution.” If they moved on, my attachment moved with them. For any one of us, good coworkers and solid leaders make what we value in the institution. Recognizing them, what they do for us, and the values they represent are far more important than loyalty to an impersonal institution.

There is little incentive for an institution to rapidly cut through the bureaucratic morass. An institution will always outlast a dissenting individual, regardless of the merit of the case. Such a faculty member may waste a part of his career tilting at windmills or agitating politically out of frustration. An institution looks out at its large pool of ever-changing stars of the moment so that it can (and often must) look at the cumulative progress of all, a measure not possible for an individual. Therefore, when the institution’s realistic time frame for change is so long as to seriously threaten one’s productivity or momentum, a change of job or focus must be contemplated.

A variant of this maxim is that institutional reputations (and those of its departments and divisions) change long after the time of their successes and failures; individual reputations change more quickly. Those responsible for changes are often long gone before their impact, for good or ill, is fully felt. The individual is forced to gauge the trajectory and often glacial speed of institutional change, no matter how difficult this can be, to judge whether the light at the end of the tunnel is daylight or an oncoming train. In other words, it is best not to confuse the current reputation of your division or laboratory with your own. You can wither in a well-known lab, and you can grow in a not-so-famous environment.

The remainder consists of those who don’t show up, attend because they have nothing better to do, or who can’t or won’t spend much energy on it. (Not incidentally, this same percentage applies to boards of directors, who, I hasten to add, are the owners of nonprofit institutions such as academic medical centers. The higher up you go in such institutions, the more important it is to know into which category each trustee fits, because trustees have enormous influence and they turn over rarely.) The most successful committees have hard-working chairmen who prepare themselves and the members before meetings, call meetings only when essential, and engage members in a productive manner. No academic committee meeting should exceed 60 min, preferably 50. No one ever complains of meetings being too short. Longer meetings are usually due to poor leadership, poor organization, or a lack of purpose.

They force others to pick up the slack or repair their mistakes, reducing everyone’s efficiency. If this continues for long, those who are consistently unproductive may become the majority because the competent learn that the institution sees no virtue in hard work and collaboration. As difficult as it may be, the best solution for all parties is to fire the individual. This is true despite the fact that one must deal with past evaluations that have been unrealistically positive, complicated grievance procedures, bureaucratic barriers, and the unpleasantness of confrontation. I have been burned several times on this issue, so I have a couple of safeguards. I’ll discuss faculty later, but for nonfaculty, at the hiring interview I usually tell them that it might not work out— because of them, because of me, or just because of bad chemistry. Therefore, if I must terminate them, it is a bit easier for both of us. It is also easier to terminate an employee during the probationary period.

The ill effects of poor leadership, at any level from CEO to department head to housekeeping, insidiously permeate an entire institution. This invariably leads to inefficiency at best and at worst leads to falling dominoes of lost opportunity or catastrophe. Leadership matters, even though its effectiveness may not be apparent in the short term. In fact, it is most effective when its workings and angst are not apparent to most of the people most of the time; in other words, “don’t let ‘em see you sweat.” What makes great leaders is not a secret—they not only have grace under pressure, which means both courage and character, they remain focused on the important aspects of an issue in the midst of chaos, and they repeatedly articulate a consistent, simple public vision. If the troops don’t know what is expected of them, what direction is set, or what the leader values most, that is the leader’s fault. However, this vision must be backed by public acts, not just words. There are many opportunities to demonstrate one’s vision, both subtle and overt. Whom the leader hires, fires, and promotes sends the most effective signal, but smaller acts can indirectly express his or her values. Good leaders also usually choose to be judged by, and take satisfaction in, the success of the team members. Top leadership jobs are full-time jobs and must be viewed as a new and specific career choice, not as a minor part-time duty.

Examples of such criteria include a long bibliography, scientific eminence, institutional longevity, ready availability, a willingness to not rock the boat, or to accept inadequate resources. Choosing leaders is not a science, but it is surprising how often management skills, interpersonal skills, and experience are undervalued. This error is most damaging when recruiting clinical leaders because of the increasing complexity of health care economics and the interface of the academic mission with hospital functions. What should one look for? It differs, of course, depending on the position. One should ask what critical skills are absolutely essential for that role at that time in that particular setting—there are usually only two or three. It could be scientific taste as much as accomplishment, i.e., a keen sense of excellent versus average science as opposed to the ability to run one’s own program successfully, or it might be in-the-trenches management experience, inter-personal skills, or the courage to clean house. My point is that we all want superb investigators, teachers, and clinicians, preferably able to walk on water, but there are other practical values that are at least as important and often define the success or failure of the leader.

The leader may have exhausted his or her reservoir of moral or financial capital, enthusiasm, and will. Moving on to something else may be best for the leader and the institution. This is a hard call for anyone to make, and it is a very lonely decision, but many have made it. My decision to leave St. Jude after 24 years was very difficult, but I thought that after 9 years as Director, I had accomplished at least 90% of what I would ever do there, no matter how long I stayed. We built new buildings and recruited nine new chairmen, and I was afraid I would just be oiling the machine for the rest of my career. That would have been bad for me and, ultimately, for the institution, which leads to the next maxim.

Fresh ideas, energy, and resources are needed for vital, creative organizations, and it is easier for a new leader to redress mistakes, adapt and restructure the organization, and clean out deadwood. The number of academic leaders who remain effective, adaptive, and unselfish for two decades or more is miniscule compared with those who stay on only because of accumulated power, political maneuvering or institutional delusion, and inertia. In this respect, it is not new space or funds that are at risk; they are comparatively easy for the seasoned leader to continue to obtain. It is scientific creativity, innovation, and organizational modification that suffer. I choose about 10 years from simple observation of the academic world.

This is a rule of leadership that is contrary to the laws of physics. With any significant problem, error, or conflict, the bigger the stink and the more contentious the conflict, the more rapid the uphill rise. Leaders often try to ignore or deflect the unpleasant mess, but the longer it incubates, the harder it will be to sanitize. A keen nose catching a faint whiff early in the process can prevent costly and time-consuming embarrassment. Many leaders do more sniffing above (chairman, dean, trustee) than below, which is where many of the most serious problems arise. For a really big stink at the highest levels, one must deal with the press. Our instincts in those cases are like those of a child —we think that if we keep it quiet, it will blow over. We naively believe that the patient who suffers a major surgical or chemotherapy error so loves the attending physician, or the grieved faculty member so loves the institution, that they certainly wouldn’t want to raise a public fuss or cause unpleasantness. And we believe that if the media learns of it, it will be discreet, or at least wait until one can gather all the facts. Wrong on all counts. If it can hit the fan, it will, and fast. You can count on it. I’ve been involved in several major institutional miscues in which the muck landed in my lap and in the press. The best approach is get the facts very quickly, inform the Trustees, get the public relations department involved, decide on a course of reparative action, and act, all on the first day, if possible. And then prepare to make a statement to the press that is brief and forthcoming. One might get lucky and dodge a bullet, but decisive action is still best.

Some hesitate to recruit a person who is smart enough and ambitious enough to compete with them. Others want a position filled at any cost because of “desperate” clinical need or other institutional pressures. If that approach continues for long, the third-class people will eventually dominate in numbers and influence and ultimately chase away any first-rate people that remain. I’ve hired my share of bad recruits. When I was younger, I just suffered with the mistake and groused about dishonest references. Later in my career, I realized that everyone will inevitably make recruiting mistakes, and it is wisest to lance the boil as soon as possible. I’ve had to fire a number of people that I hired or inherited, including several chairmen. In my experience, the following sequence of action worked best. First make certain of the facts, looking especially for a pattern of unacceptable or unproductive behavior. The immediate superior should always give the bad news in person and in private. And, if possible, he should have prepared a reasonably dignified way out for the individual. This is difficult and very unpleasant work, but I learned that letting it fester was much worse for the institution and for the individual.

“Always recruit the best athlete” or, in this case, “the best scientist,” is a stupid oversimplification. A faculty member may be very productive personally but create an atmosphere that reduces the productivity of everyone else. A small, but distressing, number of academic programs have a stifling air of distrust and scientific secrecy, leading to competing factions and an enormous waste of energy. These programs tend to attract others covered with negative ions and a purely self-serving attitude—they deserve each other.

A two- or three-page letter spelling out the specific expectations and benchmarks of accountability (11) will usually suffice. But I’ve known of offer letters that ran 20 or 25 pages. This starts a relationship on a note of distrust, which will be hard to shake off later. Lawyers may become involved, a catastrophe for all. Furthermore, this attitude may spread to other faculty, present and future. On the other hand, institutions or leaders that earn a reputation for failing to deliver on promises of resources deserve distrust, but written commitments are worthless in that case anyway. If a candidate feels he or she must have a long and detailed offer letter because of distrust, it would be better not to take the job. Trust that one’s boss or bosses will act in one’s best interest is probably the single most important factor in job satisfaction, especially in the first few years. It is the recruit’s responsibility to talk to as many as possible of the boss’s present and former colleagues to gauge that trust. Whom to talk to varies depending on rank; for example, a post-doc should talk to present and former post-docs, an assistant professor to assistants, and so forth. There is an exception. It doesn’t matter who candidates for deanships talk to—the fact that they are considering becoming a dean already shows a flair for adventure and self-delusion; therefore, evaluations by others aren’t very influential in the decision.

I can hear you thinking that this maxim is crazy, but I have seen and experienced this many times. There are two possible reasons for this incredible irony. First, the firing party has demonstrated, at least in this instance, strong leadership, high standards, and guts. I believe that coming from such an upstanding laboratory, program, or institution is quite helpful on the incompetent’s CV. Second, the person may be in the wrong type of job, and dismissal provides an opportunity move to a better position, a more appropriate setting, and/or higher pay. When he lands the nice new job, though, I assure you that his former boss will certainly not be thanked for forcing the job change. The first faculty member I had to fire was a friend and colleague, but it was clear he wouldn’t make it as a senior clinical investigator in his chosen area. He landed a job in a medical school where research wasn’t required. He was very successful at raising the quality of patient care and teaching students and house staff. Another was a scientist, a 10-year employee, whose contract wasn’t renewed because it was clear he wasn’t going to succeed as an independent investigator. He went to a small biotech company where he flourished and, incidentally, made a pile of dough. It simply fit his skills and temperament better.

That cushion is needed because the true environment and opportunity almost always end up being less, and the difficulties always turn out to be more than one thought. It is in the nature of changes that the grass always looks greener, and it may be, but just not as green as it looked.

The reason for this is obvious. One may be blinded to the warts on the new job by unhappiness in the old. For one in an unhappy job, it may be far better to suck it up and take more time to find a position with a stronger “pull.” This maxim is difficult to observe when there is extreme unhappiness in a position; the temptation is to just get out, but it can be very risky.

This is true because it will depend on the opportunity actually delivered by the institution and the energy focused on it by the individual, both of which take some time to assess. Many new recruits spend part of the first year wondering what possessed them to leave “home” or take that particular job in the first place; this is a normal reaction to the bite of reality.

Continued healthy growth requires added nutrients (resources, opportunity), mutation (new scientific track or discovery), or replating into new medium (new job). None of these actions necessarily requires leaving one’s institution, although that may be necessary. The trick is to be objective enough to know when one’s career is approaching the plateau so that a deliberate approach to the problem may begin. With no change in the culture medium, the plateau phase eventually is followed by academic death.

It is often a sign of inertia or excessive self-satisfaction. The infamous “gold watch” or its academic surrogates, a testimonial dinner, a plaque, or emeritus status, often turn out to be empty substitutes for engagement in more productive and satisfying activity, even if it is a risky change and requires leaving a familiar environment. Depending on the point in one’s career, it may be better to do something quite different. It is a cliché, but true nonetheless, that we often fully realize too late that we go around only once. As F. Scott Fitzgerald said, “There are no second acts in life”; so we have just one complex first act in which we must improvise before the final curtain.

Whether to engage in battle depends on the stakes. It is best to enter a battle with overwhelming superiority in arms and ammunition, but for a uniquely important issue, one must be willing to put the job on the line, not as an idle threat or bluff, but in one’s heart. If you would never leave and they know it, they have you by the gonads. Employees, and faculty are employees, have only one trump card after all is said and done: resignation with dignity on one’s own terms. Of course, there are colleagues who are “lookers,” who have never failed to look at a job when asked, often solely to gain leverage at the home institution. These sorts cry wolf too often, causing disruption or uncertainty, and soon people begin to wish they would just go.

There are different ways to divide these eras (12). In my view, there are four overlapping eras relevant to this thesis; although dates of primacy are given, features of all persist today. The Oslerian Era (1900–1945) was dominated by diagnostic skills, anatomic and clinical pathology, and public health. Academic positions were few and poorly paid. Effective therapeutic tools were limited in number. The autopsy was the basis of the most important conference at academic medical centers. Full-time faculty were few in number, and the “professor” of a department was usually the chairman and the best clinician—a superb diagnostician often asked to consult in difficult cases. The large charity hospitals like Cook County in Chicago, Bellevue in New York, and Boston City and Charity in New Orleans were prime teaching centers staffed by elite academic faculty. Childhood immunizations, improved sanitation, and general anesthesia had a profound impact on health. Much of the medical research was done either in pathology departments that had access to most of the clinical data, pre- and postmortem, or in a few major research institutions on the East Coast such as the Thorndike Laboratories at Harvard, Johns Hopkins, and the Rockefeller Institute. This was the era of the medical renaissance man: superb clinician, investigator, and teacher, often well read.

Next came the NIH Rapid Growth Era (1945–1970), which saw the NIH become the premier, almost obligatory, training ground for academicians, as well as the financial engine for research medical centers all over the country. Faculty in academic medical centers grew exponentially with the NIH dollars that made up 70–90% the budget of many departments in premier research centers. This is when the NIH grantees became kings, often allowed to disdain clinical or teaching duties because they were an important source of prestige and dollars for the institution.

The Medicare-Medicaid Era (1965–1990) saw academic centers restructure to increase the newly available clinical revenues that were generous enough to allow cost-shifting to support research and teaching. This is when the high revenue specialists, such as surgeons, pathologists, interventional cardiologists, and radiologists, became kings and shaped the agendas of many academic medical centers.

Academic medical centers are now in the For-Profit Era (1980-?). The dominant forces with the greatest impact on their missions, for good or ill, are managed care, health systems, and the pharmaceutical and biotechnology industry. Although more and more investigators compete for grants, industrial research has increased, and the surplus from clinical revenues has declined steeply. Thus, to sustain and develop programs, faculty and institutions have increasingly looked to industry for support. Is there a major academic medical center today that doesn’t have substantial financial ties to for-profit companies? Academics with seats on the boards of for-profit companies, stock options, or lucrative consulting contracts are commonplace. Many clinical trials are now generously supported by industry, providing an important source of revenue in academic medical centers.

By recognizing one’s era, it is possible to know where the power lies. Whether one participates or not, one must recognize and find a way to adapt to the large forces in one’s era. Failure to do so may lead to despair; this is one reason many older physicians are unhappy. However, there is a serious risk that one will undergo metamorphosis rather than adaptation, forfeiting rather than sustaining one’s professional values and commitment to public service.

The potential dangers of entanglements with the for-profit industry are usually recognized, if often ignored or disdained. Few oncologists, for example, acknowledge that they are being influenced, manipulated, and seduced by industry, especially the pharmaceutical and biotechnology industries. Payment for enrolling patients in studies, lavish parties and exhibits at professional meetings, well-compensated seats on boards of directors, and other financial emoluments have a subtle or overt influence on professional behavior.

Furthermore, few appreciate even the potential dangers of government and philanthropic support. It is possible for a so-so scientist to become a well-funded, ace “grantsman,” who follows the safe scientific niche rather than the riskier, but more interesting, course. A tally of grant dollars may be overweighted in judging the success and value of a faculty member. The peer review process can only take a snapshot through a microscope. The skills of grantsmanship are important, and grant support is certainly a key measure of success, but obtaining grants is not a perfect surrogate for scientific skills and certainly cannot address the scientific or clinical yeast the person brings to a program. I have seen not a few CVs of well-funded investigators who have little of substance to show for it, with little solid work published in strong journals.

Philanthropy can be seductive, and many of us look upon it as “free money.” But there are many examples of philanthropists influencing operations adversely or supporting substandard faculty or programs, leading to poor scientific and academic decisions. The strings attached to philanthropic giving are often subtle or invisible; it isn’t easy to say “no” to a rich and eager donor. With the best of intentions, philanthropists may cause one to build a facility before it is programmatically indicated or before operating revenue has been secured. Or they may cause a shift in scientific focus that is poorly grounded in opportunity. Skill and tact are necessary to align the needs and wishes of the donor with the long-term interests of the academic program.

Despite the problems, it can be the most fulfilling and rewarding of professions, if taken with a sharp eye for reality, a dash of iconoclasm, and a ready sense of humor. These jobs are difficult and certainly not rewarding 24 h a day; sometimes we are lucky to get 24 h a month. But we in academic medicine are blessed in many ways compared with those in most jobs. We have the privilege of working in a profession that helps the sick and dying while we are engaged in intellectual inquiry. Our profession is still highly respected by society, and we are paid quite well for doing something most of us love to do. So despite all the travails of human frailty that we must deal with every day, we should count our blessings. I am grateful that fate and early training led me into academic medicine and would do it again in a New York minute.