"Smoke Detector" - Medical Center Leader (and Former Biotech CEO) Outed as Tobacco Investor

Last year we posted about the seemingly incongruous choice of a wealthy biotechnology executive with little academic or practice experience to run the prestigious University of California - San Francisco, a health oriented university housing a respected medical school.  We wondered whether her corporate background would make it difficult to uphold the university's academic and patient care missions.

In line with our concerns, Duff Wilson, writing in the New York Times, reported:

When Dr. Susan Desmond-Hellmann was named chancellor of the University of California, San Francisco, last summer, she took over a medical institution focused on world health generally and tobacco control in particular.

But she forgot one thing in adjusting to her new role: personal stock holdings listed last year in the range of $100,000 to $1 million in Altria, owner of Philip Morris USA, the maker of Marlboro cigarettes. Altria has been blamed for thousands of deaths and repeatedly criticized by the Center for Tobacco Control Research and Education at the university.

Last week, a day after The New York Times inquired about the Altria stock, Dr. Desmond-Hellmann and her husband, also a doctor, ordered it to be immediately sold and imposed 'values screening' on their personal investments.

Experts on tobacco control were aghast:

Dr. Stanton A. Glantz, director of the university’s tobacco control center, said he was unaware of Dr. Desmond-Hellmann’s Altria stock, which was contained in a university filing but not made public until now, after a public records request by a former student who passed it on to The Times.

“I do find that kind of shocking, but at least she got rid of it,” Dr. Glantz said on Monday, adding that Dr. Desmond-Hellmann had been very supportive of the center.

Dr. Kenneth E. Warner, dean of the school of public health at the University of Michigan and a national antitobacco leader, said, “I find it frankly a bit appalling that the chancellor of a major medical center would have held such stock. It strikes me as unthinking, frankly.”

We should give Dr Desmond-Hellmann credit for selling her Altria stock as soon as its connotations were made plain to her. (And at least she was not on the board of a tobacco company, to our knowledge, as was one former president of a university and large health sciences center.)

However, this little incident underlines the clash between the culture that dominates large health care corporations and the mission of medical schools and academic medical centers. In the last 30 years, academic medicine has rushed to embrace the reigning corporate culture, not to mention corporate money. I submit that this embrace has been at the peril of the fundamental academic and patient care missions.

Academic medical leaders need to promote better patient care, and honest, responsible teaching and research. To do so, they may have to give up some of the glitz, glamor, and cash proffered by industry. If they do not make this sacrifice, they risk losing the trust of an increasingly skeptical, if not cynical public.

Post Title → "Smoke Detector" - Medical Center Leader (and Former Biotech CEO) Outed as Tobacco Investor

Bio-Tech U

The San Francisco Chronicle just reported that a new Chancellor has been nominated for the University of California - San Francisco (UCSF). UCSF is functionally a health sciences university, and its Chancellor functions as its president. The UCSF medical school is generally considered one of the elite US academic medical institutions.

Genentech executive Susan Desmond-Hellmann has been nominated to be the next chancellor of UCSF, making her the first woman or biotech leader ever asked to run the research campus and hospital system that is San Francisco's second-largest employer.

Desmond-Hellmann has served most recently as president of drug development at Genentech, the South San Francisco biotech firm that was recently acquired by Swiss drugmaker Roche. She was trained as a physician, did her internship at UCSF and has taught there recently as an adjunct associate professor while working at Genentech.

Although prior UCSF chancellors have come from more academic or scientific backgrounds, [Dr Holly] Smith said Desmond-Hellmann's biotech connections would be an advantage as the university tries to translate scientific discoveries into medical treatments.

Dr Desmond-Hellmann is, in my humble opinion, a very unusual candidate to be Chancellor of one of the country's premier academic medical institutions. According to her official Genentech bio (taken off the Genentech server, but transiently available in the Google cache here), and a biography in Nature Drug Discovery, Dr Desmond-Hellmann, after getting both an MD and an MPH, spent two years doing AIDS research in Uganda as a UCSF junior faculty member, and then spent a few years in private practice hematology-oncology. She published few articles (5, according to Medline, last in 1995), and by 1993 went to work in industry, first for Bristol-Myers-Squibb. She started at Genentech in 1995, and worked her way up to her current position, "president, Product Development. In this role, Hellmann is responsible for Genentech's Development, Process Research & Development, Business Development, Product Portfolio Management, Alliance Management and Pipeline Planning Support functions. Hellmann is a member of Genentech's executive committee." Before her nomination to be Chancellor, Dr Desmond-Hellmann was "affiliated" faculty of the Department of Epidemiology and Biostatistics at UCSF, apparently with the rank of adjunct associate professor. In that capacity, she apparently gave a single seminar in 2007, and lectured in the Designing Clinical Research course in 2003.

So, on one hand, Dr Desmond-Hellmann, to be charitable, does not have much of an academic track record, at best approximating that of a very junior medical faculty member. She also certainly has no experience in academic administration. In general, people who lead academic medicine often have substantial track records in academics and in academic administration. So, in some sense, Dr Desmond-Hellmann's appointment seems to based on the theory of the generic manager. That is, the popular notion in the business world managers can manage anything, any organization, with any mission, in any context. Managing in the complex health care context, especially managing large, complex academic medical institutions, may not be easy for those used to managing elsewhere, even in the health care corporate world.

Furthermore, the complex mission of academic medicine, which includes providing excellent care of individual patients, while discovering and disseminating the truth in a spirit of free enquiry, is very different from the mission of a for-profit biotechnology company. How well someone used to the bottom-line mentality of the corporate world would uphold the academic mission is not clear.

Dr Desmond-Hellmann came from a company known for charging very high prices for the drugs it marketed, and Dr Desmond-Hellmann was on record personally defending this practice. Quoting from a news article in the Journal of the National Cancer Institute [McNeil C. Sticker shock sharpens focus on biologics. JNCI 2007; 99: 910-914.]

Never mind their novel targets and mechanisms. It's the cost of new biologic agents that's creating a buzz these days. At thousands of dollars a month, which can mean many tens of thousands for some regimens, sticker shock has generated recent, prominent articles in both the national and trade press.

On one level, the argument is about macroeconomics. Neal Meropol, M.D., of Fox Chase Cancer Center in Philadelphia, pointed out that cancer drugs account for 40% of all Medicare drug expenditures. That makes them a major contributor to the country's high health care costs, now about 17% of our gross domestic product (GDP) and growing. That percentage is much higher than in other developed countries with higher life expectancies, he said at a forum on cancer care costs at the American Association of Cancer Research annual meeting.

On the other side of the macroeconomic debate, experts point out that the U.S. has a high GDP to begin with and so can afford to spend more on health. And cancer biologics, though among the most costly drugs, are still only a tiny fraction of total GDP, said Genentech's Susan Desmond-Hellmann, president for product development, at AACR.

Hellmann and others argue that with these drugs’ potential to alleviate the huge societal burden of cancer, biologics are worth the cost.

The industry has responded to concerns about costs by putting more resources into patient assistance programs. When Genentech received U.S. Food and Drug Administration approval for bevacizumab in lung cancer last October, it also announced a cap on expenditures for the drug for patients with family incomes less than $100,000 a year. In 2005, the median household income was $46,326.

Originally announced as $55,000, the cap actually doesn't kick in until after a patient has received 10,000 mg. At the wholesale acquisition cost, 10,000 mg is about $55,000, said Genentech spokesperson Edward Lang.

What the companies have not done so far is reduce prices. The reason, industry representatives say, is the need to recoup massive research and development costs, including high manufacturing costs for biologics. These costs have long kept biotech companies from making much of a profit overall, Hellmann said. She noted that profit levels of publicly held biotech firms have "hovered close to zero" throughout the life of the industry.

But, while Dr Desmond-Hellmann was defending pricing drugs that at more than $55,000 a year, and complaining about low industry profits, she was pocketing lavish rewards. According to Genentech's 2008 proxy statement, (the last available, since the company has been bought out by Roche), her total compensation was $8,361,348 in 2007 and $7,820,142 in 2006. In 2007, her total compensation was equal to 0.3% of the firm's total net income, and the top five company executives' total compensation was equal to about 1.5% of the firm's total revenues. In 2007, the firm's stock price declined from 91.30 on 6 January 2007 to 66.38 on 4 January, 2008, or 27%, according to Google Finance. In 2007, she held 1,616,383 shares of stock, or stock options exercisable within 60 days of January 31, 2008. In 2007 she exercised 170,000 stock options, realizing $11,556,663. So perhaps those high drug prices were needed not only to pay for research, but to make top executives, including Dr Desmond-Hellmann, very rich.

This raises further questions about her inclination to uphold the university's mission in the future.

University of California, San Francisco is a leading university dedicated to defining health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.

In any case, hiring a lavishly compensated top executive from a biotech firm known for its high drug prices to run a public health sciences university does considerably blur the line between academic medicine and the health care industry. In the Chronicle article, Dr Desmond-Hellmann declared, "I began my career at UCSF and my heart has never left it." If she does become Chancellor, let us hope that her heart will speak louder than all those millions she used to make by, among other means, charging more than $55,000 a year for bevacizumab.

Post Title → Bio-Tech U

The Retirement of a Generic Manager

A frequent theme on Health Care Renewal has been the adverse effects of health care leadership by generic managers with no background or experience in health care, and no intuitive understanding of its values. This type of leadership arose after some health care economists called for abolishing the supposed physicians' "guild," and transferring power over health care to managers as a way to control health care costs. This has not lead to control of health care costs.

The recent coverage by the New York Times of the sudden retirement of the CEO of General Motors suggests that the notion that organizations should be run by generic managers is one whose time ought to be past. Wagoner presided over a dramatic decline in the fortunes of GM.

Mr. Wagoner presided over some of the biggest losses in G.M. history. In 2002, the company had predicted that it would earn $10 a share by the middle of the decade.

Instead, G.M. lost $30.9 billion in 2008, when its per-share loss translated to more than $50 a share. G.M. stock, an economic bellwether that sold above $35 only three years ago, closed Friday at $3.62; it has fallen as low as $1.27 in the last year.

In 1994, when he took charge of G.M.’s North American operations, the company made up 33.2 percent of auto sales in the United States.

Last month, G.M. represented only 18.8 percent of American car and truck sales....

The problem may have been, in part, that Mr Wagoner was never a "car guy."

'It’s a pretty unceremonious ending,' said John Casesa, an industry analyst and managing partner of the Casesa Shapiro Group. 'G.M. lost its way in the ’70s, but the company didn’t know it until 20 years late. The hole was much deeper than he realized when he became C.E.O.'

And, Mr. Casesa said, Mr. Wagoner’s finance background might have been a poor fit: 'The most successful auto companies are run by people who came out of the revenue-generating functions — manufacturing, design, marketing — making cars and selling cars.' Mr. Wagoner, the analyst said, 'skipped the whole apprenticeship that most auto C.E.O.’s experience.'

The notion that a finance guy should run a car company makes not much more sense than the notion that a finance guy (or marketer, accountant, or lawyer) should run a hospital or a drug company. Yet now most health care organizations are run by such generic managers. Is it any wonder that while such generic managers have made a lot of money, they have been unsuccessful in controlling health care costs, much less solving any other aspect of the the health are crisis?

Post Title → The Retirement of a Generic Manager

Middlemen and a Health Care System Dominated by Bureaucrats and Managers

The Wall Street Journal today wrapped up its series on "middlemen" in health care. The summary article has some telling quotes, and some very important data. To start with the quotes,

A lot of the money goes more toward fattening middlemen's bottom lines than toward improving the quality or efficiency of American health care. 'At the end of the day, the only reasonable conclusion is that we waste a huge amount of money on the most nuttily cumbersome administrative system in the world,' says Henry Aaron, a Brookings Institution economist.

While the middleman business booms, health-care costs keep rising, the ranks of the uninsured grow, and paperwork expands as each party in the system tries to enlarge its slice of the pie. 'There's more money to be made by monitoring cash flow than monitoring patients,' says David Cutler, a prominent Harvard University health economist.

And here are the statistics. According to the article, the majority of people who work in doctors' offices, 1.8 million out of 3.3 million, do so in non clinical jobs. Nearly a majority of people who work in hospitals, 2.3 out of 5.5 million, do so in non clinical jobs. So currently almost 50% of people who work in what appear to be the most clinical settings are not doing clinical work.

Health care has been taken over by clerks, bureaucrats, and managers.

This appears to be the fruit of the movement began in the 1980's to break the medical "guild," which some economists held responsible for the high cost of health care (see post here).

The results has been even more rapidly increasing health care costs, decreasing access, stagnant quality, and of course, dispirted professionals tired of contending with myriad clerks, bureaucrats, and managers, most of whom do not seem to understand health care or believe in its values.

And this horrendously complex, bureaucratic non-system is a fertile breeding ground for the conflicts of interest and outright criminality we discuss so often on Health Care Renewal.

Some happy new year to us from the WSJ.

Post Title → Middlemen and a Health Care System Dominated by Bureaucrats and Managers

UMDNJ as a Political Sand-Box

The Newark Star-Ledger just published another in its long series of stories on the troubles at the University of Medicine and Dentistry of New Jersey (UMDNJ). As we have discussed previously, the university now is operating under a federal deferred prosecution agreement with the supervision of a federal monitor (see most recent posts here, here, here, here and here.) We had previously discussed allegations that UMDNJ had offered no-bid contracts, at times requiring no work, to the politically connected; had paid for lobbyists and made political contributions, even though UMDNJ is a state institution; and seemed to be run by political bosses rather than health care professionals. (See posts here, and here, with links to previous posts.) The most recent development (see post here with links to previous posts) was that UMDNJ apparently gave paid part-time faculty positions to some community cardiologists in exchange for their referrals to the University's cardiac surgery program, but not in exchange for any major academic responsibilities.

Now the Star-Ledger has come up with a story of some mind boggling decisions made by the former UMDNJ leadership that seemingly wasted millions on expensive building projects that now stand vacant. The article then concluded with another insightful analysis of what went wrong in the leadership culture of the university, an analysis that may generalize to other health care organizations.

First, let's summarize the blundering building projects. The first was a highly secure site to develop vaccines against biologic terror agents, which is years behind schedule because a UMDNJ leader wanted to relocate it to a piece of land owned by his neighbor. Per the Star-Ledger,

It was known as a Regional Biocontainment Lab.

It was announced in September 2003 by then-Health and Human Services Secretary Tommy Thomp son, who hailed it as 'a major step' toward providing effective vaccines and diagnostics for diseases caused by agents of bioterror as well as in fections such as SARS (Severe Acute Respiratory Syndrome) and West Nile virus.

The federal grant stipulated the project be built in Newark's University Heights, adjacent to an existing bioresearch lab operated by UMDNJ.

Memos and e-mails show that within four months, Robert A. Saporito -- then UMDNJ's senior vice president for academic af fairs -- was looking for another site, as university officials grew concerned they would be unable to find matching funds required to build the project.

The search for alternate sites was never disclosed to the public, to the political leaders who secured the money, or to the federal agency that awarded it.

Saporito was forced to resign in March after he was accused of abusing his expense account. In an interview before he left, he said changes in the original design, mandated by security concerns, led to discussions about relocating the lab. He said he explored moving the lab to Picatinny after receiving a call from William Marcellino, a developer who lived a few doors down from him in Brick Township.

When the National Institutes of Health learned about the Picatinny plan last year, the agency was clear: 'We explained to UMDNJ that alternate sites were not an option,' said John J. McGowan, an administrator at NIH.

In an August 2005 letter to the university, NIH officials complained that they had seen little progress on the project and warned 'if you are unable to show the project can be completed, we will need to begin to negotiate the return of funds.'

The next was a cancer center that sits mostly vacant.

The newest building on UMDNJ's Newark campus is a nine-story structure emblazoned with distinctive red signs identify ing it as the New Jersey Medical School/University Hospital Cancer Center.

It includes vast expanses of glass, state-of-the-art research labs, underground vaults for linear accelerators used in cancer treatment, and an outdoor garden for patients.

But no cancer treatment is going on. There are no doctors, no clinical services and no patients. While some researchers have moved in, more than half the building remains empty.

Christopher Paladino, a former university trustee, said there was never a real plan for the cancer center. He said millions were spent without benefit of any economic feasibility studies, or any examination of whether the center would actually bring in patients.

Paladino, named a trustee after the project began, concluded the center had been the product of jealousy between the school's Newark and New Brunswick campuses. In Newark, he said, there was a feeling that because the university has a cancer institute 'in New Brunswick, we should have it here.'

The article documented other expensive buildings that sit partially vacant in lieu of any realistic plans to use the space they provided. In particular,

Adjacent to the cancer center in Newark is a new, six-story building for ambulatory outpatient services completed this year. Walk through this structure, past the cool pastel walls, and there are few people. One level is vacant, as are large parts of the rest of the building.

Since before construction began in April 2003, UMDNJ officials knew they would have trouble down the road because the center was built with tax-free government bonds and money raised that way cannot be used for profit-making operations such as doctors' offices.

'The total confusion on that subject has been the major obstacle,' [Interim UMDNJ President] Vladeck said. 'We're starting to untie that knot.'

Vladeck said the complex was planned and built by people who put off the financial issues, figuring it would be constructed and 'by then, they would have to fix the problem.'

Finally, the Star-Ledger discussed a fascinating analysis of what has gone wrong with the leadership of UMDNJ.

Interviews with past and current officials indicate many projects were a product of a school that increasingly was divided into two worlds the past few years.
In one, nurses and doctors battled to provide health care in a poor, urban environment. But at the top were administrators who got their jobs through political patronage and whose basic job experience was not teaching or medicine, but state government and politics.

Paladino, who was an assistant counsel to Gov. Jim Florio, said political jobs seemed to be part of the lifeblood of the university.

'It's a Sharpe guy. It's a Rice guy. It's a McGreevey guy, or a DiFrancesco guy, he remarked, referring to former Newark Mayor Sharpe James, state Sen. Ronald Rice, and two former governors, James E. McGreevey and Donald DiFrancesco. Everyone has a guy. They don't hide from it.'

It wasn't always evil, he said, but it became a slippery slope as politicians sought comfortable jobs for their political supporters.

U.S. Attorney Christopher Christie, who is overseeing a criminal investigation into the university that was launched after a series of stories in The Star-Ledger last year, saw it all as less than innocuous.

"There were people in political life who were in charge of the budget process who made sure UMDNJ got taken care of, because they knew folks could go there and be employed,' said the U.S. Attorney. 'There was a very symbiotic relationship there between the political world and the university.'

He added that his parents once told him character was what you do when you think nobody's watching.

'UMDNJ,' Christie said, 'was the way politicians acted when they thought nobody was looking, and it's a pretty ugly picture.'

So there you have it. One fundamental problem with UMDNJ was that the University was run by people with no background or fundamental interest in health care, who did not share, even at an intellectual level, the values of health care. The leaders treated the country's largest health care university as there own political sand-box, completely disregarding its core mission, and thus completely disrespecting the patients and learners it was supposed to serve, and the health care professionals who tried to serve them.

After the revolution that turned health care over to business people, bureaucrats, and politicans, how many other health care organizations are run for the benefit of their leaders, rather than the missions they were supposed to support?

Post Title → UMDNJ as a Political Sand-Box

Putting on the Ritz?

According to an article published by the Detroit Chamber of Commerce, Gerard van Grinsven, who was appointed General Manager of the Dearborn Ritz-Carlton in 2002, has put the "wow"back into the hotel. Among other achievements, van Grinsven succeeded in having the hotel ranked number 1 for customer satisfaction among all the prestige chain's properties.

Van Grinsven had world-wide experience in the hospitality industry. He started managing a coffee-shop in a Holiday Inn in Canada. "His expertise in food and beverage ultimately sent him on an incredible global odyssey throughout many of the world’s most acclaimed hotels, including The Mandarin in Jakarta, The Oriental in Bangkok, The Ramada Renaissance in Hong Kong, the Peninsula in Manila and the Hotel Inter-Continental in Berlin."

"Van Grinsven joined The Ritz-Carlton Hotel Co. in 1994 as executive manager in charge of food and Beverage at The Ritz-Carlton, Seoul, where he led the successful opening of the largest food and beverage operation in the company. Prior to taking the helm at Dearborn he was vice president of food and beverage and vice president of pre-opening operations at the parent company in Atlanta."

At this point, Health Care Renewal readers may begin to think I have started April 1 festivities a bit too early. What does any of this have to do with health care?

Actually, the answer, albeit bizarre, is not hard to find. Yesterday, the Detroit News published an article about plans made by the Henry Ford Health System to open the new Henry Ford West Bloomfield Hospital in 2008. Who did the system hire to be CEO of the new hospital? It was none other than Gerard van Grinsven.

The Detroit News article noted that "Van Grinsven has no background in the health industry but brings years of experience managing post Ritz-Carlton hotels. Henry Ford believes that makes him the ideal person to run an upscale hospital designed to woo patients with the promise of privacy and wired rooms that overlook a pond and landscaped courtyard." Hospital "amenities will include Internet access in each room, flat-screen televisions and a wireless communication system that will eliminate irksome overhead paging."

However, "several national experts said they had never heard of someone making the jump from a career in hospitality to hospital president." Furthermore, "some critics say pouring money into pools and private suites is only going to lead to an arms race that drives health care costs higher."

I am sure Mr Van Grinsven is an excellent manager in the hospitality industry, and that anyone would enjoy staying at a hotel he runs. However, it is mind-boggling that a hospital would put a hospitality executive with no health care background, no matter how accomplished, in charge of runing a hospital. This seems to be a unique case of the idea that all managers know best about health care, again an attitude that seems to have been generated by Einthoven's call to break up the medical "guild" and turn control of health care over to managers and bureaucrats.

Hospitals and hotels both provide over-night acccomodations and food. That's pretty much where the similarity ends. Few hospital patients book stays in advance. Hospital patients arive at all hours, often very sick, and with unique needs. Sick patients do deserve health care professionals and support staff who really care about them. In my humble opinion, however, sick patients, even if they are well-to-do baby boomers, really are unlikely to care about flat screen televisions and internet access. Most sick patients care about getting better, and having a future to which they may look forward. I wish Mr Van Grinsven luck, which he will need. I just hope by the time this hospital really opens, Mr Van Grinsven has been able to delegate most of his responbilities to people who actually understand health care.

Post Title → Putting on the Ritz?

A Drug for "Eliminating Cardiovascular Risk?"

The Washington Post recently reported on an interview with Pfizer Chief Executive Officer (CEO) Henry A. (Hank) McKinnell. (The PhD seems to have been in business, from Stanford, as per his official bio.). In it, he asserted that the combination of the new drug torcetapib with atorvastatin (the latter is now marketed as Lipitor) could potentially eliminate coronary disease,

It looks like a combination of raising HDL and lowering LDL cholesterol could have dramatic impact, maybe eliminating cardiovascular risk.

This is an extraordinary assertion.
Although high LDL (bad) cholesterol and probably low HDL (good) cholesterol are risk factors for coronary artery disease (CAD), they are surely not the only risk factors. Cigarette smoking, diabetes, and hypertension are also well known risk factors. In addition, CAD clearly afflicts people who have no known risk factors.
Therefore, it is hard to believe that any treatment, no matter how potent, that addresses only cholesterol would come anything close to eliminating the risk of cardiovascular disease.
So why would Mr. McKinnell say such a thing?
The possibilities seem to be marketing hyperbole, his ignorance of the epidemiological and clinical background, or misquotation.
The first two are particularly discomfiting.
Although we expect hyperbole in the marketing of ordinary products, laundry detergent for example, this sort of hyperbole in the marketing of drugs could have serious repercussions in this context. If people were lead to believe that they could prevent all CAD by merely taking a pill to improve their cholesterol profile, this might reduce their motivation to control their blood pressure or diabetes, or to give up smoking.
On the other hand, if Mr. McKinnell is so ill-informed about the drugs his company produces that he really believes that this new combination pill will eliminate CAD, what else about pharmaceuticals doesn't he understand? Having someone in charge of the world's largest pharmaceutical company who knows so little about drugs could lead to all sorts of mischief.
So I really hope he was misquoted.
If not, I really hope that he learns to restrain his tendencies to hyperbole, and/or to become better informed about what his company makes before something really bad happens.

Post Title → A Drug for "Eliminating Cardiovascular Risk?"

Five Future Scenarios for Academic Medicine

Simultaneously published this month in PLOS Medicine in a longer version, and the British Medical Journal in a shorter version is an article by the International Campaign to Revitalise Academic Medicine (ICRAM) presenting five possible scenarios for the future of academic medicine. In the longer version are a list of "current instabilities in academic medicine," which includes some items that many will find familiar, and "drivers of change in academic medicine," most of which are pretty telegraphic.
The five scenarios are fairly extreme, and seem to be products of some fairly severe disagreement among the widely geographically dispersed members of ICRAM (see the BMJ version, "The members of the group often couldn't agree. They disagreed, ofr example, over the importance of business, particularly pharmaceutical companies, in academic medicine. Would business interests destroy or enhance academic medicine?") The scenarios include:

• "Academic Inc" - academic medicine becomes entirely a private, predominantly for-profit enterprise
• "Reformation" - academic medical centers disappear, and all "academic" activities take place in the community
• "In the Public Eye" - academic medicine as celebrity culture
• "Global Academic Partnership" - academic medicine focusses almost completely on the plight of global health
• "Fully Engaged" - academic medicine became fully engaged with stakeholders

The ideas are interesting, and the future may hold some elements of some of them. It wasn't clear whether some of the scenarios were meant as dsytopias or utopias. Surely, this article ought to generate some discussion, but my concern is that this worthwhile movement has not yet clearly defined the problems in academic medicine that it seeks to address.
The lists of "current instabilities" and "drivers of change" contain many poorly defined items. For example, the latter includes "'big hungry buyers' demanding more from health care," "managerialism," and "expanding gap between what could be done and can be afforded in health care." All these touch on issues explored in Health Care Renewal, but don't seem to quite get at the core of the problems. It may be that the problems afflicting academic medicine in countries throughout the world are so varied that it really is hard to define a set of universal issues. On the other hand, international gatherings often end of speaking "international-speak," in which crucial distinctions are blurred in order to avoid offending one party or the other.
Maybe the group will be able to get beyond "international-speak," and engage more directly with the nitty gritty issues that are afflicting academic medicine in individual countries, even if that means coming up with solutions customized to each countries' needs. Let's wish them luck.

Post Title → Five Future Scenarios for Academic Medicine

Reasoning By (Mis)Analogy: Should Hospitals be Compared to Microchip Factories?

Rant alert: I have become increasingly distressed by changes in health care prompted by poor analogies between it and various businesses. One of my pet peeves has been hospital quality improvement schemes based on what purportedly works to improve quality on production lines.
Hospitals couldn't resemble mass production in a factory less. Yes, of course, most products used in hospitals are mass-produced in a factory, and physicians and other health care professionals depend on products manufactured with great uniformity and predictability. Each patient presenting to a hospital, however, has a unique set of problems and issues. Attempts to manage these issues are based on our currently far from complete understanding of human biology, and how psychosocial factors impinge on it. Patients present at any time, with varying degrees of severity, at various stages in their life. The goal is to provide the best approach to each patient customized to that patient's situation and problems. Doing so is likely to require using drugs, devices, and equipment that will perform predictably and reliably. But the choice of what tests to do, what treatments to employ, how to discuss and inform the patient of what is going on, etc are unique to each patient.
In contrast, the goal of production lines is to produce identical products, designed by humans, based on good understanding of physics, chemistry etc., and the principles of engineering. So how would practices designed to improve the design and manufacture of goods and equipment on a production line likely apply to how hospitals take care of unique patients?
In this week's JAMA there appears a good example of the genre of applying industrial production techniques to health care, an article by Andrew S. Grove PhD, the "former chairman of the board of Intel Corporation." [Grove AS. Efficiency in the health care industries: a view from the outside. JAMA 2005; 294: 490.]
Grove starts off with this comparison: "the health science/health care industry and the microchip industry are similar in some important ways: both are populated by extremely dedicated and well-trained individuals, both are based on science, and both are striving to put to use the result of this science." These criteria are extremely broad. One could use them to compare health care with the airline industry, major league baseball, or the Communist Party in the Soviety Union under Vladimir Lenin. All these organizations could have claimed to be populated by well-trained, dedicated people, who based their work to some extent on scientific principles.
Then blithely dismissing that "one industry deals with the well-defined world of silicon, the other with living human beings," Grove goes on to tell us how to do health care better.
Particularly galling, I think, is his criticism of the slow pace of the "war on cancer" compared to the increase in the number of transistors included on microchips.
Maybe he really got to the point nearer the end, when he pushed for more and quicker implementation of the electronic medical record. "When it comes to operational efficiency, nothing illustrates the chasm between the 2 industries better than a comparison of the rate of implementation of electronic medical records with the rate of growth of e-commerce." This comparison is hard to fathom. EMRs, to be useful, need to digitally categorize data that is very hard to organize. No one yet knows how to store, for example, the contents of the medical history in anything other than a text file. Yet an electronic medical record that consists mostly of text and image files may be no easier to manipulate than a paper chart. E-commerce, on the other hand, must simply keep track of stereotyped transactions. (Readers of Health Care Renewal have seen why the EMR may not be as much of a panacea as its promoters proclaim.) But selling more EMR systems may increase the demand for Intel's chips.
I have no objection to inter-disciplinary work. And health care can obviously benefit from insights from other fields. But why are we in health care constantly berated by people based on bearing such bad analogies as those proposed by Grove?

Post Title → Reasoning By (Mis)Analogy: Should Hospitals be Compared to Microchip Factories?

MinuteClinics

One of the latest ideas in the brave new world of the health care biz is "MinuteClinics." As described here, MinuteClinics operate rapid-service, walk-in clinics located in such venues as CVS pharmacies, Target and food stores. The clinics are staffed by nurse practitioners and physicians' assistants, and treat a limited range of minor illnesses, such as "strep throat, pink eye, and bronchitis." As described by ABC News, patients are seen in a "tiny kiosk with a nurse practitioner inside."
The American Medical Associaton is wary of MinuteClinics because they do not provide continuity of care. One of our local physicians wrote an op-ed challenging their effects on the "efficiency" of primary care.
My biggest concern is that some people with apparently simple problems, even sore throats and bronchitis, actually have serious ailments. Will a nurse inside a "tiny kiosk" be able to identify them? The nurse may have a good protocol (although the contents of the protocols they use have not been made public), but I wonder how nurses in tiny kiosks can do adequate physical examinations, even for simple complaints. If they can't do a good chest examination, for example, they may miss the heart murmur that suggests a patient with a sore throat might merit antibiotics even with a negative rapid strep test, or they may miss the signs of pulmonary congestion that suggests a patient with "bronchitis" might have pneumonia or congestive heart failure.
But MinuteClinics also provide a telling example of how health care is now lead. This article provides a brief biography of MinuteClinics new Chief Executive Officer (CEO), Michael Howe, who was, it says, "recruited for his leadership experience." Howe is the former CEO of Arby's Inc./Triarc Restaurant Group, and had previously had executive positions with KFC. These days, leadership in selling fast food is now considered equivalent to leadership in health care. Would you like fries with that rapid test for strep?

Post Title → MinuteClinics

"The Catastrophic Collapse in Morale Among Doctors"

In the April 30 Lancet, a scathing editorial about the untoward influence of managers and politicians on British health care.
(Not available without a subscription, the citation is: Anonymous. The unspoken issue that haunts the UK general election. Lancet 2005; 365: 1515.)

Here are some key quotes:

• "But sadly, Labour, Conservative, and Liberal Democrat politicians have failed to address the single most important factor hindering the improvement of health services - the catastrohic collapse in morale among doctors. Doctors at all levels within the NHS are utterly demoralised."
• "They are cynical about a new cadre of managers who have little clinical understanding but create a massively overmanaged health service. And they feel let down by their own leaders, who have consistently failed to articulate a positive and assertive vision about the contribution modern medicine makes to society."
• "What UK medicine needs is a new and stronger political voice, one that is more concerned with augmenting professional standards than with protecting professional status."

Sounds familiar here in the US. As an American physician, I feel my British colleagues pain. Maybe we can get together across the Atlantic and figure out how to fight overmanagement and foster our professional values.

Post Title → "The Catastrophic Collapse in Morale Among Doctors"

A Growing Proliferation of Managers

A while back, we had a dialog with EconBlog about the myth of US health care waste. One issue I had discussed was adminstrative overhead. (See my first previous post here, and follow-up here., and on cost of high-technology, here.)
I argued that my experience as a physician (and discussion with other physicians) suggests that there is a huge administrative and bureaucratic load on physicians, and that this contributes directly and indirectly to health care costs. The best I could do at the time was to cite a study that showed that physicians in practice spend an inordinate amount (a little less than US $25K a year per physician) on "unnecessarily complex or redundant administrative tasks."
I just found some fascinating data along these lines, available from the Center for Medicare and Medicaid Services (CMS) in a series of charts (here.)
See in particular Table 1.13, Health Care Employment by Occupation.
It shows that from 1983 to 2000, the numbers of health care managers grew at a rate that far outstripped any other kind of health occupation. Taking the numbers off the PowerPoint presentation,

• The number of managers grew from 91,ooo in 1983 to 174,000 in 1990, to 752,000 in 2000.
• That could be compared with the numbers of physicians in those years (519,000 to 577,000 to 719,000), and the number of registered nurses (1,372,000 to 1,667,000 to 2,111,000)

So the growth rates from 1983 to 2000 were 1.39x (39%) for physicians, 1.54x (54%) for nurses, and a whopping 8.26x (726%) for managers.
Another way to look at it is, in 1983 there was 1 manager for every 5.7 physicians and every 15.1 nurses. In 2000, there was 1 manager for every 0.96 physicians and every 2.9 nurses. Again, by 2000, the number of health care managers exceeded the number of physicians. There were more managers than any other species of health care worker other than nurses.
If health care could function in 1983 with one manager for nearly every 6 doctors, why in the world did we need one manager per doctor in 2000?
I would love hear if anyone can come up with a justification for this massive increase in numbers, or show how this proliferation has lead to any improvement in health care.
On the other hand, ecological correlations are not a good way to prove causation, of course, but I would argue that this data suggests that attributing the simultaneous rise in health care costs, decrease in access, stagnation in quality, and dissatisfaction of health professionals like physicians and nurses to the incredible proliferation of managers (and attendant bureaucracy) is not far-fetched.

Post Title → A Growing Proliferation of Managers