Medical leadership in an increasingly complex world.

GREECE IS GOING BANKRUPT. THE EURO IS SHAKY. The oil inundating the Gulf Coast may eliminate one-third of the US seafood catch. In the midst of this chaos, the nightly news focuses on a medical breakthrough. At a cost of about $100 000, a man with metastatic prostate cancer can be treated with an infusion of his own cells and live, on average, a few months longer. The commentator questions whether insurance companies will pay for this therapy and wonders whether men who do not have metastatic cancer will demand access to the therapy, even if they have to pay for it themselves. Perhaps Yeats was right—“Things fall apart; the centre cannot hold.” The United States spends more money per person on medical care than any other developed country in the world. But Americans are not the healthier for it. Life expectancy in the United States is lower than in virtually any other developed country, and variation in life expectancy, as a function of where a person lives or grows up, is high. In the context of this dismal reality, consider the assertion in the Declaration of Independence that every citizen has the right to life, liberty, and the pursuit of happiness. What should be expected from a physician leader in this complex world? Physicians are found in leadership positions throughout US society but are rarely at the top. Physicians have been elected to both houses of Congress, but no physician has been elected president. Medical leaders are found in the executive branch of the Department of Health and Human Services, but virtually never at its highest levels. But physicians have extraordinary influence. They run the programs that spend large amounts of money to treat the elderly and the poor, at both state and national levels. They provide a moral compass when they serve as surgeon general. And most frequently, they are responsible for running large health care delivery systems and for training the future health workforce of the United States. Indeed, the teaching role has expanded from being a dean of a medical school to overseeing the entire health enterprise of an academic campus, including teaching hospitals and schools of medicine, nursing, pharmacy, and public health. Physicians also control all of the organizations that set professional standards in medicine, from individual specialty societies to organizations cutting across the entire medical establishment. What defines a successful leader of such organizations? That’s more than a rhetorical question. Medicine now makes up 17% of the US gross domestic product; thus, a large part of the country’s ability to ensure life, liberty, and the pursuit of happiness is in the hands of medical leaders. There are several possible definitions of successful leadership. Is it an indication of success if the leader of an academic medical center keeps the institution financially solvent, constructs new buildings—especially those for basic science research—moves the institution higher on the National Institutes of Health grant list, and trains physicians to concentrate on the patient by using all tools at their disposal? Are leaders of professional societies successful when they persuade Congress that the society’s members provide great scientific value and thus merit higher salaries; or if those leaders convince philanthropies to donate a disproportionate amount of money to that specialty? Is the leader of a major program, such as Medicare, successful when bills are paid promptly, adequate reimbursement is made for services rendered, and services are provided with high quality and little waste? Is the medical leader of a pharmaceutical company successful when the company develops a product that increases life expectancy by 3 months at a price of $100 000 and then convinces the public and insurers that patients must have the product and that it must be paid for with public money? Many would answer yes in all of these cases. Who wants a leader of an academic medical center who builds nothing, does not attract research grants, and fails to maintain financial stability? Certainly not the center’s board of governance. But in this complex world, are these sufficiently inclusive definitions of a successful physician leader? There are 3 competing models for improving health in a population. The first, for which virtually all of the resources are used, is the medical model, in which an individual patient visits a physician who uses his or her clinical training to diagnose and treat the patient. The second is the