Governance of teaching hospitals

Academic medical centers face tremendous challenges. Their mandate is sweeping: the delivery of excellent clinical care, the advancement of new knowledge through biomedical research, the application of discoveries for better therapies, and the education and training of a diverse group of medical students, residents, and specialty fellows. The mission is noble, but successful execution is fraught with complexity. John Kastor, an educator and cardiologist, has dealt with this complexity as chairman of the Department of Medicine at the University of Maryland. Since stepping down from that post, he has directed considerable attention to careful analyses and descriptions of changes in academic health centers and has reported his findings in various publications. His current book, Governance of teaching hospitals: turmoil at Penn and Hopkins, focuses on two institutions in an effort to analyze and understand the causes and consequences of upheaval in governance that occurred there over the last decade. This readable, carefully constructed, and useful analysis treats each institution separately, with a different narrative approach for each. To add to the reader’s understanding of the complex administrative interactions at each institution, Kastor provides a historical perspective on the personalities and forces involved when the centers were established. These explanations help frame the clear differences in governance that Kastor found at these institutions and confirm the oft-cited aphorism, “When you’ve seen one medical school, you’ve seen one medical school.” At the University of Pennsylvania, the medical effort began as part of an already established university structure. The sometimes troubled interactions among the University of Pennsylvania’s president, the Medical School dean, and the University Hospital director prior to William Kelly’s appointment as dean and CEO in 1989 are described as background for the period of Kelly’s meteoric rise and sudden fall, with his dismissal in 2000 by University President Judith Rodin. The section on Penn is divided into four parts: “Before Kelly,” “Kelly the builder,” “Kelly in trouble,” and “After Kelly.” The anything-but-tranquil periods in governance before Kelly assumed control at Penn are well outlined, especially the town-gown struggles during Dean Gellhorn’s years, which led to his departure in frustration. The section on Hopkins has two main portions: “Separate governance” and “Unified governance.” The former refers to the century-long period in which the Johns Hopkins University School of Medicine and the Johns Hopkins Hospital were under separate control, and the latter analyzes the situation after the crisis leading to the formation of Johns Hopkins Medicine, a joint entity. As Kastor writes, events moved quickly at Hopkins after open warfare developed between Michael Johns, then dean of the Medical School, and James Block, head of Johns Hopkins Hospital. As a result of the intense conflict and the division it caused within the faculty and medical staff, a new system was created in 1997, with Edward Miller named as both dean of the School of Medicine and CEO of Johns Hopkins Medicine. Clearly enormous effort was involved in the preparation of this volume. In one extensive appendix, Kastor lists the 126 medical schools now active in the US and their various models of governance. He describes the interrelations of senior administrators, such as deans and hospital presidents, in these institutions. Another appendix lists over 300 medical leaders in both institutions who were interviewed. To ensure accuracy, all respondents were able to review drafts of the text segments involving them. There is a wealth of detail and a cast of hundreds, in major to minor roles, in Kastor’s narrative, but despite the amount of detail and meticulous research summarized in this book, the narrative flows easily. The information may be more than some find useful, but the organization of the book is such that the essential story at each institution can be readily followed, even without meticulous reading of the more comprehensive sections. For others, the details of the power struggles will prove to be the book’s strongest feature. This book should be of interest and value not only to those who are directly involved in leadership roles at academic medical centers but also to anyone interested in the success of such institutions. While medical care depends on the skill and commitment of individual physicians and other health care providers and scientific advances derive from the talent and dedication of individual scientists, we all have a stake in the success of the overall mission of the great academic health centers. Kastor shows what can result from convulsions in control: endless and unproductive bickering, polarization of communities, and impressive financial losses. In his final section, Kastor leaves it to the reader to draw his or her own conclusions about the effectiveness of different governance models. Clearly the enormity of the task of developing such models could overwhelm any group of individuals involved in leadership, no matter what model is developed. Kastor’s understated but obvious theme is the need for leaders to demonstrate maturity and effective cooperation as well as drive and vision.