Governance of Teaching Hospitals: Turmoil at Penn and Hopkins
John Kastor's first book traced the history and fate of recent hospital mergers in Boston, New York City, and San Francisco. This book tells of crises in the academic medical centers of Johns Hopkins and the University of Pennsylvania in the 1990s. The stories are complex and richly (sometimes too richly) detailed and documented. The most important conclusion may be that there is not one simple conclusion. However, some things are clear. First, the strong, charismatic leaders of the institutions involved -- university presidents, medical school deans, chief executive officers of hospitals, and board chairmen -- were not selected for their posts because they "play well with others." Second, things go well when resources are plentiful and conflicts can be avoided. Problems emerge when resources are scarce, conflicting academic and clinical missions are exposed, and tough decisions must be made. Third (my conclusion, not Kastor's), excellence and serenity are not synonymous; excellence requires periodic painful change, whereas serenity protects individuals, institutions, and traditions at the price of lost opportunities. Selecting the optimal balance for a given institution at a given time is the art of leadership. Kastor describes periods of turmoil and change and the crises of leadership in these two great institutions. His method involves presenting details from carefully documented interviews with the major (and some of the minor) participants (158 at Penn and 105 at Hopkins), along with 853 endnotes. He is dealing with sensitive events and angry people, and is cautious -- too cautious for my taste. He is sometimes reluctant to help the reader distinguish central facts from rationalizations, excuses, or evasions. His methodologic dilemma is clear in a footnote to a passage discussing William Kelley's shortcomings as a leader at Penn: "After interviewing him twice . . . I sent to him, as I did for each of the major players . . . , the entire manuscript. . . . Kelley and I then spoke thirteen times . . . and exchanged four e-mails." This is a burden for someone chronicling the history of a recent conflict, and the result is a comprehensive archive that will be a vital resource for any future historian writing a more distant, analytical discussion, but it is also a work that is short on generalizations. The Penn story is the more dramatic of the two. It is built around Kelley, who was dean of the university's medical school and leader of its medical center from August 1989 to February 2000. Kelley arrived with an explosion of energy and went on to turn a money-losing hospital into an immensely profitable one. He used the resources he had developed to build research facilities, recruit faculty, purchase hospitals and primary care practices, expand in the intensely competitive medical world of Philadelphia, and radically transform the institution. In 1994, Penn appointed a new president, Judith Rodin. In 1995, Kelley's chief administrator and longtime colleague was summarily dismissed, and later that year the practice organization of the clinical faculty at Penn agreed to pay $30 million to settle a charge of Medicare overbilling. Then things got even tougher. In fiscal year 1997, the health system lost $15 million; in 1998, $90 million; and in 1999, $198 million. The financial picture was starting to improve when Rodin fired Kelley, in 2000. Penn was left with a strong academic faculty, valuable research buildings, a questionable primary care network, and a greatly strengthened role for the medical center's leader that, although it troubled the university, Kelley's successor insisted on retaining. The Hopkins story has many similarities to Penn's. The narrative theme is consistent -- things were going along, then new people came and new challenges emerged. There were fierce struggles between strong-minded people; some advocated radical changes, whereas others championed the preservation of traditional values. Crisis led to climax, with first one and then the other of the antagonists leaving. There were structural reorganizations, but often with less real change than met the eye. Kastor has provided us with great gossip, complete with comprehensive and detailed accounts of fascinating events, and with an important reminder of what can happen when an academic medical center confronts the challenges of the contemporary health care delivery system.Robert Michels, M.D.Copyright © 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.