Great Expectations for the School of Medicine

Challenges and opportunities for the future

Samuel C. Dudley Jr., Associate Professor of Medicine and Physiology

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Since I arrived at Emory in 1997, the medical school has come a long way under the leadership of Michael Johns, the executive vice president for health affairs, and Tom Lawley, the dean of the School of Medicine. There has been a general focus on fiscal responsibility, targeted acquisitions, and high-profile hirings, as well as an increase in grant funding, an improvement in national rankings, and strategic partnerships. Organization has been streamlined and goals met, but much work remains, and our new president may help. In this essay, I offer some observations on potential challenges to the School of Medicine and the university as a whole. Many of my observations were informed by my experience on the Commission on Research at Emory in the last two years.

Grady Hospital –
While my colleagues work hard and show outstanding commitment to this hospital, the reality is that a collision of forces—including billings, collections, and reimbursement trends—are making it nearly impossible to have financially solvent operations at Grady. Grady’s professional and expense budgets provide funding to the School of Medicine. The dean of the medical school then provides operating funds to the school’s academic departments. The Grady clinical finances are separate from the finances of the hospital or clinic. Thus, if Grady fails to deliver, the academic departments suffer, while Emory Hospital and Emory Clinic are relatively spared. This burden cripples the relatively smaller budgets of the academic departments. It hurts recruitment opportunities and ongoing academic development. If the university continues to provide uncompensated service to Grady patients, it might be wiser to equalize the burden across the hospitals, clinic, and university to prevent catastrophic budgetary problems in the academic departments.

Brains vs. Buildings – For the last decade or so, the university has been on a building spree. We have or will have a new hospital in Midtown, new campuses on Clairmont and in Druid Hills, several new science buildings, a new cancer center, a new pediatrics building, and so on. These buildings were all needed. The Research at Emory Commission has suggested it is time to shift priorities from buildings to brains and commit to filling these buildings with top-notch, supported faculty.

The Clinician/Scientist –
Faculty are responsible for most of the university’s academic output. They must teach, research, and serve the institution. For the clinician/scientist, service means seeing patients. As reimbursement margins have thinned, medicine has become a volume-centered enterprise, requiring each doctor to see more patients to make the same amount of money. The result is increased demands on the clinician/scientist. The demands on time are not unique to any group of faculty, but the difference is that the institution provides no salary support for a clinician/scientist. This level of support also affects
the teaching mission. The Dean’s Clinical Investigator program in the medical school addresses this dilemma to some degree, but it is hardly enough if we want this type of faculty member.

The Graduate School – While we have a Graduate Division of Biological and Biomedical Sciences, it controls no faculty salaries and therefore is relatively uninfluential. Currently, departments hold the resources and the programs do the science and teaching. This separation is not optimal. The Research at Emory Commission proposed to change that by empowering a vice provost overseeing the arts and sciences, with real salary lines to support the teaching mission. It is hoped that negotiations in hirings between the newly empowered dean and the other deans would provide sharper focus to the priorities in both teaching and research.

Priorities – The medical school is engaged now in a strategic planning process, but many of its partners and divisions still lack clear plans for the future. We cannot be good at everything, and we do not have the money for it. Therefore, setting priorities will be important at all levels. More important still will be sticking to these priorities. For example, early plans for the Joseph P. Whitehead Research Building called for it to house interdisciplinary groups, uniting scientifically related groups in one place. Instead, much of the space allocation followed standard academic division lines. In part, I think this occurred because of pressure to make more room for current investigators who were squeezed into their previous spaces. In the future, for the faculty to work at peak efficiency, such plans will need to be clearly articulated, financially supported, and followed to fruition.

Bigger is better – Several studies show an inverse correlation between clinical volume and scientific productivity. On the other hand, while Emory Healthcare does receive revenue from tuition, indirect cost recovery from grants and contracts, endowment income, and gifts, as well as clinical income, the hospitals and clinic receive revenue virtually alone from clinical income. A heavy emphasis has been placed on capturing as large a market share as possible in order
to make the academic medical center as a whole fiscally sound. Consequently, the faculty are caught in the midst of a feud over unreconciled priorities. While the right answer to this problem is unknown and we should credit Dr. Johns and his team for keeping us financially afloat, it may be time to reflect on the bigger-is-better effect on academics and faculty retention. As clinician/scientists have less
and less time, their science goes unattended so their patients will not. As their jobs become more similar to those in the private sector, physicians leave for the better pay. It might be reasonable to consider a different balance of clinical and academic work. Do we really need to compete directly with private hospitals and doctors, or can we have a unique market position that marries clinical skill with academic achievement? Can we really be as efficient at three chores as a private practice with one goal? Do we need to be full service, despite some
programs never turning a profit?

The Administration – The administration is here to empower faculty and students to achieve their best. Too frequently in the press of regulation and paperwork, the main goals of a university are forgotten. Creating a risk and reward structure for the administration that recognizes the essential nature of the job but links it to academic productivity may help clear some of the fog.

The Clinic – As the clinical right hand of the university, the Emory Clinic serves the public. In its ranks is an outstanding, hard-working, dedicated group of clinicians. To meet its mission, however, the clinic demands time from the faculty. This is the same time needed for research and teaching. The clinic
(as well as Emory Hospital and Crawford Long Hospital) does pay money to the dean in the form of an academic enrichment fund. Perhaps these payments ought to represent the true cost of a faculty member’s time—or better still the clinic should explicitly endorse research as one of its missions and fund it at a level comparable to that of the university. The separate clinic administration complicates setting and maintaining academic goals. This firewall is a hindrance to coordination of academic activity, and a more porous divide would likely enhance the university mission.

Emory College – In a recent address on “The Health Sciences in Liberal Learning,” Emory president Jim Wagner encouraged health sciences faculty to reach out to
their colleagues in other parts of the university, particularly Emory College. This was a hopeful thing to hear. In my view, the divide between the School of Medicine and Emory College is one of the impediments to the future of both. The college thinks the medical school has hoards of money and has sold out its academic integrity to get more. The medical school thinks the college faculty have it made with guaranteed salaries. The reality is that all faculty feel under stress and less supported than they would like. Emory is relatively unusual in that it has a medical school next to its college. A closer union of these institutions would not result in destruction of the character of either and would enhance the mission of both.

Funding – When we invest in the stock market, most of us buy several stocks or a mutual fund to distribute the risk. We have not applied the same approach to our endowment, however. For practical reasons, it may be unrealistic to divest too much Coke stock, but there are other untapped revenue sources. According to Research at Emory Commission report, Emory lags behind its peers (such as the University of Chicago, Columbia, Duke, and Georgetown) in bringing in unrestricted dollars to its annual fund that could be applied directly to the educational and general budget. Emory’s annual fund averages less than five million dollars, while other programs typically bring in millions more. Another issue that needs to be addressed is openness of finances. While it may be that the endowment is finite and tough decisions need to be made, until the facts are laid out for all to see, skepticism will abound. The cynicism that comes from skepticism will detract from the mission.