The University Record, September 24, 1996


Medical Center Structure and Leadership

By Robert A. Green
Professor Emeritus of Internal Medicine


Enormous uncertainty exists at the Medical Center about its structure and leadership.

There is no permanent dean of the Medical School and no permanent hospitals director, while at the highest University levels we have a soon-to-depart vice president for finance, an all but interim vice president for academic affairs and provost, and an interim president.

In an article in the Ann Arbor News on July 14, interim president Homer Neal, on the subject of the organization and possible reorganization of the Medical Center, is quoted as saying "Harold Shapiro and I (discussed) various topics relating to the preservation and transfer of institutional memory."

As a one-time associate dean of the Medical School, and one-time SACUA chair, I offer a contribution to the institutional memory. Four prior potential opportunities for reorganization will be reviewed in a necessarily short and overly simplified history. All quotations are from the Ann Arbor News article. When the phrase "the University" appears in quotation marks, it refers to the collective gray eminence of University officers and Regents whose specific influence in each decision is unknown to the public.

A bit of background: the University Hospitals director reports to the vice president for financial affairs; the dean of the Medical School, as do the other deans, reports to the vice president for academic affairs, who has the additional position and responsibilities of provost. "Reorganization" has been discussed at two levels: one which would unite the leadership of the Hospitals and Medical School ("One person really needs the responsibility and authority. That's been a problem here for years.") and the other which would unite the Medical School and the Hospitals with all the other health science schools (Nursing, Pharmacy and Public Health) under a vice president for health affairs.


Opportunity #1. Both before World War II and for 13 years after it, the dean of the Medical School was A.C. Furstenberg, a respected ear, nose and throat surgeon, who throughout his deanship maintained the private practice of his specialty at neighboring St. Joseph Mercy Hospitals. The U-M Hospitals were run by A.C. Kerlikowski, who reported directly to Wilbur Pierpont, the vice president for finance. By the end of the Furstenberg era, the need for growth and change was apparent and essential. In 1958 "The University" selected an outsider, W. N. Hubbard, to be dean of the Medical School. It soon appeared obvious to Hubbard, as well as others, that the administrative arrangements were unsatisfactory and impeded growth, but it was also clear that "the University" was unwilling to consider major change during Kerlikowski's tenure. Hubbard turned his attention to internal matters such as the curriculum and strengthening of both basic science and clinical departments. Externally he accepted the presidency of the Association of American Medical Colleges, then changing from a deans' club to an umbrella organization of medical schools, teaching hospitals and academic societies. He also attempted to build bridges and improve communication with the other health science schools by rejuvenating the Division of Health Sciences, an informal grouping of all the health science units under the academic vice president described in the Regents' ByLaws. Twelve years later, in 1970, Kerlikowski retired. "The University" established a high-level committee, chaired by Fedele Fauri, dean of social work, to review and evaluate the Hospitals structure and interrelationships. Its conclusion was that one person needed to have the authority and responsibility in the health area; it recommended a vice president for health affairs. "The University" received the recommendations, reviewed them, and did not accept them. Resistance to change was great, yet something had to be done. "The University" redefined and recreated the "Medical Center" as the Medical School, the Hospitals and the School of Nursing and created the new position of director of the Medical Center to be in charge of all three units. At the same time, however, "the University" ruled that nothing in the governance of the three units would change! Focused authority and responsibility were not part of the reorganization. Hubbard left shortly thereafter, for a positionwith the Upjohn Company, where, as the eventual president, he managed a business venture immensely larger than the Medical Center.


Opportunity #2. Hubbard's associate dean, John Gronvall, became dean and director of the Medical Center, and worked toward achieving rapprochement with the other two units, as it was realized by all that the new structure was unworkable. Indeed, "the University" had decreed that the reorganization would be reviewed after five years. When that time came, a large review committee was put together with major representation from each of the other health-related units on campus, usually by a strong person thought to be opposed to the concept of a vice president for health. As chair "the University" chose a distinguished law school professor, Alfred Conard, a fair-minded person without preconceived notions about medical center organization. Neal Vanselow, subsequently medical chancellor at Nebraska and Tulane, was the medical
school representative. To no one's surprise, the committee found the Medical Center organization unsatisfactory. But to the surprise of many, the committee voted for a vice presidency (Vanselow was said to have been remarkably persuasive). "The University" accepted the unsatisfactory structure recommendation and abolished it, as expected, but instead of moving to a vice presidency, or strengthening the position of Director, it returned to the prior entirely separate structure for Hospitals, Medical School and Nursing School!


Opportunity #3. Harold Shapiro, as academic vice president and later president, studied the issue of Medical Center organization exhaustively. He found that Medical Center concerns took too much time and energy from other University issues. The post of vice provost for medical (not health) affairs was created. Theoretically the Hospitals director would report to the vice provost, as would the dean on clinical issues, while the dean would still report to the academic vice president for non-clinical matters. The reporting lines, however, were dotted even in the University organizational charts, and the line from the hospitals director to the financial vice president remained direct and solid. Any potential for real change would depend, in part, on the energy, vision and ability of the vice provost, and the cooperation and support he or she could engender. The person who initially accepted the position then declined it. George Zuidema, who became the vice provost was, in the words of Ken Trester, "more like the chairman of the board than the president of a corporation." Major change did not occur.


Opportunity #4. In subsequent years medicine and health care underwent tremendous change on the national scene. The fourth potential opportunity for change arose under Duderstadt with Zuidema's retirement. I am unaware of the review and search process that ensued, but at least one internal candidate with impeccable academic and strong administrative credentials, William Kelley, was considered by some a desirable candidate for the post of the single responsible person, at either of the two levels. "The University," however, decided not to proceed in either direction. Kelley left the University. He is referred to in the Ann Arbor News article: "At the University of Pennsylvania one person oversees all the operations."

I have not reviewed the complex pros and cons for and against reorganization. Resistance to change presumably remains great. It is no surprise: that the Hospitals leadership might oppose a move that would remove it from its direct relationship with the vice president for finance, particularly if they were to be, or see themselves as, under the Medical School dean; that the Medical School leadership might oppose a move which would remove the dean from the direct relationship with the academic vice president enjoyed by all the other deans; that the other health science schools might oppose a move which would diminish their status, in reality or appearance, relative to the Medical School; that, as "These are big decisions when you're dealing with nearly half the assets of the university" the Regents might prefer to maintain the direct business relationship of the Hospitals and the financial vice president, free from sometimes conflicting academic concerns; and finally that the University officers themselves might oppose a reorganization which would diminish their own authority by transferring so many resources to a new vice president.

And now opportunity #5 is here. The issues are much more complex than they were in the almost wistfully simpler times 25 and even 10 years ago. It would be presumptuous for me to recommend an outcome, particularly when "the University" has enlisted the aid of numerous experts, consultants and even seers to help in the decisions. Even some options once considered heretical are on the table. Divestiture --- sale of the hospitals to an outside agency --- is one example!! Could a Medical School function effectively without control of its own hospitals? Harvard always has; that model is no longer rare, and a cynic would reply that the Medical School surely does not control the Hospitals now! The obvious necessity, whichever organizational choice is made, is single accountable leadership at the apex of the Hospitals and the Medical School.

I wish the Regents clear vision, decisive thought and even a crystal ball and magic wand as they face the knotty issues. The responsibility is theirs, and although their lack of medical administrative expertise is cause for concern, it might be difficult to create a clearly superior alternative. But once they have decided, I hope "the University" will permit those who will administer whichever system is chosen to do so without interference. I recall Gilbert and Sullivan's Iolanthe, in which non-interference by the House of Peers is predicted to lead to glorious success for Britain.

To conclude: the absence of permanent leadership at five key positions is unprecedented. Under these circumstances is it fantasy to think that the structure might be altered? Is it just possible that the absence of persons with prior involvement and opinions on the issues could lead to change? The spectrum of expectations by the many who await the denouement is wide. The outcome and reasons offered for it should be fascinating.