Insights gained into internal Medical School workings.
Courier-Journal reporter Andrew Wolfson placed a major piece in today’s Courier-Journal about the University of Louisville’s contracts with Excelcor, the company that facilitated several “Opportunities and Threats” surveys for several University-wide programs including its School of Medicine. Issues were raised about the sole-source contracts with Excelcor, the qualifications of that company, its previous relationship with UofL officials, potential for conflicts of interest, the large expense of the contracts, the source of funding, and even whether the results were of any practical use. Senior University officials are in my opinion obviously on the defensive. You can judge for yourself whether their justifications are persuasive. I think not.
I will not comment here on the obvious major issues that were raised. As the article was being prepared, I was asked to comment on the matter and in the course of doing so, I read versions of five individual committee reports from the School of Medicine made available on the website of its Dean. You can read them for yourself (the bottom 5 on this list), or if they are removed, use the links at the end of this post.
For me, the great value of these reports is to provide a few crumbs of insight into what is going on behind the walls of the School of Medicine. For longer than the past three years in which the University has forged its new relationship with Catholic Health Initiatives, very little information has been provided voluntarily. The experience of most of us who are trying to learn more is that individual faculty are reluctant to speak out because of understandable concerns over retaliation. The reports support my belief that the clinical and educational enterprises of the medical school have suffered as resources have been directed to expansion of the University’s commercial enterprises. The recent finding by the Medical School’s accreditors that UofL teaching facilities are inadequate validates my concerns.
General Comments
• Are the reports valuable and helpful, or statements of the obvious? I’ve been through such exercises myself and often wondered how useful they are. I was actually surprised at the degree of frankness and the willingness to air dirty laundry. If this process brought forth some soul-searching on the part of the School of Medicine, then that is a good thing. (I have not yet seen work-product from the other schools.)
It seems to me that most of the recommendations are things that the school should have been doing anyway and knew they should have been doing. Perhaps I am being too cynical or suspicious, but much of the process seems to be focused on initiatives from the Office of the President made necessary by the partnership with KentuckyOne Health or in support of the University’s commercial research and real-estate enterprises. In that sense, the reports give the University additional cover for doing what it has already decided to do. We hope for more than just another lobbying piece.
• Do the reports set forth a good vision for the medical school? For the report of the education committee at least, I think it is a good start. However the school has been trying to do these things for as long as I have been associated with it. The reports will only be of use if they are valued sufficiently by the school to stir them to real change. Some things will work, and some things will not be possible. Continual evaluation and a willingness to revise frequently is what must be called for. If these reports lead to a re-emphasis on education and the University’s clinical operation that have in my opinion suffered at the expense of expansion of the University’s commercial research, real-estate, and sports entertainment initiatives, then they will have succeeded in that respect as well.
• Was it all worth $335,000 for the Medical School? I cannot say, particularly since the documents that were posted are incomplete and do not contain the details said to be in attached appendices. The documents are also in different stages of development. I was not offered an opportunity to participate. The contracts to Excelcor cited in the paper total $1,151,000 to present. This amount would cover the yearly in-state tuitions of almost 50 students! I do not know what Excelcor did to earn the money, but I would have been willing to do it for less! I suspect somebody else might have been willing as well.
• In my opinion, this process appears to me to have been initiated by the Office of the President, and with respect to faculty practice activities and research, are in largest measure focused on bringing faculty activities into agreement with contractual arrangements with KentuckyOne Health and with the University’s commercial research enterprise respectively.
• I think the University should provide the full and final versions of the committee reports with all their attachments and the comments of faculty and staff. I don’t know why it would not be willing to do this because the process itself requires that the work-product be made available to the entire University community. That would include me as I am still a full member of the Executive Faculty of the School of Medicine.
Involvement of Excelcor Staff.
The names of the same three team members from Excelcor are listed on three of the four principal documents so I assume they were involved in all of them. The four committees covered clinical medicine, research, medical education, and community engagement. I believe it unlikely that the Excelcor team had content expertise in all those areas. My working assumption is they were committee moderators helping the in-house expert committee members work through a standard analysis of strength, weakness, opportunities, and threats. The outside contractors also interviewed many “at-large” medical school faculty and staff to gather information for the committees to work with, but none of that is available to me.
Consultant or Coordinator?
I would like to think that a highly-paid “consultant” would offer more than just facilitation of committee work. The University has plenty of people in its own stable who could serve that latter function. There is however, nothing intrinsically wrong with bringing in outside moderators with process expertise.
Frankly, I think some actual outside content expertise and independent evaluation is just what the medical school needs. Lacking that, the likely outcome is that the same old issues will be raised again and little significant change will result. Without the “fresh looks” that outside observers can bring, the committee members are constrained not only by their current experience, but are also more vulnerable to parroting preordained solutions that are priorities of University administration rather than the academic priorities of the Faculty of Medicine. In fact, the former seems very much to be what has occurred.
Where Did This Planning Initiative Come From?
It is my understanding that the medical school is undergoing a major survey by its accrediting agency. This exercise of self-examination may and should have been a part of that process. However I think there is more to it than that. One of the responsibilities of consultants is to help their clients get what they want. Inversely, organizations with preexisting priorities and plans are more likely to hire a consultant that will agree with them. Indeed, having a consultant’s recommendations gives an organization a tool with which to press for its desired goals. These phenomena tend to make final recommendations more predictable than they might or should otherwise be. For example, quite a few of the recommendations involve asking state and federal government for more money. Obviously having a “consultants” report in hand is one step toward reaching that goal.
In my opinion, these reports have the fingerprints of the President’s office all over them, particularly the clinical and research committees, but even in the educational committee report. One of the reports notes that the Dean of the medical school’s participation occurred through “emails.” I would like to have seen her at the head of the process for her own school. Hopefully as the committee process matured, the School of Medicine itself will have more to say about prioritizing the various recommendations.
The Clinical Enterprise Committee in particular has close ties to University Vice President Dr. David Dunn who initially engaged Excelcor. Members include his business partner, Russell Bessette; Jerry Johnson, the individual brought with some controversy from Eastern Kentucky to be Dr. Dunn’s assistant; and others who could not be considered fully independent.
The Best Possible Reason for the Initiative.
Of course, another driving force behind this process is a legitimate desire by faculty and staff to move beyond the obvious problems that are detailed in the committee reports. This is something that organizations of any size should be doing all the time, and is commendable if the organizations are truly committed to change for the better.
Consideration of Individual Committee Reports from the School of Medicine:
Clinical; Education; Research; Community Engagement; and Next Steps.
Clinical Enterprise Report.
This report was of the most interest to me because it reflects the difficult place in which the University has positioned itself by taking sides with KentuckyOne health and Catholic Health Initiatives. It must be said that taking control of the widely distributed independent faculty private practices and the income streams they generate has been a high priority for the President’s office for as long as I have been associated with it. The University has now promised to use its best efforts to get its clinical faculty to practice only at KentuckyOne Health facilities. On the other hand, various faculty practices and departments have long-standing relationships with other institutions that appear to still be very important to them.
The University itself does not have a big primary care network to refer patients to University doctors. Indeed, there is a problem with University doctors even referring to their own faculty colleagues. Despite the formation of the new multi-disciplinary group, UofL Physicians Inc., the University is perceived to have a problem with “branding.” Its doctors are marketed by several hospitals, including those which are competitors to KentuckyOne Health. Even within the University community itself, the faculty practices are considered to be difficult to access for referrals. It seems that not only were University faculty physicians not supportive of University Hospital, but the committee report tells that University faculty physicians are not very supportive even of each other. This and other issues delineated in the report are formidable problems for the University.
The recommendations of the committee include more marketing of University physicians, co-marketing with KentuckyOne, maximizing opportunities with “our new partner, KentuckyOne,” increased self-referral within University faculty practices, changes in specific office practices to facilitate inter-institutional referrals, and more. Internal practice referrals will be measured and “incented by the Dean of the School of Medicine.” [Carrots and/or sticks?] One recommendation states “explore all permissible mechanisms to encourage UofL physicians to refer patients to other UofL physicians, including incentives for an attending physician to see every hospitalized patient every day.” [They aren’t doing that now?]
The University has placed itself between a rock and a hard place by taking sides with a single competing medical system in the community. [The recommendation of a prior set of consultants.] I don’t see how they are going to get out of this. The situations described in the report were worse than I thought and obviously cannot stand if the University’s clinical operation is to have credibility. I commend the committee members for their frankness. I wish them luck.
There is a lot more to be said about the clinical report. It talks about ways of increasing the primary care physician workforce that is necessary to generate referrals to the specialty practices of the University, although I would have thought these more properly should have been in the Education report.
The report also talks about problems with the compensation models for faculty members. Again, some astonishing admissions are made.
The last portion of the clinical enterprise report speaks to the needs of doing more clinical trials, and in particular within the KentuckyOne network. I would have thought this belonged with the research committee. This is yet another element of this report that leads me to conclude that the major thrust of the clinical enterprise report is to serve the interests of KentuckyOne health as much as it does the public University of Louisville.
Vision– Good or Bad?
The vision for the clinical enterprise focuses heavily on consolidating the various University private practices and encouraging, if not mandating, more self-referrals among faculty physicians. I do not think this is a good vision. The university’s problem now is that it is isolating itself from the greater Louisville medical communities. This was an inevitable consequence of choosing sides. It is my understanding that the desired clinical integration is not going as well as hoped for. If the University has not been successful in getting its own clinical services to work well together, it will have even more difficulty requiring them to work exclusively with KentuckyOne. Battening down the hatches of further insularism is not going to help.
Research Enterprise Committee Report.
There is not too much surprising here. The concluding recommendations are to help the strongest research programs get stronger by focusing resources on cancer, neurosciences, cardiovascular diseases, and metabolic diseases. They would like to improve the NIH ranking from number 77 to number 60. [I am assuming they are referring to rank among other medical schools. UofL’s NIH funding rank has hovered around 79 ever since 2001 despite the University’s overwhelming emphasis on research.]
Despite the building of several new research palaces, even more are wanted. Of course the Education Committee is also asking for space and money. I wonder how this internal competition will be adjudicated?
Education Strategic Planning Committee Report.
This is a long report and there is a lot of material in it. It is clear to me that the educators in the school have been feeling left out, unappreciated, under-promoted, and underpaid. They have been saying that for the entire 20 years I was actively associated with the University. The University must give the impression to both its faculty and its accrediting agency that it is serious about supporting medical education. When I became an officer of the University, I was told that the top three priorities would now be research, research, and research. Of course this was meant to be a joke, but was too close to the truth to be funny. It will take action and not promises to convince me that anything is going to be different. The fact that a substantial number of the recommendations from the education committee include NIH research grants and commercial research gives me pause to worry that there will be not any meaningful change in priorities.
I did not fail to notice that one of the recommendations was to “integrate educational mission within KentuckyOne clinical partner framework.” The University of Louisville has joined itself at the hip with Kentucky one. The fate of the two organizations will rise or fall together. This whole series of committee reports appears to me to be shaped in large measure to serve the needs of the partnership. I have already been troubled by the University’s willingness to change its research policy and informed consent guidelines to accommodate Catholic Health Initiatives’ religious directives. The University must take care to protect its academic missions. Not all medical facilities and their staffs are appropriate for the training of medical professionals.
Once again I must give my faculty colleagues and the committee credit for a surprising degree of frankness, given the reluctance of University administration to open many windows. The accrediting Liaison Committee on Medical Education and the public should expect nothing less.
Community Engagement Committee.
This was an interesting report, albeit troubling to me. Once again an emphasis is given to input and participation of the two KentuckyOne Health hospitals in Louisville
Traditionally, University faculty activities have been categorized into three major contributions: clinical, research, and service. The thrust of this report is to add a fourth category in the shape of a reconceptualization of community service or outreach. If I may characterize it, community service, like charity care, is service given without expectation of reward. The new category is called Community Engagement. In this new form of community outreach, some benefit to the institution is now expected. How nice!
To this end, it is recommended that the school “develop appropriate and effective incentives, rewards, and recognition for faculty staff and students including promotion and tenure policies and practices.” Efforts must be made to “ensure that the community engagement plan is aligned, integrated and supportive of the overall strategic aims of the School of Medicine.” [Who came up with this concept?]
I suppose the concept of one hand shaking the other is not intrinsically bad, but “getting something out of it” [my words] offends me for some reason. This is a strange position for a public university to be taking. Hopefully the University will explain this in an understandable and acceptable way to our community, and that the concept of pro bono service has not entirely vanished. In a way, some redefinition was in order because in the past, faculty private practice was also included in “service.”
Full Stop!
I am at 3000 words and must now force myself to stop blabbering on. These documents provide information that may be more fascinating to me than to my readers. There is no doubt in my mind that the final product of this initiative will provide the blueprint for what we will see emerge from UofL in the next few months if not during this Kentucky legislative session. All of us deserve to have confidence that appropriate constituents had a chance to contribute to the outcome.
What do you think? Are there other reports out there that I am unaware of? Did you participate in the process? What did you think of it? What did Excelcor bring to the initiative? Are you content with the way these contractors were hired? Do you like the recommendations? If not, what is the matter with them? Let us know in the comments section, or contact me confidentially and I will summarize.
Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
Jan 19, 2014
Planning Documents (Power Point .pptx)