Ruminations on the Fourth of July, Michigan’s most important upcoming choice, brands, and mad men.

1. Happy Independence Day. The Fourth of July on a Friday this year offers a long weekend for most of us in the Michigan Urology Family, except for those on call or otherwise at work dealing with the inevitable urgencies and emergencies of urology that need attention. With a little luck, their Fourths will be easy and in 2015 they will get their chance to turn off their beepers (if we still have those archaic things). July 4 commemorates a moment in time when some mad men decided to break colonial bonds with England and form a more perfect nation centered on the rights of mankind to life, liberty, and the pursuit of happiness. No matter how you read the founding documents, it is difficult to believe that health care and education are not intrinsic and essential to those rights. We are mighty lucky to live in a place where a stable government and economy allow most people a fair shot at a safe and decent life, with opportunity for their children. By the luck of the draw we do not live in Syria, Iraq, Nigeria, or the many other places where safety and human rights are so massively lacking. The Trumbull painting of the Declaration of Independence depicts the five-man drafting committee presenting its work to Congress. It was a moment of great salesmanship, because many differing beliefs had to be accomodated. You can find the original painting in the Rotunda of the US Capital Building, where its message of accomodation is ignored routinely. A truncated version is found on the two dollar bill, although it cuts off 4 individuals on the left side and 2 on the right. Perversely, the engraver added 2 mysterious figures to the two dollar bill that are not present in the original Trumbull work.

2. A two-dollar bill doesn’t buy as much as it once did and today people may need at least ten of them to handle a co-payment for their clinic visits. With a new fiscal year upon us, however, we need to collect and count those co-pays more carefully. Challenges are ahead in health care and not the least is the implementation of a mandated costly and cumbersome “electronic medical record” that caused us to discard our functional and familiar systems. We are getting used to new programs, but find they are changing our usual patterns of workflow, especially in the operating rooms where we already see deterioration of clinical productivity and morale as well without net gain to the patient or provider. Things will get better and we will cope and innovate our way through this, but whatever spin is given to the story this deterioration in productivity and workplace satisfaction is a fact and will remain so at least in the near future. This is a national story that I hear from colleagues around the country.

3. With changes of leadership at Michigan’s highest levels we anticipate a new sense of an educational vision, hopefully a rich and grand vision, for after all Michigan is a storied educational enterprise. The historic decentralized nature of Michigan’s academic and other units has been a key factor in its many legacies of success, whether in the LS&A School, the College of Engineering, the Musical Society, the Law School, the Athletic Department, the School of Art and Design, the Libraries, or the Medical School to name just a some of our Crown Jewels. The challenge of a university president is curiously binary. On one hand a great president must get out of the way and allow the units of the school to flourish, providing resources and support. On the other hand the president’s grand vision should inspire and bind the schools, colleges, and departments to allow them to develop and pursue their own grand visions, in some alignment with each other. Even better, a leader might synergize and energize the parts to make the university greater than the sum of its units in terms of the regional, national, and international conversations and experiments necessary to create a better “tomorrow.” While leaders often complain that they must make “difficult choices”, leadership is far more than the matters of cost management choices or personal beliefs. It has been said that President Harry Truman once wished for one-handed economists – that is advisors to give him single points of view rather than saying “On one hand this … while on the other hand that … .” Truman favored simple choices between clear positions. Modern life and modern universities, in particular, rarely allow for such simplicity. The world is ambiguous, changing, and full of risks. No single person can have all the answers and create the perfect strategies, but the wisdom of crowds is an emergent phenomenon that has been the central organizing feature of human civilization. The complexity of a great university, being naturally cosmopolitan, affords rich opportunity to extract the great wisdom intrinsic to the diversity of its “crowds.” Effective leaders find ways to use their human capital so as to make the best choices, figure out the best strategies, and run the most useful experiments that will leave our children a better tomorrow. This opportunity works well only in a free society. The ideal leaders for this scenario are not clones of Harry Truman or Steve Jobs, although we certainly need folks like them among other unique players in our crowds.

4. Michigan’s Medical School began in 1850 and was a simpler place back then consisting only of a Department of Medicine and Surgery. In 1869 a faculty house was converted into a dormitory for patients undergoing surgery, a rare event at the time, in the Medical School. Thus Michigan became the first university in the world to own and operate a hospital, although that first version was a primitive one. Soon thereafter a proper hospital was constructed and then another and another until 1986 when the present fifth University Hospital opened its doors. Now we have several additional hospitals and many other facilities. The administrative structure that encompasses the Medical School and Health System at Michigan for the past dozen plus years has been led by an executive vice president for medical affairs. We currently have a gifted leader, Michael Johns, in this position, although only for an interim period. He is a Michigan Otolaryngology alumnus, former dean of the medical school at Johns Hopkins, and recent chancellor of Emory University. The choice of the next EVPMA will be a big gamble for the University of Michigan, perhaps the biggest in its nearly two centuries. The success of our “medical affairs” – and all that they encompass – will drive the University toward the mean or toward the top percentiles in terms of reputation and financial stability.

[Carol Bradford, Mike Johns, & Jim Woolliscroft at UMMS Graduation 2013]

5. I’ve been involved with a number of searches and committees that targeted leaders at lower levels. Some processes have been crisp and successful, but university committees, as we know, can tie themselves up into knots. As one looks at the process of finding a successor to Dr. Johns for this important job it seems to me that two main questions should frame the selection. The first is simply: “As EVPMA what will be your fundamental driving daily concern?” The second question is: “Have you taken an academic health care enterprise from good to great and how can you assure the many tens of thousands of stakeholders at Michigan that you will be able to do this on our scale?” The main answers I would like to hear to the first part of each question are something like: a.) executing, maximizing, and perfecting the essential transactions of health care – one patient at a time and one system at a time, and b.) yes, with good evidence. The questions may appear simple superficially, but actually what are the essential transactions of healthcare? Most assuredly they are the essential transactions of clinic visits, making diagnoses, testing, operative procedures, hospitalization, medication, counseling, reassurance, and provision of supplies. They are also the transactions of deploying clinical teams, creating access to care, implementing new technology, as well as maintaining facilities that are safe, favorable, and state-of–art. The essential transactions of education (at the medical school level, the Ph.D. and postdoc levels, the GME level, and CME levels) not only are part of this spectrum of essential transactions, but they are the foundational purpose of our medical school and hospitals. The essential transactions of scholarship, research, and technology transfer speak for themselves, forming a core expectation by society from its universities and the global healthcare enterprise.

6. If we get this leadership choice and our clinical business right then everything else will follow – excellent education, excellent discovery, and solid financial performance. Our mission is described as tripartite: education, research, and clinical care. However, of the three parts clinical care stands apart. It is not merely the context for education and discovery, but also something more. Once responsibility is assumed for clinical care it becomes the moral trump card – subjugating either other part at any given moment. As it happens the clinical care piece, in today’s world, is also the economic engine on which the rest of the missions depend. Dr. Johns understands this story and the necessary intangibles of tomorrow’s healthcare leadership. We hope his successor will understand as well.

7. Academic medicine is always in the business of job searches, less often for presidents and EVPMAs, but more often for faculty, residents, nurses, administrators and staff. Many of these people are sought for specific leadership positions, but nearly everyone we hire will be or will become a leader of one sort or another. Tomorrow’s leaders need to be far different than those of yesterday. Most jobs have a primary expectation that is usually defined unambiguously in the title. Our next EVPMA is being sought to manage medical affairs, a complex and high-stakes expectation in FY 2015 USA. Such a job description does not and should not specifically seek a cardiac surgeon, urologist, health service scientist, anatomist, pathologist, RO1 funded researcher, health policy expert, nursing educator, medical school dean, or managed care CEO. While I believe the specific attributes for a major health care leader can be found in the two questions posed earlier, a number of essential personal characteristics (many are obvious, some are intangible) for any leader fall into three categories and apply with increasing importance up the ladder of higher levels of leadership. I have enjoyed batting these thoughts around and refining them with a number of colleagues and our leaders. A. Personal characteristics: kindness, moral center-character-integrity, sense of humor, stability, social flexibility, competence, and ability to listen > propensity to talk. B. Intellectual: curiosity, ability to deal with complexity & ambiguity, skill in finding clarity, high intelligence quotient, and higher emotional quotient. C. Organizational: shared beliefs and sense of mission with the organization, a “hands-on” capability coupled with proven record of successful delegation, consensus gainer, drive to understand stakeholders & value streams, decision-maker, team player, team-builder acquisitive of diversity, solid record of accomplishment, and will to lead.

8. Higher education in America historically focused on leadership. This happened first in 1636 with the founding of Harvard College, intended to produce the next generation of civic leaders, who at the time were mainly clergymen and public figures. A second generation of higher education began in 1824 when Rensselaer Polytechnic Institute, technically-focused as its name, was fashioned on European models of higher education to create a new generation of builders and entrepreneurs. A third generation was epitomized in 1891 at the University of Chicago where the higher degree of Ph.D. became the focal point for the full-fledged implementation of a research university. Sometime since then, a new model of higher education has evolved and Michigan is a prime example. This quaternary iteration (I can find no better descriptor) encompasses schools that indeed prepare sectarian and nonsectarian leaders, as well as engineers, architects, teachers, lawyers, healthcare workers, and other key participants of modern society. In addition these universities are still the powerful research engines that provide the new knowledge on which tomorrow will depend. However this fourth generation university also encompasses performing arts, athletic teams, technology transfer, patents, business ventures, health care enterprises, social policy development, global liaisons, and other pursuits intended for the well-being of mankind and the planet. Universities are the single entity in modern civilization that exists for the purpose of fashioning a better tomorrow.

9.
The Quaternary University actually might not be such a bad term, it occurs to me. When you look up quaternary on Wikipedia you find it refers to the most recent of the time periods of the Cenozoic Era in the geologic time scale. This period began around 2.6 million years ago and is characterized by two big facts: one was (and is!) the series of glacial expansion and contraction and the other has been the proliferation of anatomically modern humans. The Quaternary Period is split into 2 parts called epochs – the Pleistocene and current Holocene, but many experts suggest that a third epoch, the Anthropocene, be considered as the era when humans began to profoundly change the global environment. If we are going to change the self-limiting path of the Anthropocene, quaternary universities may be our best (and last) hope.

10. However you may consider this time on our small blue dot of a planet (metaphor from Carl Sagan), our species has strongly marked its brand on it. The idea of branding hit full expression in healthcare recently. In the Midwest, the Mayo Clinic has been long-venerated brand since its early years under William Mayo (MD, Michigan class of 1883) and Charles Mayo (MD, Northwestern class of 1888). Henry Ford Clinic (1915) and Cleveland Clinic (1921) followed chronologically as similarly cherished brands in health care. In some ways the Michigan Block M brand in health care is a newer effort, in spite of the UM’s long history. This branding puts a label or sound bite on something that has long-existed. Patients have been seeking Michigan’s hospitals for care and physicians have been calling on UM physicians for help with their sickest patients since that first university hospital in 1869. Nowadays health care is far more complex than it was even 50 years ago requiring large coordinated teams, extensive facilities, expensive technologies, and complex systems. Health care is also far more competitive with billions of dollars in play even at single sites. Direct marketing of health plans and health care systems to prospective patients has caused even the smallest practices, hospitals, and health care systems to develop and advertise their brands. Everyone needs a brand to survive, so it seems. While commercial branding in health care is good news for television and newspaper advertising revenues, it does little to further the public good and diverts dollars from care, supplies, education, research, and development. However, it is a game that seems to be necessary today as even some of the most mediocre healthcare establishments taut their “international excellence” although marketplaces of public opinion eventually differentiate among products that are great, good, or poor. Even the slickest advertising campaigns ultimately fail if their objects of attention fall short.

11. The Economist Magazine last spring offered an article on Wally Olins, a man described as “a high priest of the religion of branding.” The intellectual footprint of Olins, who died 14 April 2014, is visible today all across the planet. To quote from the article: “The idea that not just bars of soap but organisations, people and places can have brands is such a commonplace one that it is easy to forget how recent it is. In the 1960s admen concentrated on devising brands and campaigns for specific products and markets, rather than creating an identity for the companies that made those products. The industry that churned out these campaigns was dominated by a handful of giant ad agencies, each divided between an officer corps of ‘suits’ (who managed the accounts) and an army of lower-status ‘creatives’ (who wrote the jingles).” [Schumpeter: The ascent of brand man. The Economist April 26, 2014. p. 66]

12. Interestingly, the Olins article was carried not in the obituary section of The Economist, but in the section called Schumpeter, named after Joseph Alois Schumpeter (8 February 1883 – 8 January 1950). This Austrian American economist and political scientist briefly served as Finance Minister of Austria in 1919 but was one of the most influential economists of the 20th century. He popularized the term “creative destruction” in economics and the weekly Economist section, under his posthumous byline explores themes that give evidence of that nature. While the idea of creative destruction is currently quite popular in healthcare, Schumpeter’s take on creative destruction was a rather dark view of evolutionary economics. He predicted that as capitalism leads to corporatism, the resulting social backlash would be antithetical to entrepreneurship and corporatism would become replaced by “laborism.” At least this is my take, as a non-expert in the dismal science.

Nevertheless, mad men matter and they seem to be mattering more in health care recently. The television series Mad Men began nearly 7 years ago, first airing on 19 July 2007, and its final “season” will end in 2015. While the show is entertainment its “fiction” hits close to the home of truth and reminds me of Daniel Pink’s important book “To Sell is Human.” (If you want a 30-minute version of this book you can find it, of course, on Amazon.) In a free society each of us is a salesman, and this is especially true in academic medical centers, where we sell our ideas, our expertise, our clinical services, our systems, and our trainees. As the current generation of Michigan’s faculty, residents, nurses, PAs, researchers, staff, and administrators we safeguard the integrity and the quality of our products that bear the Michigan imprimatur of “leaders and best.” We carry the honor of this responsibility one patient at a time, one resident at a time, one scientific presentation at a time, one clinic at a time, one site at a time, and one ACO at a time. Every time we fall short in any of our essential transactions of healthcare (and one way or another, at one time or another this will happen to each of us) we place our brand at risk. Perhaps, however, part of the Michigan difference is the individual and corporate learning that we derive from experience to improve ourselves, our products, and ultimately our brand. The stakes for us and the Michigan brand have never been higher and our future is more heavily contingent on the choice of the next EVPMA than for that or any other position at any time in Michigan’s past.

Best wishes, Happy Fourth of July, and thanks for spending time on “Matula Thoughts.”

David A. Bloom, M.D.