At University of Miami, Faculty Without Confidence in their Hired Managers Afraid to Identify Themselves

The University of Miami has provided some vivid examples of the contrast between the power and privileges of the leaders of large health care organizations and the subservient role of faculty and staff. <br /><br /><b>Background </b><br /><br />Back in 2006, we <a href="http://hcrenewal.blogspot.com/2006/02/tale-of-three-ironies-university-of.html">noted</a> that while the University of Miami was paying its janitorial support staff less than seven dollars an hour, and supplying them with no health insurance, its President, Donna Shalala, was living in a 9000 square foot official mansion, with staff hired to make her bed.  While Ms Shalala did not seem very perturbed about the living conditions of the lowliest University staffers, as a member of the board of directors of UnitedHealth, she approved the munificent compensation given to its then CEO, Dr William McGuire (look <a href="http://hcrenewal.blogspot.com/2006/03/questionable-timing-of-unitedhealth_20.html">here</a>), who was a billionaire until he was forced to give up  some of the backdated stock options she had approved (look <a href="http://hcrenewal.blogspot.com/2009/08/final-settlement-of-unitedhealth.html">here</a>).  More recently, we discussed how Ms Shalala's "visionary" leadership included presiding over the hiring of Dr Charles Nemeroff, who had previously been forced to resign as chairman of psychiatry at Emory University for various unethical activities (look <a href="http://hcrenewal.blogspot.com/2011/06/embedded-networks-of-influence-in.html">here</a>).  Last year, while awaiting the construction of a new presidential mansion, Ms Shalala presided over layoffs of hundreds of faculty and staff, which may have been necessitated by bad spending decisions made by her or those who reported to her (look <a href="http://hcrenewal.blogspot.com/2012/06/university-of-miami-lays-off-800-cuts.html">here</a>).  <br /><br /><b>The Faculty Protest </b><br /><br />All these shenanigans apparently finally succeeded in upsetting the faculty, as described in a <a href="http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html">new article</a> in the Miami Herald.  The article's headline was about the resignation of the University of Miami Miller Medical School's second highest ranking executive in response to faculty anger:<br /><br /><blockquote class="tr_bq">Amid roiling faculty anger over drastic budget cuts, the University of Miami announced that the No. 2 executive at the Miller School of Medicine, Jack Lord, is 'stepping down.' </blockquote><br />Dr Lord was apparently taking the fall for the previous mass layoffs, some affecting faculty in 2012:<br /><br /><blockquote class="tr_bq">[Medical School Dean Pascal]  Goldschmidt defended his administration’s performance: 'Last year we had many challenging issues to fix, as do many medical schools in the U.S. Thanks to Jack Lord’s leadership and hard work by everyone at the Miller School, we have met those challenges and turned things around financially.'  The announcement comes after a tumultuous year<i> in which the medical school suffered a severe financial crisis and its leaders responded with a major overhaul that included the layoffs last spring of over 900 full-time and part-time employees </i>— moves that angered many professors.<br /><br /> In a letter to faculty sent on Wednesday, Goldschmidt insisted the problems have been fixed. Goldschmidt credited Lord for helping improve the medical school’s finances, which showed a surplus of about $9 million for the first six months of this fiscal year — compared to a $24 million loss for the first six months of the previous fiscal year.<br /><br />Lord, a physician who had been an executive at Humana, became chief operating officer last March, as the restructuring plans started. </blockquote><br />However, the faculty's anger was not just directed at Dr Lord, who as noted above seemed to have been hired to take responsibility for the layoffs:<br /><br /><blockquote class="tr_bq">The change, announced by Dean Pascal Goldschmidt, comes as a petition circulates among tenured medical school faculty <i>expressing no confidence in both Goldschmidt and Lord</i>.</blockquote>In particular,<br /><br /><br /><blockquote class="tr_bq">Meanwhile, several sources sent The Herald a copy of a petition being circulated among school faculty members who 'wish to express, in the strongest possible terms, the concern we feel for the future for our school of medicine.' The petition blamed 'the failed leadership of Pascal Goldschmidt and Jack Lord. ... We want to make clear that <i>the faculty has lost confidence in the ability of these men to lead the school.</i>'</blockquote><br /><br />Furthermore,<br /><br /><blockquote class="tr_bq"> Many faculty members, who had spent decades at the medical school without seeing mass layoffs, were angry that the cuts were made without consulting them. A report by a faculty senate committee said medical school professors described the layoffs as 'unprofessional,' 'graceless' and 'heartless.' </blockquote><br />Yet there is no hint that Dr Goldschmidt, or President Shalala to whom he reports are yet affected by this protest.   <br /><br /><b>Tenured Faculty Scared into Anonymity</b><br /><br />In fact, while the faculty are upset, they are also afraid.<br /><br /><blockquote class="tr_bq">The report contended that the internal turmoil had prompted some faculty members to consider leaving and that <b><i>'fear is widespread.</i></b>' It also cited instances of <b><i>employees suffering retribution for criticizing the administration.</i></b><br /></blockquote>There is so much fear that the faculty constructed an elaborate mechanism to register protest while remaining individually anonymous.<br /><br /><br /><br /><blockquote class="tr_bq"> A half-dozen people closely connected to the medical school who requested anonymity told The Herald that they’ve heard that <i>between 400 and 600 of the school’s 1,200 faculty have added their names to individual copies of the petition.</i><br /><br />The petitions are addressed to the chair of the faculty senate, Richard L. Williamson, a law professor. Williamson said last week he would not comment on how many had signed the petition because it was 'an internal matter' and may never become public. He said the number of those who know how many have signed is 'extremely small and none of them will talk.'<br /><br />Three sources told the Herald that faculty are <i>sending individually signed copies of the petition to the senate chair with the understanding that Williamson <b>would not reveal their names to UM administrators</b></i>. </blockquote><br /><b>Summary </b><br /><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198_p2/um-medical-school-names-new-coo.html#storylink=cpy</div><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div><br /> So, up to half of the University of Miami's medical faculty may be so upset with the current administration, apparently in part due to faculty and staff layoffs after questionable decisions by administrators some of whom may have lived large at university expense, that they essentially voted no confidence.  Yet the faculty are afraid to put their own names on their protest.<br /><br />So this is not just a story about allegedly incompetent university executives, and about the contrast between the rewards such executives get and the results of their dubious management.  It is also a story about how the executives' power now threatens a bed-rock value of academia, the ability of faculty (and by extension, staff and students), to speak freely, even if that speech offends the university's management.  In this case, while apparently hundreds of faculty condemned the administration for autocratic, incompetent, self-serving actions, they all feared what that same administration could do to them if their identities were known.<br /><br />In the last few years there has been a lot of prattle about the "flat organization," and there have probably been at least a few small high technology start ups that really were run on a collegial basis.  However, as we have shown again and again, throughout the corporate world, extending to health care corporations, and then to non-profit health care organizations, top management insiders have assumed more power and <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">paid themselves better and better </a>at the expense of all others (look <a href="http://hcrenewal.blogspot.com/2009/12/compensation-madness-insiders-hijacking.html">here</a>).  Even now in universities, which used to be examples of collegiality, and were run in somewhat democratically  by their faculties, faculty are obviously afraid to challenge the hired managers. <br /><br />Clearly, universities in which faculty cannot disagree with management are not going to be able to exercise the free enquiry that is core to their academic role.  In a health care context, why should anyone trust medical schools or academic medical centers run as tin-pot dictatorships by some hired executives?  Clearly, real health care reform would restore free speech and free enquiry to academic medicine.<br /><br />Hat tip to Prof Margaret Soltan <a href="http://www.margaretsoltan.com/?p=38728">on University Diaries</a>.<br /><br /><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div><div style="color: black; font: 10pt sans-serif; height: 1px; overflow: hidden; text-align: left; text-transform: none; width: 1px;"><br />Read more here: http://www.miamiherald.com/2013/01/03/3166198/um-medical-school-names-new-coo.html#storylink=cpy</div>

At University of Miami, Faculty Without Confidence in their Hired Managers Afraid to Identify Themselves

The University of Miami has provided some vivid examples of the contrast between the power and privileges of the leaders of large health care organizations and the subservient role of faculty and staf…

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Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists - Did ONC Ignore This?

<div style="text-align: left;"><span style="font-size: x-small;">Note: Also see the followup Sept. 5, 2012 post "<b>Was EPIC successful in watering down the Meaningful Use Stage 2 Final Rule?</b>" at <a href="http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html">http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html</a>.</span></div><br />-----------------------<br /><br />From the Histalk blog in the 8/31/12 news <a href="http://histalk2.com/2012/08/30/news-83112/" target="_blank">at this link</a>:<br /><br /><blockquote class="tr_bq">Epic not only submitted MU Stage 2 comments to ONC, it even helpfully distributed them to their customers so they could submit the same comments under their own names. <a href="http://dclunie.blogspot.com/2012/08/why-onc-whimped-out-annotated.html" target="_blank">David Clunie</a> noticed this and lists the hospitals who sent in the boilerplate, including University of Miami, <b>which submitted the same comments five times without noticing the “Remove Before Submitting” headline that prefaced Epic’s explanation of why its customers should share its opinions with Uncle Sam.</b></blockquote><br />From the primary source linked in the Histalk note:<br /><br /><blockquote class="tr_bq"><a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0147" target="_blank">Epic via University of Michigan Health System Meaningful Use Workgroup</a> also the <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0241" target="_blank">same Epic comments from University of Miami</a> <b>(who liked them so much they <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0241" target="_blank">submitted it twice</a> and then a <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0326" target="_blank">third time</a> and then a <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0313" target="_blank">fourth</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0299" target="_blank">fifth</a> time)</b> and again from the <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0123" target="_blank">Martin Health System</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0137" target="_blank">Metro Health Hospital</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0306" target="_blank">The Methodist Hospitals</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0404" target="_blank">Fairview Health Services</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0358" target="_blank">Sutter Health</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0338" target="_blank">Parkview Health System</a> and the <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0284" target="_blank">Everett Clinic</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0255" target="_blank">Dayton Childrens'</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0254" target="_blank">UMDNJ</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0243" target="_blank">NYU Langone Medical Center</a> and <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0142" target="_blank">Hawaii Pacific Health</a> and finally as submitted by <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0285" target="_blank">Epic themselves</a> - others like the <a href="http://www.regulations.gov/#%21documentDetail;D=HHS-OS-2012-0004-0158" target="_blank">Community Health Network</a> just stated they had read and agreed with Epic's comments - Imaging - concur that DICOM is not needed for that objective and PACS images do not need to be duplicated - concerned about single sign on if two systems - View, Download and Transmit to 3rd Party - images are not in the EHR but the PACS - patients would need DICOM viewers - size of the images is a problem - disks are better (<b>also if you look at some copies of this, there are some pretty funny "<i>remove before submitting to ONC</i>" notes that say things like which versions support what and how much it would cost to retrofit, etc.; how embarrassing, both for Epic and their lackeys at these institutions)</b></blockquote><br />I certainly admire David Clunie's endurance at being able to slog through all of that and appreciate his shedding some sunlight on the "remove before submitting" notes, but - I don't think it's funny at all.<br /><br />Among other things, it represents <b>taint of the submissions </b>via <a href="http://hcrenewal.blogspot.com/search/label/ghost%20writing" target="_blank">ghostwriters</a> (unattributed authors) with obvious <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest" target="_blank">conflicts of interests</a>, topics often addressed at HC Renewal.<br /><br />Here's an example I verified, the submission to the government from Dayton Children's Hospital:<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirxuPSNKvfNLmw5qDGu4JlMVP-MPi6cFKz36m3M_3lZOGY90p1U3Tw36P-mHfyXcyEVGviytPAI6tSdBcvjEgKryW9vAZbve_nooHA5H5vj4Fhdgt7Zn83CBGGrHw6qAX9nedacFQbfZxS/s1600/remove_before_submitting.bmp" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="348" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirxuPSNKvfNLmw5qDGu4JlMVP-MPi6cFKz36m3M_3lZOGY90p1U3Tw36P-mHfyXcyEVGviytPAI6tSdBcvjEgKryW9vAZbve_nooHA5H5vj4Fhdgt7Zn83CBGGrHw6qAX9nedacFQbfZxS/s400/remove_before_submitting.bmp" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><b>"Informational Comments for Organizations Using EPIC (remove before submitting to ONC)"</b> - click to enlarge.  At least here they say they are "in total agreement"<i> with EPIC's concerns and recommendations</i>.  <br /><br /></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td></tr></tbody></table><br /><br />Another example - University of Miami:<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOJPENnCLi6R2iGZR_GWK9akDzTBYxtYsy5YZi0rONJsZqF8FSCNxjVeO1MUYeGQLEHOqG8vndOhgb2rUn9OWCSMUNLLXGrtAjJAE9CNRdd4WLijC4RFOjLwEvXwoV4B2pF_awkyAzyTLl/s1600/miami.bmp" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="392" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOJPENnCLi6R2iGZR_GWK9akDzTBYxtYsy5YZi0rONJsZqF8FSCNxjVeO1MUYeGQLEHOqG8vndOhgb2rUn9OWCSMUNLLXGrtAjJAE9CNRdd4WLijC4RFOjLwEvXwoV4B2pF_awkyAzyTLl/s400/miami.bmp" width="400" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><b>A danger of dealing with incompetents:  they neglect to tidy up for you</b> - click to enlarge.  (Corollary question: note the line "<b>Our</b> <b><i style="color: red;">[Epic's - ed.]</i></b> comments stem from the fact the <b>we believe </b>..."  So - what opinions belong to the 'public commenting organization', and which to the company?  Likely the whole thing belongs to the latter's ghostwriters, but can anyone really tell?  That's the problem with tainted submissions.)</td></tr></tbody></table><br />Others is the links above I checked such as Martin and Methodist have the same boilerplate about the "chart search feature."  Some retain the "reminder" to remove; in others it has been erased.  However, the boilerplate remains.<br /><br />I actually find the "advice" from EPIC in the latter document stunning regarding a "chart search feature" (e.g., search note text, and probably also ad hoc clinical searches such as 'find my patients whose blood sugars have been > 100 in the past month'). <b> These are "features" critical to quality care that <i>should have been present decades ago</i></b> <b>**</b> [see note below].  Emphasis mine:<br /><br /><br /><blockquote class="tr_bq">... Focus certification on the <b>minimum floor set of capabilities required to complete meaningful use objectives. </b></blockquote><br />Is this a tacit admission "certification" is a sham?  Is this in patients' best interests?<br /><br />and <br /><br /><blockquote class="tr_bq"><b style="color: red;">Informational Comments for Organizations Using Epic (remove before submitting to ONC) </b><br />We’ve heard your requests for a chart search feature, and our desire to see this certification criterion removed does not mean we don’t want to develop such a feature. <b>In a future version of Epic</b>, we want to develop the best possible chart search feature based on your input. <b>However, if this criterion stays in the Final Rule, we worry we’ll have to divert attention from future chart search features you’ve requested to focus on a simplified, less valuable version of the feature to meet certification.</b> </blockquote><br />In my opinion, this translates to: "we are already overextended, so help us stymie the experts' and government's efforts to make it a criteria for certification, and to hell with your doctors and nurses who need a search feature right now."<br /><br /><b>Can you imagine in 2012 a word processor, database or operating system without a search feature?</b>  That's the kind of antediluvian IT the clinicians have to put up with.  <i>And this industry speaks of "innovation?"</i><br /><br />It would come as no surprise - to me, at least - if other health IT sellers were engaged in similar activities.<br /><br />I am unable to judge whether stealth lobbying by sellers using their clients, which enables the sellers to then line their pockets through favorable government legislation based on echoed comments of clients, is legal or ethical.  My belief, however,  is that it is at best a questionable practice.  It is certainly <b>inherently unfair e.g., <i>anti-competitive</i> in regard to smaller health IT companies</b><b> </b>who might be able to meet more stringent MU2 certification criteria<b>, and unfair to private citizens </b>who have no such captive mouthpieces at their beck and call.  <br /><br />While perhaps not as bad as possible<i> 'Combination in Restraint of Trade'</i> as in my April 2010 post <b>"Healthcare IT Corporate Ethics 101"</b> (<a href="http://hcrenewal.blogspot.com/2010/04/healthcare-it-corporate-ethics-101.html" target="_blank">link</a>), this situation should probably be brought to the attention of health IT watchdogs such as Sen. Grassley.<br /><br />This May 2012 post might also be of interest:  <a href="http://hcrenewal.blogspot.com/2010/05/did-epic-ceo-judy-faulkner-of-epic.html" target="_blank">Did EPIC CEO Judy Faulkner of Epic declare that 'healthcare IT usability would be part of certification over her dead body'?</a>  ONC never responded to the questions I raised in the post.<br /><br />Another question:  why did ONC <b>apparently turn a blind eye towards these "accidental inclusions"? </b><br /><br />Yet another question:  <b>is the MU2 Final Rule invalid</b> due to the influence the industry clearly had on the submitted "public" comments, which can now reasonably be viewed as tainted?<br /><br />-- SS<br /><br /><b>Addendum:</b><br /><br />I've informed the Senator via his email and staff voicemail lines.  I've also created a short URL to more conveniently access this post:  <a href="http://www.tinyurl.com/epic-stealth">http://www.tinyurl.com/epic-stealth</a><br /><br />Also see the followup Sept. 5, 2012 post "<b>Was EPIC successful in watering down the Meaningful Use Stage 2 Final Rule?</b>" at <a href="http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html">http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html</a>.<br /><br />-- SS<br /><br /><span style="font-size: x-small;">Note:</span><br /><br /><span style="font-size: x-small;">**<b> </b>For instance,<b> </b>I had  implemented a robust search feature of clinical notes, all comment fields and the comprehensive clinical, genetic and genealogical dataset in the Yale-Saudi Clinical Genetics EHR - <b>in 1995.</b></span>

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Health IT Vendor EPIC Caught Red-Handed: Ghostwriting And Using Customers as Stealth Lobbyists - Did ONC Ignore This?

Note: Also see the followup Sept. 5, 2012 post "Was EPIC successful in watering down the Meaningful Use Stage 2 Final Rule?" at http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html…

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More "Visionary" Leadership That Turned Out to be "More Interested in Flash than Substance" - Continuing Troubles at the University of Miami

Over the last 20 years or so, health care organizational leaders somehow ceased to be mere mortals, and became visionaries.  The latest example of how their visions turned out to be cloudy <a href="http://www.miamiherald.com/2012/07/22/2918375/um-med-schools-big-ambitions-led.html">appeared</a> in the Miami Herald.<br /><br /><strong>Background: Donna Shalala as "Visionary" President of the University of Miami</strong><br /><br />Donna Shalala, formerly the US Secretary for Health and Human Services, became President of the University of Miami in 2001 (see her official biography).  She has since been hailed literally for her "<em>visionary leadership</em>" (as <a href="http://www.med.miami.edu/news/view.asp?id=466">recipient</a> of the Health Leadership Award from the National Hispanic Medical Association in 2005).  In 2008, then US President George W Bush <a href="http://weblogs.sun-sentinel.com/news/politics/dcblog/2008/06/bush_awards_donna_shalala_meda_1.html">awarded</a> her the US Medal of Freedom, the highest US civilian award, as "one of our nation’s most distinguished educators and public officials. She has <em>worked tirelessly to ensure that all Americans can enjoy lives of hope, promise and dignity</em>.")<br /><br />At the University of Miami, as <a href="http://chronicle.com/article/Fast-Growth-Strategy-Has-Its/127941/">described</a> in a detailed investigative report by Paul Basken in the Chronicle of Higher Education in 2011, Ms Shalala pursued a grand strategic vision to " bring the University of Miami into the ranks of the nation's elite research universities."  In an interview at that time, she claimed to have had "a very disciplined strategic plan to make this place much, much better, to move into the top ranks of American universities."<br /><br /><strong>Cracks in the Wall Appear in 2011</strong><br /><br />However, Mr Basken reported that by 2011, that strategy was showing signs of failure.  He noted problems including rising deficits and a worsening credit rating; allegations that the university was failing to meet the needs of the poor patients for whom its doctors had traditionally cared for at Jachson Memorial Hospital while favoring paying patients at its newly acquired medical center; and concerns about conflicts of interest affecting top leadership of the university, including Ms Shalala (see our post <a href="http://hcrenewal.blogspot.com/2011/06/embedded-networks-of-influence-in.html">here</a>).  At the time, university leadership scoffed at the importance of these problems.  For example, Ms Shalala ridiculed doctors "who gripe" that the university had become over-extended by pushing research over patient care as "these people complaining they want to <em>live their little lives</em> without being researchers."  <br /><br />After the 2011 report came out, Ms Shalala <a href="http://chronicle.com/article/Shalala-Articles-Conclusions/128021/">ridiculed</a>  it in print as "a shocking example of irresponsible and lazy reporting."<br /><br />Note that on Health Care Renewal, we had previously raised questions about Ms Shalala's conflicts of interests, particularly her role on the board of UnitedHealth at the time its CEO was receiving hundreds of millions in back-dated stock options (in 2006, look <a href="http://hcrenewal.blogspot.com/2006/03/questionable-timing-of-unitedhealth_20.html">here</a>); and about her priorities, including the contrast between her lavish compensation, which encompassed her residence in a fully-staffed mansion, and how the university treated its low level workers, particularly its janitors who did not receive health insurance (also in 2006, look <a href="http://hcrenewal.blogspot.com/2006/02/tale-of-three-ironies-university-of.html">here</a>).  <br /><br /><strong>The Cracks Widen in 2012</strong><br /><br />In retrospect, Mr Basken's article appears quite responsible and accurate.  Last week the Miami Herald <a href="http://www.miamiherald.com/2012/07/22/2918375/um-med-schools-big-ambitions-led.html">reported</a> that Ms Shalala's "ambitious moves vaulted UM’s medical school to the national stage — but they may also have seriously damaged it."  Soon after Ms Shalala ridiculed the Chronicle of Higher Education article, already internal reports showing even more trouble were appearing.  <br /><blockquote>As far back as October, billionaire car dealer Norman Braman wrote in a memo to fellow UM trustees that he and colleagues had been receiving anonymous letters for months 'outlining <em>a host of wrongdoings,</em> mostly at the medical school. Braman and others closely tied to the school warned UM officials the medical school was spending too much, too fast in the push to build a world-class medical center.</blockquote><br />There were problems beyond those described by the CHE article:<br /><blockquote>The medical school also had major problems of its own. According to internal documents, the school suffered from <em>bloated staffing, a faulty billing system and prices that sometimes ran much higher</em> than at other South Florida hospitals. <em>Internal controls apparently were weak</em> at best: A whopping $14 million in expensive cancer drugs disappeared from a UM pharmacy over three years before an employee was charged with theft in June 2011.<br /><br />The medical school’s difficulties even began to impede its relationship with the ailing, taxpayer-financed Jackson Health System, endangering a decades-long partnership with the public hospital system.</blockquote><br />The Herald article includes substantially more detail to support these assertions. <br /><br />Trustee Braman summarized it thus:<br /><blockquote><em>Poorly conceived decisions by the medical school administration have put the university at significant risk</em> and, at the same time, injured Jackson Memorial Hospital.</blockquote><br />As we <a href="http://hcrenewal.blogspot.com/2012/06/university-of-miami-lays-off-800-cuts.html">noted</a>, earlier this year the university's financial problems lead to layoffs, but at the same time, the university was building an even fancier mansion for President Shalala. After the lay-offs, Braman said they were:<br /><blockquote>a real tragedy that never should have happened. ... The <em>people at the top were very much more interested in flash than substance</em>.</blockquote><br /><strong>Summary</strong><br /><br />Since the early 1990s we have suffered the rise of extremely confident, extremely well-paid, "visionary" health care leaders. Anyone within the organization who doubted their visions risked being labeled a malcontent or worse. Any skeptic outside the organization might be met by a barrage of propaganda from the organization's well financed public relations operation. Yet the visions these leaders produced often appeared to be clouded at best. <br /><br />One of the most striking early examples remained anechoic for a long time. The then CEO of the Allegheny Health Education and Research Foundation, Sharif Abdelhak, was publicly labeled a "visionary" and "genius" for assembling a large, vertically oriented health care system, which eventually went bankrupt. Abedlhak went to jail. (Look <a href="http://hcrenewal.blogspot.com/2012/04/pittsburgh-experiment-ii-another-echo.html">here</a> for summary). In the greater business world, whose culture now seems to rule health care, there are other examples of such failed visionaries (look <a href="http://hcrenewal.blogspot.com/2012/05/ceo-as-false-messiah.html">here</a>).  Yet this case, and other since, have largely been ignored.<br /><br />However, as the case of the leadership of the University of Miami now seems to show in retrospect, many people seem to fall again and again for the now tired hucksterism of the "visionary," or "genius" leader selling grandiose and often self-serving pipe dreams. <br /><br />Maybe it would be enough in health care to simply aspire to good patient care, responsible education, and honest research. <br /><br />Meanwhile, health care professionals, health policy leaders, and the public at large should start showing appropriately pointed skepticism of our current self-proclaimed "visionary" leadership.

More "Visionary" Leadership That Turned Out to be "More Interested in Flash than Substance" - Continuing Troubles at the University of Miami

Over the last 20 years or so, health care organizational leaders somehow ceased to be mere mortals, and became visionaries.  The latest example of how their visions turned out to be cloudy appeared in…

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University of Miami Lays Off 800, Cuts Research Funding, Builds New Presidential Mansion

Despite the trillions of dollars flowing through the US health care systems, prominent not-for-profit health care organizations seem to be complaining more often that the money going to them is not enough.  <br /><br /><strong>The Lay-Offs and Research Cutbacks</strong><br /><br />Recently, for example, the University of Miami announced that its medical center would have to tighten its belt.  In April, <a href="http://www.miamiherald.com/2012/04/24/2765289/um-medical-school-cutbacks-coming.html">according to</a> the Miami Herald,<br /><blockquote>University of Miami President Donna Shalala announced Tuesday that <em>the medical school will take 'difficult and painful but necessary steps' next month to reduce costs, including staff cuts</em>.In a letter to employees, she called the cuts 'significant' but provided no details about how many employees might be laid off.<br /><br />'The process will take place in stages, and affected employees will be notified during the month of May,' Shalala wrote. 'Reductions will not impact clinical care or our patients and will primarily focus on unfunded research and administrative areas.'<br /><br />Shalala said the cuts were necessary because of 'unprecedented factors' including the global downturn of 2008, decreased funding for research and clinical care, plus cutbacks in payments from Jackson Health System. The Jackson reductions 'have had a profound effect on our finances,' she wrote.</blockquote><br />Placing the blame for the medical school's financial problems on Jackson Health System, the local safety-net health system, did not sit well with that organization's leadership. In another Miami Herald <a href="http://www.miamiherald.com/2012/04/17/2753691/jackson-health-system-chairman.html">story</a>, its chairman stated that the real problem might be:<br /><blockquote><em>'investments that they have made that may or may not have panned out,'</em> including the purchase in 2007 of Cedars Medical Center, across the street from Jackson Memorial, for a price that several experts say was far too high.</blockquote><br />In fact, we discussed <a href="http://hcrenewal.blogspot.com/2011/06/embedded-networks-of-influence-in.html">here</a> allegations that the University of Miami Medical School's purchase of a facility that was renamed the University of Miami Hospital adjacent to Jackson was meant to take insured patients from that already struggling facility.<br /><br />Nonetheless, the Medical School proceeded with its cuts, which resulted in 800 layoffs (see Miami Herald story <a href="http://www.miamiherald.com/2012/05/08/2789495/um-laying-off-800.html">here</a>.) The next Miami Herald <a href="http://www.miamiherald.com/2012/05/12/2795449/university-of-miami-job-cuts-could.html">story</a> suggested that the cuts would disproportionately impact worthy researchers, for example, <br /><blockquote>When Nobel Laureate Andrew Schally arrived in South Florida six years ago, he was greeted with great fanfare and named a distinguished professor of pathology at the University of Miami medical school. Now he says his work is one of the many casualties of the school’s budget slashing.<br /><br />Schally says UM told him several weeks ago that his annual funding of $150,000 for research would end May 31, part of widespread cuts in the medical school that could eliminate up to 800 jobs this month and trigger major reductions in research.<br /><br />'I was shocked... We developed so many drugs for the university,' Schally says. 'They are killing the goose that laid the golden egg.'</blockquote><strong>The President's New House</strong><br />The headline of another Miami Herald <a href="http://www.miamiherald.com/2012/05/28/2821494/um-presidents-house-sells-for.html">story</a> last week suggested that things had gotten so bad that the cuts were even going to affect top university leadership's lifestyle:<br /><blockquote><em>UM president’s house sells for $9 million</em></blockquote><br />We had <a href="http://hcrenewal.blogspot.com/2006/02/tale-of-three-ironies-university-of.html">posted</a> about University of Miami President Donna Shalala's lavish university funded living conditions a while ago. Now it seems she would be giving up<br /><blockquote>'tropical ambiance,' 4.6 acres of lush gardens, and a prestigious Gables Estates address.</blockquote><br />This "rare piece of Florida history" also had<br /><blockquote>a guest room created specifically to host the Dalai Lama during His Holiness’ visits to South Florida.</blockquote><br />So can we conclude that the University is really tightening its belt when its President is forced to move out of such a lush environment? Not really.<br /><br />In fact, Ms Shalala may be moving to even more plush surroundings, courtesy the university's supposedly challenged budget:<br /><blockquote>The 32-acre Pinecrest development, built on land donated to the university by UM law grad-turned-philanthropist Frank Smathers Jr., exclusively houses UM faculty. Shalala will now join their ranks as both boss and neighbor.<br /><br />Decades ago, the grounds were home to Smathers’ Arabian horses and world-renowned mango collection. The UM-built homes are clustered in the center one-third of the acreage 'to safeguard the botanical integrity of the estate,' according to the university’s website. The remaining land is dominated by lush plants and fruit groves, and is maintained by Fairchild Tropical Botanical Gardens.</blockquote><br />In particular,<br /><blockquote>“<em>It’s a very bold house,”</em> Taylor said of Shalala’s new digs. “It’s a dominant house in the neighborhood.”<br /><br />Taylor said the all-white exterior of the new home is a noticeable contrast to the more-earthy tones of other houses nearby. The university is calling it the 'Ibis House' after UM’s beloved (and also all-white) mascot.<br /><br />Shalala’s new home will sit on a quarter-acre of land — dramatically less property than she enjoyed before. On the plus side, Shalala, just as in her old home, <em>will enjoy about 9,000 or so square feet of interior space, and an in-home elevator </em>connecting the first and second floors.<br /><br />The new home is also situated in a unique gated community that offers a community <em>clubhouse, tennis courts and pool, and meticulously landscaped gardens.</em></blockquote><br />Was anyone really expecting that Ms Shalala would have to find her own housing, like the 99 percent have to?<br /><br /><strong>Summary</strong><br />So here we have another example of how the notion of CEO exceptionalism has filtered down from large for-profit corporations to even non-profit, ostensibly mission-oriented health care institutions. Leaders of health care organizations are now deemed to be so important, at least in the eyes of their hired public relations staff, that they must be given every luxury. Perhaps if housed in any space smaller than 9000 feet, Ms Shalala would be so confined as not be able to think great thoughts anymore, like how many layoffs would be needed to sufficiently cut costs. Worse, maybe without such free housing, she would just decide that the institution would not be showing enough gratitude, and so her amazingly brilliant leadership would have to seek new pastures.<br /><br />Maybe, on the other hand, Ms Shalala's new house is just another demonstration how health care has become dominated by leadership whose own compensation and privilege seems to come before the mission., and sees no problem in asking for "difficult and painful" cuts from those who do the real work on the ground while building itself new mansions. <br /><br />So as usual, it is time to say that true health care reform would foster leadership  that upholds the core values of health care, and focuses on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research.

University of Miami Lays Off 800, Cuts Research Funding, Builds New Presidential Mansion

Despite the trillions of dollars flowing through the US health care systems, prominent not-for-profit health care organizations seem to be complaining more often that the money going to them is not en…

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Embedded Networks of Influence in Health Care: An Illustrative Case

At the 12th International Anti-Corruption Conference (IACC), sponsored by Transparency International, one of the <a href="http://www.12iacc.org/modules.php?name=Content&pa=showpage&pid=45">plenary sessions</a> was devoted to the topic of "embedded networks of influence."  The session description included this description of the topic as:<br /><blockquote>the major stumbling block in the fight against corruption, namely, <em>the power of 'embedded networks' in advancing personal or group interests through state institutions</em>. The extent of their power can create what is known as “state capture” meaning democratic governance failure. It will take a close look at the influential role of private sector, especially of the multinational private sector.</blockquote>A recent <a href="http://chronicle.com/article/Fast-Growth-Strategy-Has-Its/127941">investigative report </a>in the Chronicle of Higher Education illustrated a striking case of how one key individual has affected health care through multiple connections to what can be regarded as embedded networks of influence, thus tying in to many of the topics we have discussed on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>. <br /><br />The article focused on the University of Miami and its current President, Donna Shalala. Let me summarize the set of relevant topics in roughly chronological order and note how the article links them to President Shalala.<br /><br /><strong>Speech Codes and Restrictions on Free Speech within Academia</strong><br /><br />As I wrote in my 2003 article, (Poses RM. A cautionary tale: the dysfunction of the American health care system.  Eur J Int Med 2003; 14: 123-130.  Link <a href="http://www.ejinme.com/article/S0953-6205%2803%2900029-3/abstract">here</a>), speech codes and other restrictions on free speech within academia created the framework for the suppression of clinical research that may offend those with vested interests:<br /><blockquote>Failure of universities to champion the academic freedom of their clinical researchers may stem from their abandonment of their own academic core value of free enquiry. There is abundant evidence that universities may restrict expression and limit academic freedom. In <em>The Shadow University</em>, Kors and Silverglate charged that 'universities have become the enemy of a free society.' Universities have punished faculty and students who raised unpopular viewpoints.</blockquote><br />In the Chronicle,<br /><blockquote>Ms. Shalala, ... was previously president of Hunter College of the City University of New York and chancellor of the University of Wisconsin at Madison....</blockquote><br /><em><a href="http://www.shadowuniv.com/">The Shadow University</a></em>, the pioneering work on challenges to individual rights by leaders at academic institutions, dealt with Ms Shalala's role as a leading early proponent of silencing speech that offended academic leaders.<br /><blockquote>Wisconsin chose to enact a speech code. On March 29, 1990, the Wisconsin ACLU joined a suit against the university, announcing that the important moral goals of toleration and equal opportunity 'can be accomplished through means other than the creation of rules which infringe upon the fundamental freedom to express ideas.'<br /><br />The speech code was drafted with the help of UW-Madison Law School professors Richard Delgado, Gordon Baldwin, and Ted Finman.... On June 9, 1989, <em>upon recommendation by Chancellor Shalala</em>, it was adopted by the Board of Regents...."</blockquote>The speech code was soon declared unconstitutional by a federal court, which held:<br /><blockquote>the policy was unconstitutional precisely because 'the UW rule regulates its speech upon its content.'</blockquote>Ms Shalala then:<br /><blockquote><em>recommended a new code</em> to the regents in the spring of 1992, which they adopted in March.</blockquote>However, <br /><blockquote>Faced with another lawsuit, the regents reversed themselves</blockquote>For these and similar efforts, as <a href="http://www.washingtonpost.com/wp-srv/politics/govt/admin/stories/shalala010893.htm">discussed</a> by Evans and Novak in 1993, Ms Shalala was dubbed "the Queen of PC" [political correctness].<br /><br />Speech codes and other restrictions on free speech in the academic setting seem mainly to be used to target speech that administrators find offensive, including speech critical of management practices. This is echoed in the Chronicle story, which suggested how fearful University of Miami faculty now are of criticizing Ms Shalala:<br /><blockquote>Others, including several current and former faculty members, outline their complaints in far more detail. But they do so anonymously, saying <em>they don't want to tangle head-on with such a politically powerful president.</em></blockquote>Ms Shalala's prominence in academics, probably more due to rather that in spite of her hostility to free speech and free enquiry, may have enabled her to join another and even more powerful network of influence, this one at the center of the US political world.<br />  <br /><strong>The Rise of Commercial Health Insurance </strong><br /><br />In <a href="http://wendellpotter.com/deadlyspin/"><em>Deadly Spin</em></a>, former CIGNA executive Wendell Potter documented how clever and unscrupulous use of public relations and marketing techniques enabled commercial health care insurance and managed care companies to increase dominance of US health care, while allowing health care costs to soar, and denying access to larger numbers of patients.  <br /><br />The Chronicle article briefly alluded to Ms Shalala's role in the rise of for-profit health insurance.  Despite being labelled "farthest to the left and most controversial of all President-elect Clinton's Cabinet appointments," again per Evans and Novak, Ms Shalala departed the University of Wisconsin in 1993 to become US Secretary of Health and Human Services. In that role, she presided over the administration's failed attempt at health care reform, as Potter wrote,<br /><blockquote>When President Bill Clinton was forced to give up on comprehensive health care reform in 1994, <em>the damage was far more extensive than anyone could have imagined - the administration's defeat emboldened health insurance companies to totally redefine the mission and methods of an industry that now strands nearly fifty million people without insurance</em>. <br /><br />As I outlined..., <em>insurers knew after the Clinton disaster that the coast was clear for them to abandon nonprofit practices, long-standing commitments to public service, and traditional insurance models</em> and turn instead to satisfying Wall Street investors' desire to make money, by limiting spending on health care.</blockquote>Note that my only quibble with what Wendell Potter wrote is that it may be that the insurance companies' top executives, rather than their stockholders who benefited the most from these changes, as we will address below.<br /><br />Ms Shalala remained Secretary of HHS until 2001, but after the failure of the health care reform proposal in 1994, her department apparently did nothing to try to ameliorate the changes to health care that Potter described above.<br /><br /><strong>Bloated Executive Compensation Disproportionate to Any Measure of Organizational Performance</strong><br /><br />We have frequently discussed how health care leaders now seem entitled to get huge amounts of <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">compensation</a> disproportionate to their organizations' performance and their responsibility for it.  <br /><br />Despite Ms Shalala's reputation in the 1990s as an extreme leftist, upon leaving her role in the Clinton administration, she almost immediately embraced the for-profit corporate model of health insurance. In a notable example of what now is called the "revolving door" that went unnoticed at the time,  Ms Shalala went from would be regulator of commercial managed care to leader of commercial managed care.  As noted by the Chronicle:<br /><blockquote>Debates over ethical boundaries are not new to those involved in the university's growth surge. <em>Ms. Shalala was on the compensation committee of the board of the health insurer UnitedHealth Group when it was caught in one of the nation's largest-ever stock-options scandals.</em> She also received low-cost loans in 2002 as part of a favors-for-politicians scandal at Countrywide Financial Corporation.<br /><br />Both Ms. Shalala and [University of Miami medical school dean] Dr. Goldschmidt have <em>served on the boards of companies directly or indirectly affected by the university's business decisions. The university had $30-million in annual business with UnitedHealth Group when Ms. Shalala was on its board.</em></blockquote>Note that Ms Shalala served as Secretary of Health and Human Services from 1993 to 2001, (see <a href="http://en.wikipedia.org/wiki/United_States_Secretary_of_Health_and_Human_Services">this list</a>), then joined the board of UnitedHealth Group within months (see <a href="http://www.bizjournals.com/twincities/stories/2001/05/21/daily20.html">this article</a>.)<br /><br />We discussed in considerable detail the ethical failings of UnitedHealth Group while Ms Shalala had fiduciary responsibility as a board member for its conduct. A particularly striking failing was how the board of directors granted sufficient back-dated stock options to the company's former CEO to make him a billionaire on paper.  The resulting <a href="http://hcrenewal.blogspot.com/2006/08/more-entangled-web-unitedhealth-case.html">scandal</a> was followed by his <a href="http://hcrenewal.blogspot.com/2006/10/another-really-big-one-bites-dust-ceo.html">resignation</a>.  Later, Dr McGuire was forced to <a href="http://hcrenewal.blogspot.com/2007/12/some-payback-by-former-managed-care-ceo.html">give back</a> some the options.  The <a href="http://hcrenewal.blogspot.com/2009/08/final-settlement-of-unitedhealth.html">final settlement</a> of the fiasco cost UnitedHealth $895 million, and Dr McGuire $30 million and the cancellation of 3.6 million stock options.  As we most recently summarized <a href="http://hcrenewal.blogspot.com/2010/08/despite-scandal-former-unitedhealth-ceo.html">here</a>, former CEO William McGuire was one of the top 10 best compensated CEOs of the first decade of the 21st century, despite the company's multiple ethical failings.  <br /><br /><strong>Conflicts of Interest, Especially Involving Key Opinion Leaders who Promote Marketing Objectives Cloaked in Academic Respectability</strong><br /><br />We have extensively discussed the web of <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> that now pervades health care. For academic health care leaders, the most intense kind of conflict of interest may be created by service on the board of directors of a for-profit health care corporation.  Note that corporate directors, as we have discussed previously, have a fiduciary duty to exhibit "unyielding loyalty" to the stockholders of the company and their interests  [Per Monks RAG, Minow N.<em> </em><a href="http://www.amazon.com/Corporate-Governance-Robert-G-Monks/dp/1405116986"><em>Corporate Governance</em></a><em>,</em> 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.].  We first <a href="http://hcrenewal.blogspot.com/2006/03/new-species-of-conflict-of-interest-in.html">started to discuss</a> the intense conflicts of interest generated when leaders of academic medicine are also members of boards of directors of for-profit health care corporations in 2006.  The issue really made the big time in 2010 when the New York Times published <a href="http://www.nytimes.com/2010/08/01/business/01prez.html">a front page article</a> in its Sunday Business section about whether university presidents who also were corporate directors were part of an "academic-industrial complex."  As we noted above, Ms Shalala's service on the board of UnitedHealth Group created such a conflict, and she apparently presided a similar board level conflict of interest affecting her medical school dean.  <br /><br />A particularly pernicious kind of conflict of interest may be created when a company selling health care goods or services pays an academic to become a "<a href="http://hcrenewal.blogspot.com/search/label/key%20opinion%20leaders">key opinion leader</a>."  Industry spokespeople and key opinion leaders themselves tout KOLs as clinical, educational, and/or scientific experts chosen for their expertise to advance medicine, science and public health.  There are documented instances (e.g., see posts <a href="http://hcrenewal.blogspot.com/2008/06/key-opinion-leaders-were-sales-people.html">here</a> and <a href="http://hcrenewal.blogspot.com/2010/10/not-best-and-brightest-drug-marketers.html">here</a>) in which defectors from marketing departments of commercial health care corporations described KOLs as salespeople who could be more influential hidden within their professional or academic cloaks.  Even some physicians paid to be speakers on behalf of pharmaceutical corporations have acknowledged their role as salespeople in fancy dress (see post <a href="http://hcrenewal.blogspot.com/2010/11/of-drug-talks-deception-and-denial.html">here</a>).  There are cases of documents revealed by discovery in legal actions that show how companies planned organized stealth marketing efforts for drugs that included activities by KOLs (e.g., see post <a href="http://hcrenewal.blogspot.com/2009/09/lexapro-marketing-plan-was-meant-to.html">here</a> about marketing of Lexapro, and <a href="http://hcrenewal.blogspot.com/2006/08/stealth-marketing-of-neurontin.html">here</a> about Neurontin).<br /><br />The Chronicle recounted how Ms Shalala also was linked to one of the better known examples of industry paid KOLs:<br /><blockquote>Dr. Goldschmidt did not fully report the income from such corporate associations on the medical school's financial-disclosure Web site, even while promoting the site as evidence of his faculty's commitment to openness.<em> He also brought to Miami a repeat violator of financial-conflict-of-interest standards, Charles B. Nemeroff, to serve as a professor and chairman of the department of psychiatry and behavioral sciences</em>.</blockquote>In a <a href="http://chronicle.com/article/U-of-Miamis-Deal-Making/127935/">companion article</a>, the Chronicle summarized Dr Nemeroff's career thus:<br /><blockquote>Dr. Nemeroff had <em>quit as chairman of Emory University's psychiatry department in December 2008 after the university received complaints about his secretly receiving money from GlaxoSmithKline and other pharmaceutical companies while helping promote their products</em>.</blockquote>We (Dr Bernard Carroll more than yours truly)  have posted previously about Dr Nemeroff's exploits, including those at the University of Miami, <a href="http://hcrenewal.blogspot.com/search/label/Charles%20Nemeroff">numerous times</a>.  <br /><br /><strong>The Fall of Municipal Hospitals, the Rise of For-Profit Hospitals</strong><br /><br />We have frequently discussed how the leaders have <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">undermined</a> health care organizations' core missions, and particularly how hospitals and hospital systems have strayed from their patient care mission to make more money. The Chronicle suggested how Ms Shalala's leadership of the University of Miami has enriched the institution's teaching hospital at the apparent expense of the local municipal hospital system:<br /><blockquote>Another set of problems, cited by current and former university faculty and Jackson staff members, stems from the 2007 takeover of a facility that became the University of Miami Hospital, across the street from Jackson. The purchase has <em>greatly expanded the university's ability to direct many of the area's most profitable patients and procedures to the new facility and to other university-owned hospitals, further worsening Jackson's own considerable budget woes.</em></blockquote>In addition,<br /><blockquote>The university's patient-enrollment practices were part of the problem. <em>The inspector general of the U.S. Department of Health and Human Services and the U.S. Attorney's Office for the Southern District of Florida are looking into the question of whether university doctors routinely enrolled Jackson patients in research projects without telling the hospital</em>.<br /><br />In a 2008 letter from Jackson officials to university leaders, Nathan Anspach, who was vice president for physician services at the hospital, described a series of failed efforts 'to stop new clandestine research' at Jackson by university doctors.<br /><br />Meetings with university officials aimed at stopping the practice 'went badly,' Mr. Anspach wrote, and Dr. Goldschmidt, the medical-school dean, was 'outwardly annoyed' by Jackson's requests for information that would help it identify research patients in the building.<br /><br />Ms. Shalala was copied on at least some of the correspondence, including a 2006 letter in which Marvin O'Quinn, then-president and chief executive of the Jackson Health System, which runs Jackson Memorial, warned Dr. Goldschmidt about the<em> legal risks of submitting claims for patient care that should be covered by a medical study.</em><br /><br />The current director of compliance at Jackson Health System, Diana Salinas, said the allegations are a matter of investigation by the two federal agencies. Ms. Shalala and Dr. Goldschmidt told The Chronicle that they were unfamiliar with the matter. 'This must not be a very big issue,' Ms. Shalala said, 'because none of the Jackson senior leadership has ever brought it up with me.'</blockquote>Finally,<br /><blockquote>And the departing chief executive of the Jackson Health System, Eneida O. Roldan, whose appointment two years ago was supported by the university, said medical-school officials made clear from the start 'that they were going to take cardiology across the street.'<br /><br />Ms. Dixon-Shim, of the support-workers' union, is among those who say they've seen it happen.<em> 'Most of the indigent patients, they're staying at Jackson,' she says. 'But most of the private patients, the physicians are taking them over to their area' at the university-owned hospitals.</em></blockquote>Note that we previously <a href="http://hcrenewal.blogspot.com/2011/02/send-mercenaries-guns-and-money.html">discussed</a> how Jackson's financial troubles lead to a bid by for-profit Steward Health Care to take it over.<br /><br /><strong>Summary</strong><br /><br />So, through her mutiple roles that allowed her to serve at several key nodes of networks of influence in health care, one person has been linked to multiple dysfunctional aspects of US health care that arguably have been responsible for our increasing costs, declining access, and poor quality.  Note that these multiple roles seem to have been logically and even ideologically inconsistent, suggesting that multiplying her roles within the  networks may have been more compelling to her than logical or ideological rationales for particular actions.<br /><br />We have discussed before, the leadership of health care organizations has become incredibly interrelated, interlocked, and incestuous. It appears that top leaders of various health care organizations may be more familiar with and identify more with each other, and with other hired executives and managers, than with their organizations, their organizations' missions, and their organizations' professionals, staff, students, clients, and patients.  It now appears reasonable to characterize the relationships among health care leaders as embedded networks of influence.  <br /><br /><br />So to repeat- I strongly believe that there needs to be much more investigation, academic, journalistic, and perhaps legal, of the identity, nature, and culture of the leaders of health care, and their relationships. A few bloggers cannot do it all. Obviously, <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">the anechoic effect</a> mitigates against medical and health care academics looking into their own leaders. However, failing to understand who is leading our march to the brink of health care failure ought not to be something such academics would want on their conscience.<br /><br />Finally, and obviously, health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research.<br /><br />If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.

Embedded Networks of Influence in Health Care: An Illustrative Case

At the 12th International Anti-Corruption Conference (IACC), sponsored by Transparency International, one of the plenary sessions was devoted to the topic of "embedded networks of influence."  The ses…

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IMPEACHMENT: IT’S ABOUT THE INSTITUTION, NOT THE PERSON

IMPEACHMENT: IT’S ABOUT THE INSTITUTION, NOT THE PERSON<br /><br />The impeachment trial of Judge G. Thomas Porteous of Louisiana this week was a lesson in civic ethics. The lessons of the Porteous trial apply to academic medical centers, professional medical societies, medical journals, and granting agencies like NIH. <br /><br />The Porteous trial is a straightforward case of bribes, kickbacks and corruption involving a Federal judge. The most enlightening arguments came from prosecutor Rep. Adam Schiff, D-California, laying out the case for impeachment in the Senate. He gave a lucid presentation of the logic and the historical origins of the impeachment process. The key points are these: impeachment serves to protect the dignity, honor, and credibility of the office more than to punish the wayward office holder; and impeachment is a constitutionally sanctioned way to clean the Augean stables without necessarily having to prove criminal liability. It is sufficient to demonstrate that the bad actors have brought disgrace on their offices.<br /><br />What this means for us in medicine is that legalistic charges and defenses are not the right way to go in exposing and ejecting bad actors from our field. In the highly publicized cases of ethical compromise over the past few years, our group disapproval, when there was any at all, generally has run on two parallel tracks. The first is legalistic, and it favors the bad actors, who flaunt their constitutional protections with the taunt, prove it. The second ground of disapproval is esthetic, based on the tackiness of the bad actors’ behaviors – regardless of technical legalities, what they do is an affront and an insult to professional standards and mores. When we look at how recent incidents in medicine actually played out, however, we see a disconnect. The bad actors have narrowed the debate to the first ground of disapproval, while forcing the second off limits. In this strategy, they have received conscious or unconscious assistance from the professional establishment. The focus has been on legal technicalities involving the bad actors rather on preserving the dignity and credibility of high offices in academic medicine.<br /><br />For instance, when Charles Nemeroff was exposed by Senator Grassley for conflict of interest in his NIH grants, he came up with the contrived legalistic defense that his unreported payments from GlaxoSmithKline were for ‘CME-like’ presentations, and thus somehow exempt from disclosure. Nemeroff’s obfuscations finally collapsed of their own weight and Emory University took decisive action against him, even though they had sufficient evidence dating back at least 4-5 years. In the end, Emory had to go through the wringer to discipline Nemeroff, and the institution suffered grave damage to its reputation for a number of years as the price of delay.<br /><br />For instance, when Thomas Insel, the Director of NIMH, assured Pascal Goldschmidt, Dean of the School of Medicine at the University of Miami, that Nemeroff was absolutely in good standing for applying for new NIH grants if he left Emory for Miami, despite a 2-year ban at Emory, he hewed to the letter of the law while disregarding its spirit in order to help his friend. Moreover, when Insel appointed Nemeroff to two new NIH Research Review Committees, he established beyond any doubt that he was intent on trying to help Nemeroff get back into circulation, and that he failed to grasp the gravity of the dishonor that Nemeroff inflicted on the field. This obtuseness on Insel’s part damaged the credibility and reputation of NIMH. To his credit, NIH director Francis Collins finally ‘got it’ and forced a review of the NIH ethics rules that had been entrusted to Insel.<br /><br />For instance, when Pascal Goldschmidt, Dean of the School of Medicine at the University of Miami, claimed he had done due diligence in his recruitment of Nemeroff as chair of his psychiatry department in 2009, he focused on the legalistic aspects of Emory’s review of Nemeroff, while failing to understand the degree of negative publicity associated with Nemeroff’s name. He ended up hiring someone who is an object of ridicule, and he in turn is ridiculed by association.<br /><br />For instance, when Stanford University learned of Alan Schatzberg’s boundary violations vis a vis his NIH-funded projects and his personal corporation, they first pushed back on legalistic technical grounds. Only later did the Stanford administration get the message by removing Schatzberg from his Principal Investigator role with NIH grants, and eventually appointing a new chair of psychiatry. Meanwhile, the public image of Stanford suffered.<br /><br />For instance, when the American Psychiatric Association was warned that Alan Schatzberg was a problematic candidate for election as President of the association on account of his history of ethical compromise, they went ahead anyway and they have since had opportunity to regret that decision. Here again, the professional society appears to have lost sight of the ethical forest for the legal trees. The credibility and reputation of the APA have suffered because of the taint associated with Schatzberg’s presidency.<br /><br />For instance, when the New York Times recently exposed the ghostwriting associated with the 1999 textbook of Charles Nemeroff and Alan Schatzberg, the so-called authors responded with typical legalistic defenses. They and the University of Miami and the American Psychiatric Association Press (the publisher) again lost sight of the ethical forest for the legal trees. This stereotyped, public relations driven response ignores the visceral and esthetic distaste most observers felt on learning about the collusion between the ‘authors,’ the professional writing company and the sponsoring pharmaceutical corporation. Even the defense that it occurred a long time ago fails. In the Porteous trial, the prosecution established that dishonorable events in an officer’s past are grounds for impeachment, whether or not they also occurred during the person’s time in office. <br /><br />For instance, when Harvard Medical School planned a <a href="http://cme.hms.harvard.edu/cmeups/pdf/03124280.pdf">new CME program </a>on psychopharmacology in mid-2011, they engaged a number of compromised academic speakers, including Nemeroff and Schatzberg. What the hell was Harvard thinking? I told the Course Director, Carl Salzman, that this amounts to pandering. He replied defensively that Nemeroff and Schatzberg are well regarded speakers and that he would ensure that they gave unbiased presentations. That’s not the point. The point is that they have done serious damage to our field, and for Harvard Medical School to give them top billing amounts to denial of the elephant in the living room. It’s collusion in service of their public rehabilitation. I told Dr. Salzman that his logic amounts to compartmentalized thinking. I might have added that Adolf Hitler gave a lot of great speeches that received rave reviews and that compartmentalized thinking was widespread in the nation of Germany between 1928 and 1945. Meanwhile, Harvard Medical School gets a black eye through its association with these compromised individuals. So do the other speakers who will be on the panel. Who needs this kind of taint? Dr. Salzman can defend Nemeroff and Schatzberg all he wants on specious legalistic grounds, but who cares? Harvard Medical School could use some moral clarity.<br /><br />So, we come back to the impeachment trial of Judge Porteous. Impeachment protects the institution. When sleazebags get into positions of authority and trust they need to be dumped, and our professional and academic institutions need to have enough spine to dump them. At the very least, we don’t need to tolerate institutions like Harvard Medical School pandering to compromised academic bad actors. For shame.

IMPEACHMENT: IT’S ABOUT THE INSTITUTION, NOT THE PERSON

IMPEACHMENT: IT’S ABOUT THE INSTITUTION, NOT THE PERSONThe impeachment trial of Judge G. Thomas Porteous of Louisiana this week was a lesson in civic ethics. The lessons of the Porteous trial apply to…

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