From Brooklyn to Duke
In January 1989, the Duke University Board of Trustees provided me with the awesome privilege and responsibility of being Duke's chancellor for health affairs. From the perspective of my humble beginnings in Bensonhurst, Brooklyn, the likelihood of my being offered this lofty position would have seemed so remote as to be considered impossible. Nonetheless, through a remarkable journey, highly convoluted and fraught with precarious turns, the story described in this book came to pass.
I was born in Brooklyn, New York, in 1940, the son of immigrants who fled the Ukraine at the time of the 1918 pogroms. My mother saw her father murdered at the hand of Cossacks. My father was a tough, persistent businessman who started with a push cart and worked his way up to owning a small but successful department store in the blue-collar section of Bensonhurst, Brooklyn.
Even when I attended public schools in Brooklyn in the 1950s, I knew I wanted to be a doctor, never mind the improbability posed by the foibles of life as the child of immigrant parents growing up in hardscrabble Bensonhurst. I attended tough neighborhood public schools in Bensonhurst and graduated from New Utrecht High School in 1957 at the lower rungs of the top quartile of my class. Most of my neighborhood friends were tough kids and had no intention of attending college, and even though I had a notion of a medical career, scholastics were not my highest priority as I was a product of the Brooklyn environment. With my parent's guidance, I made the unusual decision to go to Washington College, a small liberal arts school in Chestertown, Maryland. While there, I had my fun and flings, and while yet not truly focused on academics, I knew I would somehow become a doctor. Yet what we "know" about ourselves when we are in our twenties is a thin reed indeed, as most people discover to their eventual delight or dismay. Fortunately, graduating as a good but not outstanding student from Washington College gave me the opportunity to be admitted to an excellent state medical school.
On the first day of medical school at SUNY Downstate, I was so excited yet terrified at this momentous step toward fulfilling my life's dream that I could barely breathe. Fortunately, for the first time in my life, I deeply relished what I was learning, and study became my highest priority. I managed to graduate at the top of my class. When I came to Duke for my residency, I was closer still to living that dream, but like most of our dreams, it might have vanished in a waking moment as Duke's medical residency program was among the nation's most demanding. Certainly, it was then that my half-century love affair with Duke University began.
From that residency it was off to a research career at the National Institutes of Health (NIH), but it could have been to Vietnam had I not been awarded the highly sought after opportunity to become a research associate at the NIH. Soon after beginning my research there, I was fortunate to stumble onto seminal insights about the inflammatory process that enabled a basic understanding of how this complex system works. I stumbled in a fortunate way; I just as easily might have stumbled in vain and not pursued a career in academic medicine. From the NIH, I returned to Duke as an assistant professor and head of the Rheumatology Division at the Durham Veterans Affairs Hospital — the very place I had come to know so well during my residency. I worked my way up to being a successful physician-scientist, a Howard Hughes Medical Institute investigator, chief of the Rheumatology and Immunology Division at Duke, and Frederic M. Hanes Professor of Medicine. But in 1987, after a head-spinning ten-week sabbatical fellowship in Germany that allowed me to step away from Duke, I left the university for the burgeoning for-profit world of biotechnology at Genentech in San Francisco. No fellowship in Germany, most likely no Genentech.
Another career turn was soon to follow as on a brisk October afternoon in 1988, after less than two years at Genentech, I was driving back to San Francisco with David W. Martin, Jr, from a research retreat at Lake Tahoe. Dave, like me, was a senior vice president at Genentech. We had spent the previous three days in intense scientific discussions with our colleagues on the company's research team. Genentech was emerging as the number one biotech company at that time, employing some of the most innovative medical scientists in the country.
As Dave and I rounded a turn, in the distance I could see the San Francisco-Oakland Bay Bridge and, beyond it, the city of San Francisco. I was struck by the beauty of the surroundings and told Dave — who had been an undergraduate at Duke as well as a Duke medical school alumnus and resident — that finally, I felt as though I had left Duke and that San Francisco was now my home. Little did I appreciate the irony of that remark!
That afternoon I stopped by my office at Genentech before going home. As I approached my desk, I saw two pink telephone message slips. One was from my friend Dolph O. Adams, who at the time was a Duke professor of pathology; the other was from Robert J. Lefkowitz, a professor of medicine at Duke and my closest friend. I called Bob first. On hearing my voice he said, "Sit down and write the exact time and date on a piece of paper because once I give you this message, it will change your life forever." I was standing at the time and looked over at the clock, which read 4:35. It was set five minutes fast to help keep me on time, and I was a bit perplexed as to what time to write down. As I sat down at my desk, I wrote 4:35 and prepared to take notes. Bob told me that the search committee for Duke's chancellor for health affairs, of which he was a member, had chosen me to succeed William G. Anlyan. Bob said that Duke needed me and that it was beshert — "fated" in Yiddish, written in the Great Book, as it were — that I should return to Duke as its next chancellor for health affairs.
In many ways, the idea of leaving Genentech constituted a very difficult proposition. I loved my role in that company during my eighteen months there. I had the exhilarating experience of being transformed from an academic physician-scientist to a member of a new and exciting industry. I had had the challenging responsibility of leading the Food and Drug Administration (FDA) licensing of Activase, the first biotechnology blockbuster drug, and I had already been promoted to senior vice president. What's more, upon learning of Duke's offer, Genentech's chief operating officer and president, G. Kirk Raab, made me a most attractive offer to stay.
The idea of leaving Genentech was so difficult, and the temptation to stay was so compelling, that I almost did not accept the job at Duke. I temporized for what now seems to have been months, but which was in fact only days. In the end I felt I had no choice; deep emotional reasons drove me to accept the Duke offer to become its next chancellor for health affairs and dean of its School of Medicine.
I realized this job would involve tasks freighted with awesome responsibilities. My professional experience to that point had focused mainly on scientific research, teaching, and clinical practice, and what I knew beyond that I had learned outside of a university environment. To succeed at Duke, I understood that sound administration and foresightful management suited to university realities were required. Beyond this, neither the exact nature of the job nor a precise vision of what I wanted to achieve was yet clear to me.
But I took the job anyway because my experience had shown me that, with hard work, I could succeed. Up to that point, I had always taken the opportunity to assume a greater degree of responsibility and authority within the field of medicine when it availed itself, and I had never regretted doing so. I had the confidence that I would somehow do what needed to be done and that the institution and I would grow to success together. Put a bit differently, I was too unsure to be cocky, but I was too confident to be reticent. Things worked out, or so it seems to me now more than a decade after the end of my tenure. Duke and I did grow together, and we experienced the growing pains that inevitably accompany success.
As I have already suggested, the outcome of my tenure contrasts starkly with the inchoate vision I had at the outset. I confess to having little understanding of the nature of the job I had assumed, the complexity of the institution I would be leading, or the changes that would be needed to protect its viability in a rapidly evolving health care environment. Even to imply that at the beginning I understood, let alone planned for, the outcomes we achieved would be tendentious as well as plainly false. At the same time, my approach to my responsibilities was neither entirely incremental, opportunistic, nor in any sense random. What in retrospect might be understood as the result of a coherent plan was in reality something a good deal subtler.
Between master planning and reactive incrementalism lies another more flexible and realistic path to success — obeying fundamental underlying principles and applying them in steps to address needs, opportunities, and threats as they arise. John Maynard Keynes famously said that in the long run we are all dead, which is true enough. But failing to manage short-term challenges can be fatal, too, as all doctors understand. One must manage them, however, with a forward-leaning, integrated view of the future framed by clearly defined objectives.
Our underlying principle at Duke was to maximize the benefit to society of our core missions of education, research, and clinical care. This was not motherhood and apple pie; we really wanted to leverage the power of our academic missions to solve real-world health problems. Hence, principle-based decision making was coupled, when practical, with strategic planning to form a core for all we did. As we responded to pressing needs, we were able to anticipate and finally develop the means to synthesize a more coherent understanding of multiple complex issues and to create novel solutions based on a synthesis of our core capabilities.
So, while the outcome of fifteen and a half years of cumulative contingent judgments could not have been anticipated in 1989, the principles and processes underlying our approach ineluctably led to what we accomplished. In retrospect, I realize that the underlying principle of my life was to consistently choose a path that allowed me to have the broadest impact for good as a physician. Thus the path to medical school led me to be a physician, followed by the decision to pursue medical research so I could broadly expand medical knowledge. This steered me toward becoming an administrator to broaden my impact and to continue a logical progression not planned at the outset but made inevitable by adhering to principles.
I never thought of myself as a particularly religious person in the ritual sense, but I now understand how the underlying principles of always learning and seeking to do what is good, embedded in me from childhood, set a path through myriad contingencies that had what now seems an inevitable outcome.CHAPTER 2
History of the Academic Medical Center
Medicine has been practiced in various forms since the earliest days of human history, yet the ability of science to affect the profession did not emerge in earnest until the latter part of the nineteenth century. Until then, the prevalent theory of health and disease was that both resulted from the relative imbalance of four putative bodily humors: yellow bile, black bile, blood, and phlegm. The humoral theory had no scientific basis and the dominant therapies it spawned; e.g., bloodletting, moxibustion, provided no effective interventions. Toward the end of that century, however, emerging sciences began impacting medicine. Rival microbiologists Robert Koch in Germany and Louis Pasteur in France unequivocally identified microorganisms as causative agents of specific diseases. Their demonstrations proving that infectious microbes caused dreaded diseases such as tuberculosis and rabies had a profound impact on physicians and the public alike. An external causative agent was at work after all, not a mystical one: a microbe was directly responsible for many diseases. The findings, which came to be called the "germ theory" of disease, clearly debunked previous metaphysical theories and gave rise to the pathophysiological approach to disease.
Scientific progress accelerated in the new century as immunologists, such as Elie Metchnikoff and Paul Ehrlich, described innate and acquired mechanisms of resistance to infections (e.g., immunity), and others identified as "serum sickness" resulting from the administration of serum from immunized animals used as therapy for infections. Applying physics to medicine led to the use of X-rays for diagnostic imaging, and advances in chemistry allowed the synthesis of new specific therapeutic agents. Chemists such as Hermann E. Fischer in Germany developed capabilities to synthesize specific molecules to treat diseases, popularizing the concept of a "magic bullet" for the treatment of conditions such as syphilis. This added considerably to the excitement of the new era in medicine.
Thus, by the beginning of the twentieth century it had become clear that scientific research had the potential to transform the practice of medicine from an unscientific humoral imbalance model to one based on an understanding of the scientific basis of disease. However, medical practice at that time was virtually untouched by this new and expanding knowledge. Rather, it remained anecdotal, unscientific, and unregulated, with hundreds of "storefront" medical schools granting licenses with virtually no scientific training imparted.
Fortunately, the then young Carnegie Foundation commissioned a seminal study of medical education in the United States. It chose Abraham Flexner, the son of German-Jewish immigrants, to lead this effort. He published his book-length report, which became known as the Flexner Report, in 1910. The report examined the status of medical education state by state and, to varying degrees, found much to criticize. Flexner's central point was that physician training was insufficiently enriched by science.
Flexner's findings crystallized widely felt dissatisfactions into a framework for a revolution in medical education and, ultimately, set the stage for the American century in medicine and research. His conclusions profoundly affected medical education and helped define the structure of the contemporary academic medical center, as the creation became known. In the arrangement he fostered, medical faculty responsible for teaching medical students were also involved in research and clinical care. Thus the faculty would be educators as well as physicians and scientists involved in creating new knowledge. The clinical practice of medicine would be taught to medical students and residents in training by the clinical faculty in a "teaching" hospital affiliated with the medical school. This institutional design caught on with alacrity in the United States due, ironically perhaps, to the then shallow roots of its institutional arrangements; it did not flourish as readily in Europe, despite the presence of great human capital, because institutional traditions were more rigidly entrenched.
The best early example of this vision was the "Johns Hopkins model," an outstanding school of medicine with its teaching faculty also involved in research while practicing in the Johns Hopkins Hospital in Baltimore, Maryland. In the Flexner model, students would be steeped in medicine based on science and would aim to master the pathophysiology of disease to the extent that current science would allow. Those aims would be the underlying paired goals of training and practice.
Flexner's new model provided a platform for substantial investments and progress in biomedical research. Shortly after World War II, the U.S. government began its historic and strong support of biomedical research, largely in academic medical centers. The national investment in those efforts, now well over $1 trillion and counting, was spearheaded after the war by enhanced funding for the NIH as a consequence of the influential Vannevar Bush report.
The augmented funding that stimulated biomedical research performed in academic medical centers in turn spurred greater sophistication in our understanding of human diseases and the development of new technologies to diagnose and treat them. The explosion of knowledge about the complexity of human disease simultaneously drove the growth in clinical specialization. Academic medical centers, the nexus of medical education, research, and practice, became the primary drivers of clinical specialization. As a result, the number of medical schools in the United States fulfilling Flexnerian criteria grew from a dozen in 1910 to more than 140 today, and their size and complexity have increased as the potential for research and clinical application has expanded. Academic medical centers not only have provided much of the research needed for the rapid developments of new diagnostics and therapeutics but also have become the sites to validate them clinically. Indeed, the pharmaceutical and biotechnology industries, among the greatest national economic drivers, would be unsustainable without academic biomedical research and clinical validation.