- Email: [email protected]
Problems that deans face
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Problems that deans face* Richard M. Caplan, M.D. Iowa City, IA
I come neither to praise deans nor bury them, but rather to provide information about some major issues that now confront medical schools and their chief operating officers, namely, the deans. I am not a dean, but I have worked parttime in my dean's office for 12 years as an associate dean with responsibilities mainly related to continuing medical education. I therefore attend many local and national meetings and am exposed to many readings, discussions, and hand-wringing sessions. It is easy, then, to grow inured to the usual topics and agonies and to assume that everyone surely knows about these matters. But everyone does not, it seems. Yet it is vital to the stability of our educational system, in fact to our medical care system, that not only administrators but also faculty members and practicing physicians better understand some of the pressures and problems. It is appealing to speak of an educational web or scaffolding in which medical faculties and schools are enmeshed. The choice of metaphor matters, for a web implies being trapped and devoured. A scaffold, though, suggests a structure that gives support and permits working and climbing to a higher level; maybe it also suggests a place where games may be played. When I began my dermatology residency at the University of Michigan in 1958, I learned of the recent retirement of Dr. A. C. Furstenberg, who From the Department of Dermatology, University of Iowa College of Medicine. Supported in part by a grant from the National Cancer Institute (No. R25 CA18017-08), Reprint requests to: Dr. Richard M. Caplan, Professor of Dermatology and Associate Dean for Continuing Medical Education, University of Iowa College of Medicine, Iowa City, IA 52242. *Derived from a presentation made to the American Dermatological Association, Banff, Canada, June 25, 1981.
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had been dean of that college of medicine for many years. It was then the largest medical school in the country in terms of student enrollment. Not only did Dr. Furstenberg conduct its affairs with the help of just one able secretary, but he also served as head of the Department of Otolaryngology and also conducted a busy private practice in the local community hospital. I have no doubt that he was a very talented and energetic man, but such a range of responsibilities with such a meager support system would be absolutely unthinkable for a dean today. So many complexities have entered the operations of an academic medical center that a very able person needs a large staff of assistant managers and supporting personnel. Even then it is difficult to "get the job done" because the dean no longer has the authority that he once had. On the contrary, the dean's powers are markedly constrained and he must work much more through persuasion than edict. True, some individuals may seek "favors," and when denied, conclude that the dean is a powerful and dictatorial figure. However, such a scenario portrays a very limited perception of the total milieu and behavior of the dean. The rate o f change in our world seems staggering. Those who have read Future Shock and The Third Wave by Alvin Toffler have encountered many persuasive examples of this, and those who follow the scientific literature realize how rapidly and tumultuously the very "facts" are changing. This theme of change, change, change is so prevalent that it is hard not to believe the Greek philosopher Heraclitus absolutely correct in arguing that the one eternal constant was change itself. The reader may think that money is the basis of all issues that concern the dean. In my view, to think so is simplistic and naive, like saying, "All you need to understand skin disease is to know biochemistry." Yes, money is vital to the exis0190-9622/82/110694+08500.80/0 © 1982 Am Acad Dermatol
Volume 7 Number 5 November, 1982
tence of the institution and it does relate in some way or other to almost everything else, just as biochemistry relates in some manner to all aspects of skin disease. But I submit that if you bestowed a great amount of money on the dean, you would find him remaining almost as unsatisfied as was King Midas. The cynical view of the golden rule ("He who has the gold makes the rules") is not totally true. I will discuss some major areas of pressure for deans under these headings: "Relationships With Governments,.... Curriculum,"' 'Diversity of Educational Responsibility," "Personnel and Recruitment," "Relationships to Other Groups," "The Justification of Education," "Societal Needs," "Maintenance of Quality," and "Miscellaneous Issues." RELATIONSHIPS WITH GOVERNMENTS The relationships with governments center largely on money, but not totally so, Medical schools since the late 1960s have received directly from the federal government large infusions of money designed to stimulate schools to admit and teach larger numbers of students. That support was directed toward relieving what was perceived as a serious shortage of physicians. The medical schools, damned at the time for being too few in number and training too few students for the needs of the nation, have since responded so well to the social needs and to the various governmental, financial incentives that the "general wisdom" today states we are on the brink of having too many physicians. Many critics now seem to blame this on the medical schools and expect them to correct it. The federal government is rapidly eliminating its subsidies that were designed to stimulate the production of more physicians. Therefore, capitation payments have ended, support for new construction of medical teaching facilities has stopped, and special project initiatives such as support for minority recruitment and development of family practice programs have been reduced greatly. Student loan and scholarship funds represent an important federal activity under constant attack from the administration's planners. Likewise under much pressure to reduce are the dot-
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lars paid via complicated reimbursement formulas through Medicare and Medicaid channels to teaching hospitals, many of which are components of medical school operations. The federal government during the past twenty years has provided major support for research and development. That support has yielded immense changes not only in our biomedical knowledge and technics but also in the physical structure and even the very nature of what a medical school is. In addition, there has come to be great reliance upon the private practice earnings of medical school faculty members. Thus, the ability of the faculty to generate money, using their skills in performing research and in taking care of patients, subsidizes the schools increasingly. Nor can a high-quality medical school any longer survive on its tuition, interest earnings, alumni gifts, endowments, or state appropriations. In the case of my own medical school, for example, a large state-supported institution, the state-appropriated funds presently account for only about 16% of the operating budget of the medical school (not counting clinical care operations), while another 7% comes from tuition sources and all the rest comes from grants and private practice earnings. Another consequence of this change in funding ratios will be an increasing reliance at many schools on volunteer teachers. Another major aspect of the relationship between governments and medical schools is the matter of control. There seem always to be legislative efforts to manipulate and dictate what medical schools shall teach. For example, the California legislature has considered a requirement that medical schools should teach courses in sex education and nutrition; federal initiatives have supported curricular preceptorships in family practice; other support has enticed the schools to develop special curricula to produce physicians' assistants. Governmental manipulation of the process of admissions has become onerous. As examples: governments have stimulated the development of new schools; state governments have specified, in some cases, that only residents of that state can be admitted to its state-supported school; the federal government has influenced the admissions process
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to stimulate the entry of educationally disadvantaged groups, especially the traditional racial minorities; 2 years ago the federal government even went so fat" as to make all federal funds for the institution contingent on the "forced" admission at each school of approximately five students who were American citizens who had taken preclinical training in foreign medical schools. The courts, too, have been active in ways that matter to the medical schools. Lawsuits have been filed by students in relation to admission, to dismissal, or to the time or requirements for graduation. A New York law that insists on public release of items and answers from standardized tests such as the Medical College Admissions Test has caused its developer, the Association of American Medical Colleges (AAMC), successfully to seek temporary injunctive relief from the rule, and is the basis on which it now gives the test in that state. There is also the controversial issue of the Regents of the State of New York choosing to perform independent accreditation of medical schools outside the United States in an effort to deal with the dilemma and pressure of American medical students graduating from foreign schools. Additionally, governmental regulatory agencies intrude into what medical schools do. These include, for example, the Food and Drug Administration (FDA), whose rulings influence greatly the curriculum of pharmacology courses, as well as the conduct of patient care in clinical clerkships, and what research is or is not stimulated. The Department of Agriculture may specify, for example, that all animal cages in an institution need to be replaced, which may represent a cost of many hundreds of thousands of dollars; at hostage to ensure compliance is all federal support of any kind coming to the parent institution. Another example is the GMENAC, a federal organization set in motion to study problems of medical manpower needs and make recommendations. GMENAC has aroused much controversy; its methods and conclusions have been debated, criticized, and obviously feared. Another way to gauge the relationship between the federal establishment and the medical schools is to look at some of the headlines in the AAMC's weekly activities report. From some recent issues
are these illustrations: whether to eliminate National Boards as a route to licensure and implement a new system; establishment of a student loan marketing association; compensation for research injuries; Veterans Administration (VA) appropriations and whether a cap should be placed on special pay given to physicians in the VA systems; the debate over the administration's manpower bill, which contains within it such vital matters as numbers to be trained, curriculum grants, area health education centers, and the national health service corps; federal initiatives in longterm gerontology care; and presidential requests to nullify previously authorized expenditures through the Department of Health and Human Services. CURRICULUM The traditional medical school curriculum currently receives much pressure for change. New disciplines clamor, if not for departmental status, for at least some sort of curricular representation-preferably as a requirement for the students. Examples include genetics, bioethics, nutrition, oncology, family practice, to say nothing of the old struggle about department status for dermatology, neurosurgery, anesthesia, urology, radiation therapy, medical humanities, and so on. These battles will probably continue always because classification schemes, whether devised by Aristotle, Linnaeus, or anyone else, will always require changes. The influence of today's dean on these issues is usually far less than most people think. True, the dean has considerable authority about who shall be hired and, of course, that relates to what is taught. In most schools, though, a powerful curriculum committee along with the faculty guard jealously their rights to declare what shall constitute the course of study for medical students. Indirectly, the dean's influence on curriculum comes through establishing departments or new programs, or just by choosing which faculty members will serve on the curriculum committee. As in most patterns of governance, considerable differences exist among the schools regarding the authority the dean can or will choose to exert. These curriculum-related activities are important and even powerful, but certainly not dictatorial.
Volume 7 Number 5 November, 1982 DIVERSITY OF EDUCATIONAL RESPONSIBILITY
In most medical schools the dean serves as chief academic officer, not only for the education of medical students, but also in many settings, for residents as well. Further, his responsibilities encompass related educational programs, for example, radiation technology, occupational therapy, physical therapy, dietetics, laboratory technology, physicians' assistants, and so on. A relatively recent development for many medical schools, but now including essentially all, is an interest and responsibility to provide continuing education for the relevant practicing community. American medical schools now largely accept the principle that they should take some corporate responsibility for the entire continuum of medical education, meaning not only their traditional role for medical student education, but also for residencies and continuing education. Large numbers of faculty participate as teachers in much continuing education activity, although often not at their own school or in its behalf. The number of invitations to faculty for this kind of participation has grown greatly in recent years, and in the case of a small number of popular and effective teachers, the tail seems almost to be wagging the dog. Medical school deans also carry responsibility for programs serving graduate students who seek degrees in basic science departments. Deans must often supervise students of other health science colleges, such as dentistry, nursing, pharmacy, and so on, and of course in many medical schools there is a large student body from other colleges of the parent university, particularly Liberal Arts, taking courses within the various departments. Added to all these is the obligation that most colleges of medicine feel, in varying degree, to participate somehow in the processes of patient education and even public education. Deans almost always feel themselves bedeviled by the processes of accreditation. Not that they are opposed to standards and concern for quality, mind you, but simply that the process is always arduous, " f u s s y , " and very time-consuming. Since all schools have a great many programs, each of which has at least one if not multiple avenues to seek its accreditation, there flows almost
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a steady stream of visiting accreditors through the administrative offices of medical schools. Those periodic internal and external examinations require special preparation, sometimes a fair amount of anxiety, and certainly a good deal of time to be spent by the dean and key faculty members. Although a dermatology department may have its residency program accredited only every 4 years, the dean may have to meet the accreditors and teams of them literally tens of times per year. PERSONNEL AND RECRUITMENT
Finding new talent is a major task, headache, and opportunity for the dean. A surprising diversity of people must be sought and hired. Not only are there the traditional academic types in clinical and preclinical departments, but there are also those who operate the various service units such as Research in Medical Education, Medical Graphics and Photography, the bioengineering shop, the animal care facilities, the computer services, and such institution-wide facilities as transmission or scanning electron microscopy and tissue culture units. Shortages of personnel chronically plague the dean. High-quality faculty members of all persuasions are hard to attract, especially department heads. A dean is eager to attract the best-quality department heads he possibly can. This generally means that the person must have credentials as a first-class scientist, for although it is true that such a person may not necessarily become an effective administrator, it is unlikely nowadays that a second-class scientist will be able to build or maintain a first-rate department. Recruitment is very difficult because of the financial competition with private practice and because of the chilling influence of faculty members having greater difficulty today in obtaining outside grants to support their research. If full-time clinical teacher-investigators in fact find they are unable to support and do their research, but instead make their way within the medical school largely by seeing private patients and contributing to the practice plan coffers, they will be strongly tempted to decide that if all that time is to be given to seeing patients, they might as well be "on the outside," reaping the considerably greater financial rewards available in that other setting. Whether the presently projected sur-
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plus of physicians will make it easier to recruit for academe in the future remains to be seen. In any event, the frequent changes of personnel in a large institution keep constant pressure on the dean, even though much of the seeking-and-persuading falls to department heads or faculty committees. Obligations toward affirmative action (formal, imposed regulations in behalf of equitable hiring of minority members) add an annoying sense of regimentation and also many process steps that deans and department heads must obey. The recruitment of faculty also involves high cost--not only all the time of the dean and others just mentioned, but also the large cost of transportation, entertainment of visitors and committee members, telephone calls, and, ultimately, major commitments to new chairmen in respect to hiring new faculty members for that discipline, providing new or renovated space for offices, clinics, or laboratories, and allowing increased salaries. Further, a wise dean will recognize, as a matter of selfinterest for himself and the institution, the importance of his giving personal guidance and support to a new department head. And the stresses and litigiousness of our age prompt occasional formal grievances or lawsuits from faculty members, which the legitimate concern for due process plus the bureaucratic structure of a university can convert into a prolonged nightmare for a dean. "Recruitment" does not yet mean the need to find student applicants. However, important changes are taking place; the reasons for them and their implications remain unclear. In fact, the number of students applying to American medical schools has decreased in the last few years such that in the autumn of 1981 about 35,600 applied, compared to a peak of about 42,000 annually in the period 1974-1976. Correspondingly, 48% of those who applied received admittance to U.S. allopathic schools in the fall of 1980. This increase corresponds to the greater number of places and the decrease in the total number of applicants. RELATIONSHIPS TO OTHERS
A dean must interact with many other organizations. That requires much tact and time. Since approximately 1910, when the Flexner report helped to bond medical schools to a parent uni-
Journal of the American Academyof Dermatology versity, the medical school deans have had to relate to university presidents, academic and financial vice-presidents, and to fellow deans within the large university, as well as to boards of regents, legislative committees and members, and various departments of local governments. At some schools there have been developed branch medical campuses which the dean must then oversee. Most medical schools have affiliated hospitals with varying degrees of formal governance and interaction. As may be supposed, among all these relationships there arise many political and financial hassles. Relationships of the dean extend to national organizations through grant-related activities, and also because the deans often have impressive personal reputations they wish to maintain and nurture. That involves such activities, for example, as service to the National Institutes of Health, private foundations, national and local fund-raising organizations, and editorial commitments. The deans must maintain contact with the communications media, partly to foster positive images and partly to offset what in recent years has tended to be a veritable flood of articles critical of physicians and the institutions that train them. The deans must relate to hospital administrators, especially in affiliated hospitals. Internally, they have their department heads, faculty members, and students, all seeking, as a part of the modern clamor for participation and governance, to have a voice in how things shall be done. And externally, there are the alumni of the institution itself, a great many other practicing physicians in their geographic area, and the politicalscientific-educational organizations that physicians seem to generate in profusion. The deans must relate to the general public about such problems as medical manpower (including "why my child wasn't admitted to medical school last year"), explain and justify medical costs (as if he were responsible for them all), defend and monitor appropriately the use of hazardous substances, show concern generally about environmental pollution as it affects health, stave off the never-ending attacks of antivivisectionists, and serve on committees and commissions appointed for civic, state, and federal purposes. Es-
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pecially do deans of publicly sponsored medical schools have occasion to testify at legislative hearings, as well as jockey behind the scenes to obtain both defensive and offensive advantage regarding appropriations and legislative rules bearing on curriculum, admissions, personnel, and so on. THE JUSTIFICATION OF EDUCATION Deans must justify education. That may seem strange to the highly educated who are sympathetic to it, but much of the world, even in American society, lacks this acceptance of a high priority for education. Therefore, deans need to define their educational process, make it accountable, manage it appropriately and effectively, evaluate it a/most to the point of fetishism or nonsense, respond to audits by university and governmental auditors, satisfy accrediting groups such as the Joint Commission on Accreditation of Hospitals, keep at peace with the Professional Standards Review Organizations, and in forum after forum testify eloquently to the vital importance of the institution they shepherd. SOCIETAL NEEDS Deans must have concern about society's needs, and show it. They must recognize their role in contributing to medical and health manpower and try to keep it at highest quality. They must recognize the need to contribute new knowledge, a mission felt by all universities, which involves relationships with major organizations doing research and paying for it, such as the National Institutes of Health and the pharmaceutical industry. Medical schools are looked to by society to develop demonstration projects that test the feasibility of new ideas. Medical schools are expected to provide health care to certain segments of society. Most medical schools serve both an important referral function and also provide some degree of primary care needed by persons living near the school. (The claim for such care has even been known to provoke riots in the neighborhood.) MAINTENANCE OF QUALITY Maintaining institutional vigor is full of challenges great and small, mountains and nettles, since instruction, scholarship, and health care de-
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livery are all expected to be of the highest possible quality; no amount of internal politics nor inadequacy of facilities or funding makes acceptable excuses. Sabbaticals or research /eaves must be protected in order that faculty members may be stimulated to develop original ideas, learn new technics, and replenish enthusiasm. Quality means some sort of review periodically of departments and units. The deans are much embroiled in, and troubled by, decisions about appointments, promotions, and tenure. All of these add up to the general issue of morale. And these deliberations must happen in a marketplace competing briskly for services. This concern for quality may represent an attempt to defeat the second law of thermodynamics, which seems to apply to institutions as well as other natural phenomena: any system, a medical school included, will deteriorate and grow chaotic, becoming slower and colder and ultimately stop, unless there is an infusion of energy, preferably constant rather than episodic. For a medical school that renewal of spirit requires leadership, imagination, a sense of direction, money, loads of energy, and satisfaction with recognized accomplishments and achievements as a base for new knowledge and vigorous instruction. MISCELLANEOUS ISSUES
Still other important issues face the deans regularly that demand investigation, decisions, and implementation. One especially challenging example includes topics of biomedical ethics: for example, how should an institution behave and instruct regarding the technological imperative which argues that whatever technology can do in research or patient care should be done, no matter what the implications about cost or personal autonomy. Likewise, the dean faces these challenges: to prevent medicine as a profession from becoming calloused and mechanical, forsaking its traditional characteristics of humaneness and broad humanitarian learning; to respond suitably to the consumerism movement, not only in terms of governments but also in terms of ideas about health, and "alternative" systems of health care and its delivery; to select and monitor ethical review boards that must simultaneously strike a balance between assisting investigators to do research
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and at the same time protecting research subjects; occasionally to preside over a debate that grapples with the tough problem of when the pursuit of scientific knowledge changes from necessity to luxury, or whether we can, either financially or ethically, afford certain kinds of research; and adjust to certifying boards and licensing bodies that make decisions which influence what medical schools must do. A dean shares the problems of any manager trying to run his office when there are too many people reporting directly to him. Management theory suggests that having five to seven people reporting to a manager is probably optimal. A medical school dean is liable to have anywhere from twenty to fifty people reporting directly to him. The task of delegating becomes gigantic. In the face of it all, the dean struggles to maintain an institutional thrust while trying to obtain a sense of personal accomplishment. Creativity requires some spare time for reflection or objective viewing of the larger picture, something exceedingly difficult among the constant welter of telephone calls, visiting dignitaries, and deadlines of major projects. SUGGESTIONS
Here are a few suggestions that might aid readers of this article to assist the dean to whom they personally relate, as he works to guide the institution that involves so much of their pasts and futures: 1. Be empathic witn his circumstances and those of the entire university. Learn what issues face him, such as those discussed above. Then you can at least have a common universe of discourse if you encounter him at a faculty meeting or a cocktail party. 2. Be a team player, or try to be. At least avoid being an adversary. Physicians, used to functioning as masters of their own domains, almost always are so fiercely independent that they sometimes have trouble working as part of a team. 3. Help him muster support. You as a practitioner or faculty member and he as a dean both need all available help from other individuals and institutions.
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4. Contribute money to your medical school, to the institution that provided your residency, and to the Dermatology Foundation. 5. Those working in medical schools should make practitioners feel welcome in the departmental clinics and educational activities. Be as helpful to the practitioners and their continuing educational needs and interests as you possibly can. Likewise, try to help those of other departments and units, for "He who would have a friend must be friendly." 6. Faculty members should participate in school affairs. The person (especially a department head) who tries to keep a low profile all year long except at " g i m m e " time is likely not to be received with great enthusiasm. Volunteers are always needed for committee activity, such as curriculum committee, search committees, student prizes committee, animal care committee, audiovisual advisory committee, and lecture committee. Participate in activities of general university government; be at least as active for your own school as for regional and national specialty organizations. 7. If those who now carry some sort of administrative responsibility feel a deficiency in their skills of business, planning, or administration, they should work to improve. If specialized help or simply more help is needed to manage the department, then get it. Carefully guard against one of the worst sins of all, namely, spending more money than you have. Correspondingly, try to learn more in a formal sense about the process of education. And faculty members might consider the ultimate in service: offering themselves as a candidate to be the dean or a part of the dean's staff. 8. Those readers who are not department heads or faculty members can contribute dollars and lobby in behalf of education in general, not only dermatologic education. Such "lobbying" refers not just to efforts aimed at legislators and governmental officers, but means "talking it up" with patients, colleagues, and acquaintances. To paraphrase John Donne, "no department is an island,
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but a piece of the whole." Offer as much teaching help as you can. If nothing else, at least give verbal encouragement to those who seem to be trying to work hard at it. After all, even secure and effective people welcome kind words. SUMMARY
If there be good news in this story, it is like that embodied in the Chinese ideogram for crisis, which consists of the sign for danger plus that for opportunity. We are entering a time when deans, pressured by declining resources, will seize any opportunity
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to identify dross and prune it from their schools. They and each of us must recognize the highest quality personnel and activities that we have and nurture them. Discarding the rest will lead to improvement; after all, if a thing is not worth doing, it is not worth doing well. Those who value the educational enterprise-and I think all of us dermatologists, having thrived through our years of formal educational experience that have brought us where we are, do value it--must be among those who come to its defense. This is our chance to show, as leaders, what wise choices, effective leadership, and hard work can accomplish. Let's be at it!
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Problems that deans face* Richard M. Caplan, M.D. Iowa City, IA
I come neither to praise deans nor bury them, but rather to provide information about some major issues that now confront medical schools and their chief operating officers, namely, the deans. I am not a dean, but I have worked parttime in my dean's office for 12 years as an associate dean with responsibilities mainly related to continuing medical education. I therefore attend many local and national meetings and am exposed to many readings, discussions, and hand-wringing sessions. It is easy, then, to grow inured to the usual topics and agonies and to assume that everyone surely knows about these matters. But everyone does not, it seems. Yet it is vital to the stability of our educational system, in fact to our medical care system, that not only administrators but also faculty members and practicing physicians better understand some of the pressures and problems. It is appealing to speak of an educational web or scaffolding in which medical faculties and schools are enmeshed. The choice of metaphor matters, for a web implies being trapped and devoured. A scaffold, though, suggests a structure that gives support and permits working and climbing to a higher level; maybe it also suggests a place where games may be played. When I began my dermatology residency at the University of Michigan in 1958, I learned of the recent retirement of Dr. A. C. Furstenberg, who From the Department of Dermatology, University of Iowa College of Medicine. Supported in part by a grant from the National Cancer Institute (No. R25 CA18017-08), Reprint requests to: Dr. Richard M. Caplan, Professor of Dermatology and Associate Dean for Continuing Medical Education, University of Iowa College of Medicine, Iowa City, IA 52242. *Derived from a presentation made to the American Dermatological Association, Banff, Canada, June 25, 1981.
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had been dean of that college of medicine for many years. It was then the largest medical school in the country in terms of student enrollment. Not only did Dr. Furstenberg conduct its affairs with the help of just one able secretary, but he also served as head of the Department of Otolaryngology and also conducted a busy private practice in the local community hospital. I have no doubt that he was a very talented and energetic man, but such a range of responsibilities with such a meager support system would be absolutely unthinkable for a dean today. So many complexities have entered the operations of an academic medical center that a very able person needs a large staff of assistant managers and supporting personnel. Even then it is difficult to "get the job done" because the dean no longer has the authority that he once had. On the contrary, the dean's powers are markedly constrained and he must work much more through persuasion than edict. True, some individuals may seek "favors," and when denied, conclude that the dean is a powerful and dictatorial figure. However, such a scenario portrays a very limited perception of the total milieu and behavior of the dean. The rate o f change in our world seems staggering. Those who have read Future Shock and The Third Wave by Alvin Toffler have encountered many persuasive examples of this, and those who follow the scientific literature realize how rapidly and tumultuously the very "facts" are changing. This theme of change, change, change is so prevalent that it is hard not to believe the Greek philosopher Heraclitus absolutely correct in arguing that the one eternal constant was change itself. The reader may think that money is the basis of all issues that concern the dean. In my view, to think so is simplistic and naive, like saying, "All you need to understand skin disease is to know biochemistry." Yes, money is vital to the exis0190-9622/82/110694+08500.80/0 © 1982 Am Acad Dermatol
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tence of the institution and it does relate in some way or other to almost everything else, just as biochemistry relates in some manner to all aspects of skin disease. But I submit that if you bestowed a great amount of money on the dean, you would find him remaining almost as unsatisfied as was King Midas. The cynical view of the golden rule ("He who has the gold makes the rules") is not totally true. I will discuss some major areas of pressure for deans under these headings: "Relationships With Governments,.... Curriculum,"' 'Diversity of Educational Responsibility," "Personnel and Recruitment," "Relationships to Other Groups," "The Justification of Education," "Societal Needs," "Maintenance of Quality," and "Miscellaneous Issues." RELATIONSHIPS WITH GOVERNMENTS The relationships with governments center largely on money, but not totally so, Medical schools since the late 1960s have received directly from the federal government large infusions of money designed to stimulate schools to admit and teach larger numbers of students. That support was directed toward relieving what was perceived as a serious shortage of physicians. The medical schools, damned at the time for being too few in number and training too few students for the needs of the nation, have since responded so well to the social needs and to the various governmental, financial incentives that the "general wisdom" today states we are on the brink of having too many physicians. Many critics now seem to blame this on the medical schools and expect them to correct it. The federal government is rapidly eliminating its subsidies that were designed to stimulate the production of more physicians. Therefore, capitation payments have ended, support for new construction of medical teaching facilities has stopped, and special project initiatives such as support for minority recruitment and development of family practice programs have been reduced greatly. Student loan and scholarship funds represent an important federal activity under constant attack from the administration's planners. Likewise under much pressure to reduce are the dot-
Problems that deans face
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lars paid via complicated reimbursement formulas through Medicare and Medicaid channels to teaching hospitals, many of which are components of medical school operations. The federal government during the past twenty years has provided major support for research and development. That support has yielded immense changes not only in our biomedical knowledge and technics but also in the physical structure and even the very nature of what a medical school is. In addition, there has come to be great reliance upon the private practice earnings of medical school faculty members. Thus, the ability of the faculty to generate money, using their skills in performing research and in taking care of patients, subsidizes the schools increasingly. Nor can a high-quality medical school any longer survive on its tuition, interest earnings, alumni gifts, endowments, or state appropriations. In the case of my own medical school, for example, a large state-supported institution, the state-appropriated funds presently account for only about 16% of the operating budget of the medical school (not counting clinical care operations), while another 7% comes from tuition sources and all the rest comes from grants and private practice earnings. Another consequence of this change in funding ratios will be an increasing reliance at many schools on volunteer teachers. Another major aspect of the relationship between governments and medical schools is the matter of control. There seem always to be legislative efforts to manipulate and dictate what medical schools shall teach. For example, the California legislature has considered a requirement that medical schools should teach courses in sex education and nutrition; federal initiatives have supported curricular preceptorships in family practice; other support has enticed the schools to develop special curricula to produce physicians' assistants. Governmental manipulation of the process of admissions has become onerous. As examples: governments have stimulated the development of new schools; state governments have specified, in some cases, that only residents of that state can be admitted to its state-supported school; the federal government has influenced the admissions process
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to stimulate the entry of educationally disadvantaged groups, especially the traditional racial minorities; 2 years ago the federal government even went so fat" as to make all federal funds for the institution contingent on the "forced" admission at each school of approximately five students who were American citizens who had taken preclinical training in foreign medical schools. The courts, too, have been active in ways that matter to the medical schools. Lawsuits have been filed by students in relation to admission, to dismissal, or to the time or requirements for graduation. A New York law that insists on public release of items and answers from standardized tests such as the Medical College Admissions Test has caused its developer, the Association of American Medical Colleges (AAMC), successfully to seek temporary injunctive relief from the rule, and is the basis on which it now gives the test in that state. There is also the controversial issue of the Regents of the State of New York choosing to perform independent accreditation of medical schools outside the United States in an effort to deal with the dilemma and pressure of American medical students graduating from foreign schools. Additionally, governmental regulatory agencies intrude into what medical schools do. These include, for example, the Food and Drug Administration (FDA), whose rulings influence greatly the curriculum of pharmacology courses, as well as the conduct of patient care in clinical clerkships, and what research is or is not stimulated. The Department of Agriculture may specify, for example, that all animal cages in an institution need to be replaced, which may represent a cost of many hundreds of thousands of dollars; at hostage to ensure compliance is all federal support of any kind coming to the parent institution. Another example is the GMENAC, a federal organization set in motion to study problems of medical manpower needs and make recommendations. GMENAC has aroused much controversy; its methods and conclusions have been debated, criticized, and obviously feared. Another way to gauge the relationship between the federal establishment and the medical schools is to look at some of the headlines in the AAMC's weekly activities report. From some recent issues
are these illustrations: whether to eliminate National Boards as a route to licensure and implement a new system; establishment of a student loan marketing association; compensation for research injuries; Veterans Administration (VA) appropriations and whether a cap should be placed on special pay given to physicians in the VA systems; the debate over the administration's manpower bill, which contains within it such vital matters as numbers to be trained, curriculum grants, area health education centers, and the national health service corps; federal initiatives in longterm gerontology care; and presidential requests to nullify previously authorized expenditures through the Department of Health and Human Services. CURRICULUM The traditional medical school curriculum currently receives much pressure for change. New disciplines clamor, if not for departmental status, for at least some sort of curricular representation-preferably as a requirement for the students. Examples include genetics, bioethics, nutrition, oncology, family practice, to say nothing of the old struggle about department status for dermatology, neurosurgery, anesthesia, urology, radiation therapy, medical humanities, and so on. These battles will probably continue always because classification schemes, whether devised by Aristotle, Linnaeus, or anyone else, will always require changes. The influence of today's dean on these issues is usually far less than most people think. True, the dean has considerable authority about who shall be hired and, of course, that relates to what is taught. In most schools, though, a powerful curriculum committee along with the faculty guard jealously their rights to declare what shall constitute the course of study for medical students. Indirectly, the dean's influence on curriculum comes through establishing departments or new programs, or just by choosing which faculty members will serve on the curriculum committee. As in most patterns of governance, considerable differences exist among the schools regarding the authority the dean can or will choose to exert. These curriculum-related activities are important and even powerful, but certainly not dictatorial.
Volume 7 Number 5 November, 1982 DIVERSITY OF EDUCATIONAL RESPONSIBILITY
In most medical schools the dean serves as chief academic officer, not only for the education of medical students, but also in many settings, for residents as well. Further, his responsibilities encompass related educational programs, for example, radiation technology, occupational therapy, physical therapy, dietetics, laboratory technology, physicians' assistants, and so on. A relatively recent development for many medical schools, but now including essentially all, is an interest and responsibility to provide continuing education for the relevant practicing community. American medical schools now largely accept the principle that they should take some corporate responsibility for the entire continuum of medical education, meaning not only their traditional role for medical student education, but also for residencies and continuing education. Large numbers of faculty participate as teachers in much continuing education activity, although often not at their own school or in its behalf. The number of invitations to faculty for this kind of participation has grown greatly in recent years, and in the case of a small number of popular and effective teachers, the tail seems almost to be wagging the dog. Medical school deans also carry responsibility for programs serving graduate students who seek degrees in basic science departments. Deans must often supervise students of other health science colleges, such as dentistry, nursing, pharmacy, and so on, and of course in many medical schools there is a large student body from other colleges of the parent university, particularly Liberal Arts, taking courses within the various departments. Added to all these is the obligation that most colleges of medicine feel, in varying degree, to participate somehow in the processes of patient education and even public education. Deans almost always feel themselves bedeviled by the processes of accreditation. Not that they are opposed to standards and concern for quality, mind you, but simply that the process is always arduous, " f u s s y , " and very time-consuming. Since all schools have a great many programs, each of which has at least one if not multiple avenues to seek its accreditation, there flows almost
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a steady stream of visiting accreditors through the administrative offices of medical schools. Those periodic internal and external examinations require special preparation, sometimes a fair amount of anxiety, and certainly a good deal of time to be spent by the dean and key faculty members. Although a dermatology department may have its residency program accredited only every 4 years, the dean may have to meet the accreditors and teams of them literally tens of times per year. PERSONNEL AND RECRUITMENT
Finding new talent is a major task, headache, and opportunity for the dean. A surprising diversity of people must be sought and hired. Not only are there the traditional academic types in clinical and preclinical departments, but there are also those who operate the various service units such as Research in Medical Education, Medical Graphics and Photography, the bioengineering shop, the animal care facilities, the computer services, and such institution-wide facilities as transmission or scanning electron microscopy and tissue culture units. Shortages of personnel chronically plague the dean. High-quality faculty members of all persuasions are hard to attract, especially department heads. A dean is eager to attract the best-quality department heads he possibly can. This generally means that the person must have credentials as a first-class scientist, for although it is true that such a person may not necessarily become an effective administrator, it is unlikely nowadays that a second-class scientist will be able to build or maintain a first-rate department. Recruitment is very difficult because of the financial competition with private practice and because of the chilling influence of faculty members having greater difficulty today in obtaining outside grants to support their research. If full-time clinical teacher-investigators in fact find they are unable to support and do their research, but instead make their way within the medical school largely by seeing private patients and contributing to the practice plan coffers, they will be strongly tempted to decide that if all that time is to be given to seeing patients, they might as well be "on the outside," reaping the considerably greater financial rewards available in that other setting. Whether the presently projected sur-
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plus of physicians will make it easier to recruit for academe in the future remains to be seen. In any event, the frequent changes of personnel in a large institution keep constant pressure on the dean, even though much of the seeking-and-persuading falls to department heads or faculty committees. Obligations toward affirmative action (formal, imposed regulations in behalf of equitable hiring of minority members) add an annoying sense of regimentation and also many process steps that deans and department heads must obey. The recruitment of faculty also involves high cost--not only all the time of the dean and others just mentioned, but also the large cost of transportation, entertainment of visitors and committee members, telephone calls, and, ultimately, major commitments to new chairmen in respect to hiring new faculty members for that discipline, providing new or renovated space for offices, clinics, or laboratories, and allowing increased salaries. Further, a wise dean will recognize, as a matter of selfinterest for himself and the institution, the importance of his giving personal guidance and support to a new department head. And the stresses and litigiousness of our age prompt occasional formal grievances or lawsuits from faculty members, which the legitimate concern for due process plus the bureaucratic structure of a university can convert into a prolonged nightmare for a dean. "Recruitment" does not yet mean the need to find student applicants. However, important changes are taking place; the reasons for them and their implications remain unclear. In fact, the number of students applying to American medical schools has decreased in the last few years such that in the autumn of 1981 about 35,600 applied, compared to a peak of about 42,000 annually in the period 1974-1976. Correspondingly, 48% of those who applied received admittance to U.S. allopathic schools in the fall of 1980. This increase corresponds to the greater number of places and the decrease in the total number of applicants. RELATIONSHIPS TO OTHERS
A dean must interact with many other organizations. That requires much tact and time. Since approximately 1910, when the Flexner report helped to bond medical schools to a parent uni-
Journal of the American Academyof Dermatology versity, the medical school deans have had to relate to university presidents, academic and financial vice-presidents, and to fellow deans within the large university, as well as to boards of regents, legislative committees and members, and various departments of local governments. At some schools there have been developed branch medical campuses which the dean must then oversee. Most medical schools have affiliated hospitals with varying degrees of formal governance and interaction. As may be supposed, among all these relationships there arise many political and financial hassles. Relationships of the dean extend to national organizations through grant-related activities, and also because the deans often have impressive personal reputations they wish to maintain and nurture. That involves such activities, for example, as service to the National Institutes of Health, private foundations, national and local fund-raising organizations, and editorial commitments. The deans must maintain contact with the communications media, partly to foster positive images and partly to offset what in recent years has tended to be a veritable flood of articles critical of physicians and the institutions that train them. The deans must relate to hospital administrators, especially in affiliated hospitals. Internally, they have their department heads, faculty members, and students, all seeking, as a part of the modern clamor for participation and governance, to have a voice in how things shall be done. And externally, there are the alumni of the institution itself, a great many other practicing physicians in their geographic area, and the politicalscientific-educational organizations that physicians seem to generate in profusion. The deans must relate to the general public about such problems as medical manpower (including "why my child wasn't admitted to medical school last year"), explain and justify medical costs (as if he were responsible for them all), defend and monitor appropriately the use of hazardous substances, show concern generally about environmental pollution as it affects health, stave off the never-ending attacks of antivivisectionists, and serve on committees and commissions appointed for civic, state, and federal purposes. Es-
Volume 7 Number 5 November, 1982
pecially do deans of publicly sponsored medical schools have occasion to testify at legislative hearings, as well as jockey behind the scenes to obtain both defensive and offensive advantage regarding appropriations and legislative rules bearing on curriculum, admissions, personnel, and so on. THE JUSTIFICATION OF EDUCATION Deans must justify education. That may seem strange to the highly educated who are sympathetic to it, but much of the world, even in American society, lacks this acceptance of a high priority for education. Therefore, deans need to define their educational process, make it accountable, manage it appropriately and effectively, evaluate it a/most to the point of fetishism or nonsense, respond to audits by university and governmental auditors, satisfy accrediting groups such as the Joint Commission on Accreditation of Hospitals, keep at peace with the Professional Standards Review Organizations, and in forum after forum testify eloquently to the vital importance of the institution they shepherd. SOCIETAL NEEDS Deans must have concern about society's needs, and show it. They must recognize their role in contributing to medical and health manpower and try to keep it at highest quality. They must recognize the need to contribute new knowledge, a mission felt by all universities, which involves relationships with major organizations doing research and paying for it, such as the National Institutes of Health and the pharmaceutical industry. Medical schools are looked to by society to develop demonstration projects that test the feasibility of new ideas. Medical schools are expected to provide health care to certain segments of society. Most medical schools serve both an important referral function and also provide some degree of primary care needed by persons living near the school. (The claim for such care has even been known to provoke riots in the neighborhood.) MAINTENANCE OF QUALITY Maintaining institutional vigor is full of challenges great and small, mountains and nettles, since instruction, scholarship, and health care de-
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livery are all expected to be of the highest possible quality; no amount of internal politics nor inadequacy of facilities or funding makes acceptable excuses. Sabbaticals or research /eaves must be protected in order that faculty members may be stimulated to develop original ideas, learn new technics, and replenish enthusiasm. Quality means some sort of review periodically of departments and units. The deans are much embroiled in, and troubled by, decisions about appointments, promotions, and tenure. All of these add up to the general issue of morale. And these deliberations must happen in a marketplace competing briskly for services. This concern for quality may represent an attempt to defeat the second law of thermodynamics, which seems to apply to institutions as well as other natural phenomena: any system, a medical school included, will deteriorate and grow chaotic, becoming slower and colder and ultimately stop, unless there is an infusion of energy, preferably constant rather than episodic. For a medical school that renewal of spirit requires leadership, imagination, a sense of direction, money, loads of energy, and satisfaction with recognized accomplishments and achievements as a base for new knowledge and vigorous instruction. MISCELLANEOUS ISSUES
Still other important issues face the deans regularly that demand investigation, decisions, and implementation. One especially challenging example includes topics of biomedical ethics: for example, how should an institution behave and instruct regarding the technological imperative which argues that whatever technology can do in research or patient care should be done, no matter what the implications about cost or personal autonomy. Likewise, the dean faces these challenges: to prevent medicine as a profession from becoming calloused and mechanical, forsaking its traditional characteristics of humaneness and broad humanitarian learning; to respond suitably to the consumerism movement, not only in terms of governments but also in terms of ideas about health, and "alternative" systems of health care and its delivery; to select and monitor ethical review boards that must simultaneously strike a balance between assisting investigators to do research
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and at the same time protecting research subjects; occasionally to preside over a debate that grapples with the tough problem of when the pursuit of scientific knowledge changes from necessity to luxury, or whether we can, either financially or ethically, afford certain kinds of research; and adjust to certifying boards and licensing bodies that make decisions which influence what medical schools must do. A dean shares the problems of any manager trying to run his office when there are too many people reporting directly to him. Management theory suggests that having five to seven people reporting to a manager is probably optimal. A medical school dean is liable to have anywhere from twenty to fifty people reporting directly to him. The task of delegating becomes gigantic. In the face of it all, the dean struggles to maintain an institutional thrust while trying to obtain a sense of personal accomplishment. Creativity requires some spare time for reflection or objective viewing of the larger picture, something exceedingly difficult among the constant welter of telephone calls, visiting dignitaries, and deadlines of major projects. SUGGESTIONS
Here are a few suggestions that might aid readers of this article to assist the dean to whom they personally relate, as he works to guide the institution that involves so much of their pasts and futures: 1. Be empathic witn his circumstances and those of the entire university. Learn what issues face him, such as those discussed above. Then you can at least have a common universe of discourse if you encounter him at a faculty meeting or a cocktail party. 2. Be a team player, or try to be. At least avoid being an adversary. Physicians, used to functioning as masters of their own domains, almost always are so fiercely independent that they sometimes have trouble working as part of a team. 3. Help him muster support. You as a practitioner or faculty member and he as a dean both need all available help from other individuals and institutions.
Journal of the American Academy of Dermatology
4. Contribute money to your medical school, to the institution that provided your residency, and to the Dermatology Foundation. 5. Those working in medical schools should make practitioners feel welcome in the departmental clinics and educational activities. Be as helpful to the practitioners and their continuing educational needs and interests as you possibly can. Likewise, try to help those of other departments and units, for "He who would have a friend must be friendly." 6. Faculty members should participate in school affairs. The person (especially a department head) who tries to keep a low profile all year long except at " g i m m e " time is likely not to be received with great enthusiasm. Volunteers are always needed for committee activity, such as curriculum committee, search committees, student prizes committee, animal care committee, audiovisual advisory committee, and lecture committee. Participate in activities of general university government; be at least as active for your own school as for regional and national specialty organizations. 7. If those who now carry some sort of administrative responsibility feel a deficiency in their skills of business, planning, or administration, they should work to improve. If specialized help or simply more help is needed to manage the department, then get it. Carefully guard against one of the worst sins of all, namely, spending more money than you have. Correspondingly, try to learn more in a formal sense about the process of education. And faculty members might consider the ultimate in service: offering themselves as a candidate to be the dean or a part of the dean's staff. 8. Those readers who are not department heads or faculty members can contribute dollars and lobby in behalf of education in general, not only dermatologic education. Such "lobbying" refers not just to efforts aimed at legislators and governmental officers, but means "talking it up" with patients, colleagues, and acquaintances. To paraphrase John Donne, "no department is an island,
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but a piece of the whole." Offer as much teaching help as you can. If nothing else, at least give verbal encouragement to those who seem to be trying to work hard at it. After all, even secure and effective people welcome kind words. SUMMARY
If there be good news in this story, it is like that embodied in the Chinese ideogram for crisis, which consists of the sign for danger plus that for opportunity. We are entering a time when deans, pressured by declining resources, will seize any opportunity
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to identify dross and prune it from their schools. They and each of us must recognize the highest quality personnel and activities that we have and nurture them. Discarding the rest will lead to improvement; after all, if a thing is not worth doing, it is not worth doing well. Those who value the educational enterprise-and I think all of us dermatologists, having thrived through our years of formal educational experience that have brought us where we are, do value it--must be among those who come to its defense. This is our chance to show, as leaders, what wise choices, effective leadership, and hard work can accomplish. Let's be at it!