J Thorac Cardiovasc Surg 2001;121:S12-S16
© 2001 The American Association for Thoracic Surgery
Developing the Academic Surgeon: A Symposium |
Building a clinical program in a single institution
William A. Baumgartner, MD,
R. Scott Stuart, MD
From The Johns Hopkins Hospital, Baltimore, Md.
Address for reprints: William A. Baumgartner, MD, The Johns Hopkins Hospital, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287-4618.
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Abstract
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A successful clinical program within either a single institution or a multi-institution complex requires the recruitment and retention of excellent faculty, a strong residency program, a successful, recognized research program, and leaders with administrative, organizational, and leadership skills.
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Introduction
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Most opportunities for new chiefs are in established programs, but occasionally one might have a chance to develop a new academic thoracic surgical program. Although several obstacles can stand in the way of the attainment of an excellent clinical program, we feel that a few guiding principles will provide the best opportunity to build a clinical program in a single institution.
These principles, based on experience in the Division of Cardiac Surgery at The Johns Hopkins Hospital, include (1) the recruitment and retainment of excellent faculty members, (2) the development of a strong residency program, (3) the maintenance of a productive research program, and (4) education in administrative, organizational, and leadership skills.
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Advantages of developing a clinical program in a single institution
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A successful clinical academic program can clearly be achieved in the setting of multiple institutions. But the development of a program in a single institution or health system is usually more facilitatory and less complex. At a single institution, all faculty are aligned along a similar institutional culture and set of core values. There is also a common marketing and planning goal of a single institution or health system. When one is dealing with multiple institutions, there can often be conflicting hospital views regarding advertising and marketing. This can occasionally cause conflict within faculty of the same clinical group. Dr Starnes' program at the University of Southern California as outlined in the preceding article is an excellent example of how a multi-institutional approach can work successfully.
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Recruitment and retainment of excellent faculty
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The three R's constituting the development of an excellent faculty are recruitment, reward, and retainment. In past years, academic institutions would often recruit excellent faculty, but as these faculty members matured and gained promotional rank, and their salaries and other needs increased, these centers were willing to allow them to depart. The feeling was that it was possible to recruit a younger faculty member, at a lower base pay, who would build a clinical practice—and the cycle would be repeated. This is not the trend today.
The recruitment of faculty is probably the most important step in the development of any successful academic program. The selection process can include individuals from within the residency program or surgeons from outside the institution. The primary advantage of internal recruitment is that you know the technical and the personal skills of the resident. Likewise, the resident is aware of your values and principles of management. A relationship has already been established. Total recruitment "from the inside," however, can lead to an "inbred" group, and this may result in a lack of innovative ideas, techniques, or new programs.
An external recruit will bring a different set of ideas and techniques. Occasionally, a recruit from outside might bring a culture or set of core values that are not compatible with yours or the group's. Our own division consists of 9 faculty; 8 are active in the operating room. Five individuals are from The Johns Hopkins University residency program, and 4 were recruited from outside the institution. This hybrid approach is probably the best arrangement.
All faculty should share the same core values. The core values of The Johns Hopkins School of Medicine are listed in Table I. A collegial environment in which all faculty look out for each other leads to improved satisfaction. Communication between the division director and the faculty, as well as within the faculty, is essential in maintaining this environment. Each person should appreciate individual talents and interests of his or her colleague. An alignment of incentives is encouraged. For example, in our own division we have individuals who would prefer to always be in the operating room, those who enjoy clinical research, those who participate in basic research, and those who are involved in educational research using various tools, including the Internet. Faculty generally participate in 2 or more of these missions. There are also individuals in the group who assist the division chief in the "running" of the clinical practice. This latter responsibility can be quite involved, as it relates to various aspects and personnel of the clinical practice, including nursing, physician assistants, case managers, quality improvement initiatives, and utilization review.
The successful development of a young faculty member is key to the future of the division. We are fortunate that a strong "in-house" cardiology division often refers to the division rather than to a specific surgeon. We have constructed our operating room schedule so each surgeon has a number of O.R. slots per week. Additional cases can be added, driven by volume. This environment provides younger surgeons with an immediate opportunity to build a practice. It also removes some of the competitiveness for volume.
Establishing a defined O.R. schedule provides some predictability for all faculty, allowing time for academic and family activities. We think it is also important to create an individual niche for each faculty member and then promote that individual within that particular program, service, or operation. In addition to pediatric cardiac surgery, we have individuals who direct programs for transplantation, ventricular assistance, clinical and basic research, off pump surgery, minimally invasive surgery, and aortic surgery. This allows faculty members to become proficient in their field, and it creates an opportunity for them to gain national exposure. This type of organization allows our faculty the option to perform scholarly work, in a specific area of research, clinical skills, or education, necessary for advancement at The Johns Hopkins University School of Medicine, which maintains a one-track promotional system.
Faculty reward is measured many ways. Faculty promotion represents the most important reward. It requires some type of scholarly activity in one of the missions. Traditionally, this has been in the areas of basic and clinical research, but more recently education and teaching using innovative techniques have resulted in promotion. Financial compensation can be provided in a variety of forms. At our institution, there is a base salary and a supplement, which is provided once a year. This supplement is based on clinical productivity as well as on academic achievements in various fields, as described above. These supplements are negotiated with the department chairman and the dean.
Because national recognition is part of most promotional systems, faculty members are encouraged to submit abstracts, make presentations, and write about their field of expertise—whether it is clinical activity, research, or education. First- or senior-authored papers published in peer-reviewed journals, chapters, and/or books help faculty members gain national recognition.
Other rewards or benefits of an efficient clinical practice can be related to lifestyle. Although not easily quantified, these may involve reasonable on-call coverage, predictability of one's O.R. schedule, and camaraderie among the faculty members.
Appropriate reward clearly leads to faculty retention. Promotional and financial attainment is crucial, but creating the proper environment is also important to retain excellent faculty. This involves fostering a sense of collegiality, encouraging individual interests and niches, and focusing on quality-of-work issues in such matters as on-call schedules, operative slots, and time away. The commitment to foster the development of young faculty will generally lead to long-term retainment. These eventual senior members of the division generally have developed large clinical practices. If these individuals leave your division, it should be for the right reason: an offer for significant advancement in the academic ranks.
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Strong residency program
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Although not entirely necessary for the development of a clinical service, a strong residency program provides several advantages to the overall success of an academic clinical program. Residents provide the stimulus for faculty to keep current in their particular field. With the advent of the Internet and specialty Web sites, the resident can educate himself or herself on a particular procedure or disease, which will prompt questions to faculty. Faculty members are stimulated to educate themselves about recent developments and think about innovative ways to refine their practice.
In our own program, residents spend an elective 6-month rotation in their second year of a 3-year program. They generally choose rotations outside of the United States. Their salary and air transportation is provided by the division, which provides the incentive for programs to accept them for the 6-month period. Residents return with the experience from whichever institution they worked in for that period. This has been viewed as a value-added component of our residency program.
Residents also provide a service element to all divisions/departments, especially in regard to specific programs such as transplantation and assist devices. To provide the proper atmosphere, the program director and faculty have to be committed to residency training and education. It has to be a core value of the program.
1,2 The fundamentals of such a program are listed in Table II.
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Productive research program
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Webster's dictionary defines research as: "investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories or areas in the light of new facts, or practical application of such new or revised theories or laws." 3 Research has traditionally been carried out at academic medical centers in "wet-labs" involved in basic (bench top or animal) research. This type of research has diminished in thoracic surgical programs during the last 10 to 15 years, for a variety of reasons.
In this era in which surplus funds from clinical revenue have disappeared, young investigators are being encouraged to increase their clinical workload to support themselves. This is a significant threat to the development of a thoracic surgical research investigator. (It is, however, out of the scope of this article to discuss this in detail.)
In addition to turning to the traditional funding sources, such as the National Institutes of Health, the American Heart Association, and the American Cancer Association, some divisions have employed PhD researchers, to provide continuity in the laboratory as well as to assist in the investigations. Because these individuals are not always self-supporting, salary support is generally needed from the division or department. Collaboration also remains an excellent way to carry out basic research, utilizing the expertise of talented scientists in their specific area of interest. However, funding even in this scenario remains problematic.
Basic research is the foundation on which translational research is performed, which is important to the development and evolution of a strong division or department of thoracic surgery. Translational research provides an opportunity to receive funding from corporate support and carry out clinical studies that may have an important effect on patient care and outcome. This type of research activity also distinguishes the academic clinical program from good community programs, perhaps even providing some degree of a competitive edge. However, the primary goal of translational research should be discovery, with the development of innovative techniques, procedures, and methods of care.
Several requirements are needed to ensure a successful clinical research program. Translational research generally requires an adequate number of patients for investigative trials. A clinical database is essential to gather and store information. Faculty should be willing to participate in these types of endeavors. These opportunities currently are increasing as a result of the explosion of new biotechnology companies and products. Although there are several corporate options, each clinical investigation requires careful evaluation of the device, procedure, or drug before any patients are committed to this area of research.
Educational research has not received much emphasis in academic medical centers. A strong academic division with a residency program, whether in a single institution or in multiple institutions, has as its mission both the training and the education of medical students and residents. The educational area of research should be fertile ground for future investigation. With the use of Web-based technology, educational content can be presented in a variety of formats, enhancing the content and making it available beyond the confines of the classroom. It is particularly appealing to programs that make use of multiple institutions. Residents and faculty are able to access educational material wherever a computer terminal is available. As wireless technology develops, this educational content will be available at the point of care, with hand-held devices. Success of this educational mission is dependent on the school of medicine's recognition of it as a scholarly endeavor, thereby qualifying the individual for both promotional advancement and financial reward.
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Administrative, organizational, and leadership skills
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The development of administrative, organizational, and leadership skills is another important area in building a strong clinical program. It is also an area in which most divisional chiefs have had little experience in their undergraduate or postgraduate education.
A clinical service should be organized around service excellence. This concept has received a significant amount of attention recently, and it has variable definitions. Our definition of service excellence is service that creates an atmosphere where quality care is provided to patients in a considerate and expeditious manner and where referring physicians are addressed in a similar way.
The cardiothoracic service, like other surgical specialties, is built on referral patterns from cardiologists, pulmonary medicine specialists, and oncologists. In our division, we have a "just say yes" policy in regard to patient referrals from outside physicians. We also strive to carry out the patient's operation 24 to 48 hours after the initial phone call. This service standard applies both to our outside cardiologists as well as to our inside colleagues. To facilitate this practice, we use a hospital service called the "Hopkins Access Line" (HAL). This is a physician-to-physician referral system with specially trained operators, called "expeditors." These individuals will expeditiously contact the Hopkins physician who is being requested by the referring physician and then maintain surveillance of the phone call in order to facilitate transfer of the patient to the specific nursing unit and accepting physician. HAL also provides easy access to the referring physicians for faculty who wish to communicate information and updates on the patient's condition. Transfer of patients arranged by HAL has steadily increased each year(Fig 1). There have been 180,430 HAL encounters since its initiation in January 1993. The breakdown of these encounters is seen in Table III. Each encounter averages 7 phone calls, which has resulted in 1,263,010 phone calls being made in the past 7 years regarding patients and their care.
Service excellence as it is applied to patients is promptly responding to patients' needs. In addition to expediting care and providing frequent communication, physicians should be compassionate. This will set the example for all staff working in the clinical area.
It is important to support your faculty and residents. We have stressed the importance of providing for them financially and in the area of promotional advancement. It is also important to attend committee meetings and take on added responsibility in your school or hospital in order to be a voice for your faculty within the institution. Although these meetings can occasionally result in no significant outcomes, it remains important to maintain a presence.
As a chief, promote your faculty and residents. Allow them to develop their particular area of clinical expertise even if it infringes on your own. Encourage them to be the first or senior author on papers and chapters. Pass on invited lectures or other national and regional committee responsibilities when possible. Communicate with your faculty and residents. Have frequent (weekly) faculty meetings, with periodic retreats, to review the status of the division and develop strategic plans for future development and direction. Be fair, consistent, and sensitive. Finally, work as hard as your faculty.
Educate yourself regarding business and financial matters. The Thoracic Surgery Research and Educational Foundation has organized the Harvard Healthcare Course, which is presented twice a year. There are also several other business of medicine and leadership courses taught at a variety of institutions. Divisional or departmental chiefs should take advantage of these courses. Although they require time away from the clinical practice, these courses provide for a better understanding of health care as well as the business and financial aspects of medicine. Leadership and conflict resolution are also important topics to be learned. These educational experiences will help guide you in building a better division or department.
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Conclusion
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Building a successful clinical program within a single institution is logistically easier because of a variety of advantages. There is generally a single culture and a set of values adhered to by all members of the division, as well as a unified marketing and planning strategy by a single hospital or system.
Whether confined to a single institution or involving multiple institutions, a successful clinical program requires the recruitment and retainment of excellent faculty, the presence of a strong residency program, and a successful and recognized translational research program. Finally, it is important for the divisional or departmental director to develop the necessary administrative, organizational, and leadership skills to run the division, work with the faculty and other members of the division, and take a leadership role in the school or hospital. If you combine these elements with a work ethic equal to or surpassing your faculty colleagues, the chances of your developing and maintaining a successful clinical program will be significantly increased.
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Footnotes
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Read on April 29, 2000, at the Eightieth Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada. 
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References
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- Baumgartner WA. Retooling thoracic surgery education for the 21st century. Ann Thorac Surg 1998;65:13-6.[Free Full Text]
- Baumgartner WA. Reassessing our core values. Ann Thorac Surg 2000;69:321-5.[Free Full Text]
- Merriam-Webster's Collegiate Dictionary. 10th ed. Springfield (MA): Merriam-Webster; 1996. Research; p. 995.
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Abstract
Introduction
