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 Also: Professionals must be problem solvers Building a base for the future  |
Story by Jon Saxton  t doesn't
take much prompting to trigger an impassioned discourse from Michael Johns
about how tough things have been for physicians and other health professionals
over the last decade or so.
"It's been really hard to be a health professional recently," Johns says. "What was once considered a noble calling is now regarded as just another interest group to be managed and a cost center to be downsized." Pressed on how that relates to what he does now as head of the Woodruff Health Sciences Center (WHSC), Johns doesn't hesitate. "It's why I do what I do. Since the day I entered this profession, I have seen not just patients and research opportunities, I have seen issues and problems that needed to be addressed. I am impatient with problems and driven to find solutions." As a head and neck surgeon, Johns spent the latter part of his practice years battling on two fronts: First, trying to work around conventional roadblocks to emerging opportunities for more efficient and effective care. And second, trying to parry the leading wave of administrative and regulatory burdens created by managed care organizations and policy makers under the rubric of market discipline. When he was appointed chair of otolaryngology-head and neck surgery at Johns Hopkins School of Medicine, Johns soon became frustrated by the cumbersome processes and inefficiencies (for both physicians and patients) necessitated by inpatient care for relatively minor and routine surgery cases. With no Hopkins tradition of performing outpatient surgeries and with no outpatient facilities to speak of, he improvised same-day surgeries by commandeering surgery space and the necessary supporting team. It wasn't long before he was in the dean's office suggesting that, based on his experience and success, Hopkins should make better provisions for outpatient surgery. He was soon in charge of creating what is now the state-of-the-art Johns Hopkins Outpatient Center. Within a few years, he was the new dean of the Johns Hopkins School of Medicine. So what is the biggest problem health professionals face today? "We've lost a great deal of status and esteem," Johns says. "It's partly our own fault; we got complacent in the boom years of fee-for-service medicine. But now, we've been on the defensive for so long that our profession has lost some of its dignity. We have to get it back. We have to earn it back. And until we can regain this lost ground, it's going to continue to be tough to have our views heard in defining the future of health care in this country." |
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 ver the
past two decades, all health professionals have had to confront and contend
with huge forces for change. Traditional care models have been questioned,
recast, and sometimes replaced. New processes, technologies, and accountabilities
have been imposed. But much of the change has been driven less by physician
leaders than by policy makers and managed care executives intent on imposing
new business models, cost-control mechanisms, and global market discipline
on a medical profession steeped in tradition and controlled locally in
guild-like fashion.
This pressure for change would have been difficult enough had the health professions marshaled their own resources and contended with the many new demands and developments in health care. But the collapse of the Clinton health reform plan in 1993 was the last straw for 20th century health care reform. Without a vision for meaningful change, the health professions, and medicine in particular, found themselves on the defensive. They faced an all-out assault from those newly empowered by the policy vacuum and touting market-based solutions to health care reform and cost containment. The failure of the medical profession to rally for a coherent and cost-effective health care system damaged organized medicine's already diminished influence and professional standing in the public eye and among policy makers. E. A. Krause, a leading scholar specializing in the study of professions, characterizes the plight of the medical profession in America over the last two decades as the fall of a giant. "No profession in our sample has flown quite as high in guild power and control as American medicine, and few have fallen as fast," he concludes. Johns agrees with this assessment. "Whether we like to acknowledge it or not, we are in a major political battle over the future of our professions and how much influence we will have over our nation's health policy," he says. The battle for health professional self-determination must be won first at the local level, including at Emory. This struggle to ensure that professionals here can mold their own future has been a focal point of Johns' tenure as director of the Woodruff Health Sciences Center. "Our situation here at Emory is like that of other major academic health sciences centers," explains Johns. "We are all being tested. Can we adjust to new rules, roles, and accountabilities? Can we move away from outdated models and create the new models of care and prevention required for the 21st century? Can we respond with the creativity, vision, and day-to-day determination and follow-through that is required of leadership?" The challenge is getting past the built-in inefficiencies of academic missions and other roadblocks to change. That includes the traditions of professional autonomy, epitomized by the old analogy that likens organizing academic professionals to herding cats. |
 Building a base for the future 1996
Researchers move into the 325,000-
The Clinic B Vivarium is expanded to The 68,000-square-foot Emory Faculty Renovations and an addition are made to
Completion is slated for the 130,000- |
 hen you
look at it, we're in a battle," Johns says. "We were hit harder originally
than any of us expected, and we have been on the defensive ever since.
But even on the defensive, you have to think about how you are going to
get back on the offensive. How are you going to battle back?
"What I've tried to do is lead us to make the right investments and to provide the right resources and support to enable our health, research, and education professionals to take the initiative in solving the problems they face," says Johns. "One important way we've done that is by significantly adding to and upgrading our facilities for research, care, and education. It's extremely difficult to do first-rate work in third-rate facilities. It's virtually impossible to make tomorrow's discoveries with yesterdays tools." Indeed the investment in all of these areas has been remarkable, given tight finances in health care. Since 1996, the WHSC has made an unprecedented investment - $524 million - in construction and renovation for the health sciences, amounting to almost 1.8 million square feet for classrooms, offices, research laboratories, and clinical areas. But these much-needed improvements are only a part of the investment that has been made to empower Emory's professionals. Johns continues, "We've brought in exceptional leaders at all levels throughout the organization -- individuals who understand what's required to reach the highest levels of achievement. We've worked hard to be strategic and to define together how to prioritize our resource development and investments. Our deans and directors work together better than the leaders of any other academic health center that I'm aware of, and we are pursuing new cross-disciplinary and interprofessional initiatives every day. "We've completely reorganized our clinical operations, first by creating Emory Healthcare to achieve new efficiencies and better operations. John Henry (Emory Hospitals CEO) and John Fox (Emory Healthcare CEO) have both achieved remarkable results. John Henry brought our hospitals together. And it was his vision that led to the complete redevelopment of Emory Crawford Long Hospital in midtown. John Fox is overseeing the launch of One Emory Healthcare, to bring the remainder of our administrative and human resources operations together into one seamless organization. "We have brought people like Don Brunn into The Emory Clinic, people who really understand the business of clinical medicine and can educate and guide our faculty and staff to be successful in this environment. We've brought in nationally known leaders like Marla Salmon to head the School of Nursing and Stuart Zola to take the helm of Yerkes. We appointed Tom Lawley, dean of the School of Medicine, and reappointed Jim Curran, dean of the Rollins School of Public Health. We've recruited some of the world's leading scholars, scientists, educators, and clinicians to add strength and dynamism to a core of strong programs throughout the health sciences center. We've even provided direct support financially to specific areas." One other important way that Johns is seeking to provide resources for leadership is through the creation of the new Woodruff Leadership Academy (WLA). The WLA will provide advanced training in the dynamics and skills of leadership to WHSC faculty and staff with the specific aim of developing leaders from within the institution. The course features a curriculum developed and taught with the aid of national experts in leadership and leadership training. Its first class of 20 fellows is a cross-section of faculty and staff nominated by senior leadership throughout the health sciences center. The fellows will attend multiple-day seminars once a month from January through May and will continue academy activities throughout the rest of 2003, with a new class to be selected next fall. Leadership training of this sort, while relatively common in many industries, is virtually unheard of in academia, where leadership is usually recruited from the outside. Johns hopes that this unique WHSC program will help develop a broad cadre of Emory leaders who will make their marks both at Emory and elsewhere. |
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n Johns'
eyes, these initiatives constitute an ongoing investment in the structure,
the operational capacity, and the intellectual brainpower that make remarkable
things happen. All he wants in return is the commitment of faculty and
staff to do remarkable things.
"Sometimes," Johns says, "it's a little disconcerting to hear people complain about their situation or their salary or their workload -- not because I don't understand that things have been hard, but because I truly believe that professionals should be problem solvers. They should be people who size up a situation and then organize the resources and wherewithal to do what is necessary to get the best possible outcome. "I have always thought that the moment you start to complain, you lose the power to control your own destiny. When you lapse into the complaining mode, what you are really saying is: 'I'm not capable of solving this myself with my wits and resources, and I want somebody else to do it for me.' You are asking to have the solutions taken out of your hands. I've seen this at the national level, where people in Congress hear certain health leaders or policy people complaining about our problems, and so they go ahead and create a new regulation that further narrows the scope of our discretion. "But here at Emory, we have really made progress. When I first arrived here more than six years ago, there was a mindset among some people that their chairman or their dean or someone else was supposed to solve everyone's problems. More often than not now, other people are taking the initiative. They're coming forward not with problems, but as leaders with new and better solutions, trying to move forward with new ideas, rather than just trying to maintain the status quo. "That indicates to me that we have turned the tide. That our investments are paying off. That, at least here at Emory, we are regaining our footing and are responding like leaders and change agents. It means we are battling back with new ideas and a renewed sense of the health professional as leader." |
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 uch still
has to be done to recapture the high ground. One of the most important
battles lost in the late 1990s was the budget battle. The Balanced Budget
Amendment (BBA) passed by Congress in 1997 is on track to divert more
than $1 trillion from health care-related spending over ten years. Already
more than $300 billion has been lost nationally. Emory's clinical system
has seen a reduction in revenues of at least $100 million since the BBA
was enacted. The result is far fewer dollars to invest in creating better
care, research, and training programs.
"But we can't sit around and moan about not having enough resources," says Johns. "We just have to go out and find them." To that end, Johns has initiated an intensive priority-setting and planning process to develop significant fund-raising initiatives and possibly a broader philanthropy campaign for the WHSC. The process includes faculty and staff leadership of the WHSC, along with the university provost and others. High among identified priorities are significantly increasing scholarship support for students and identifying new resources for key programs in areas such as the neurosciences, infectious disease and bioterrorism, preventive health, vascular medicine, aging, and cancer prevention and treatment. And there is still more to do in adding and improving upon key facilities, with proposals encompassing a dedicated medical school education building, significant enhancement of outpatient facilities at The Emory Clinic, and modernization of Emory University Hospital. "Now that we have made the basic investments and have turned the corner," explains Johns, "there are extraordinary opportunities for us to emerge as one of the top few pioneering centers of discovery and innovation in this new century. "What we need now," he continues, "is to take the next step. What we are doing right now is what leaders do when the battle begins to turn: we are assessing our strengths and where we need to resupply, redeploy, or add resources. "Most important," Johns insists, "we're looking ahead to where we can decisively focus our resources for maximum effect. I believe that if we can do this and make our case well, we will find the support necessary to reach our goals." To Johns, there is nothing more important to the future of health care than the people who must provide leadership in making that future. In a recent talk to WHSC's human resources department, Johns described his vision. "My vision comes down to empowering you," Johns said. "It's about maximizing the opportunity - even perhaps the expectation - for anyone at Emory with vision, insight, and determination to be an innovative leader in their own right. I challenge each of you to help create or build something special - something that moves us forward in our common purpose - 'Making People Healthy.'"
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Academic medicine professionals have, until recently, functioned in a relatively protected, self-regulated, and unchanging environment, under well-established and stable systems of academic and professional conduct. This traditional model of the medical professional stressed the autonomy and authority of the sole practitioner. Performance expectations were built around individual accomplishment. It is now widely accepted that this model of the medical professional is outdated and unsuited to the task of forging an integrated system of health care. Less universally agreed upon is what should or can replace it. Most often proposed is the concept of the team player, the professional who learns and works as part of a multidisciplinary care, research, or educational team. Ideally in such teams, each individual brings special expertise and shares leadership when needed. |
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he key
to health professionals regaining lost professional status is to restore
their roles as leaders and change agents, says Michael Johns, executive
vice president for health affairs. They must be empowered to solve problems
and create new models.|
In this vernacular, professionals are best understood as "knowledge workers." According to management expert Peter Drucker, knowledge workers, unlike manual laborers and others, are not "directed" workers. They are self-directed and motivated by effectively applying their specialized knowledge. They expect their work to be defined not by its quantity or its costs but by its results. Their education teaches knowledge workers to be independent and lifelong learners. Leaders in the academic setting must understand that knowledge workers are best employed and managed as "associates" rather than "subordinates." The analogy here is that they should be engaged in the same way that a conductor directs an orchestra. The health professional is the paradigmatic knowledge worker, and the academic health center is a leading employer/educator of these professionals. It is clear that ordering health professionals within highly regimented structures and regulations demotivates them and discourages self-directed development and expert problem solving. Managed care has taken this approach, and it has largely failed. |
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Copyright © Emory University, 2002. All Rights Reserved.
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Web version by Jaime Henriquez.