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0 HARVARD MEDICAL SCHOOL DEAN'S REPORT 1976 -1977 j

CONTENTS I. Organization of Harvard 1 Ability to Innovate 2 Problems of Autonomy 6 Outlook for the Future 7 II. Continuing Education 10 Admissions 12 Finances 12 Staff Changes 1'3 III. School of Dental 1ledicine 14 Appendix 17 Tables 24. Cover photo: Dr. Robert H. Ebert, right, with~ his successor as dean of the Harvard Medical School~ Dr. Daniel, C. Tosteson

• HARVARD UNIVERSITY MEDICAL SCHOOL To the Presi,dent of the Uhiversity: Silr--As Dean of the Faculty of Medicine, I'have the honor to submit a report for the academic year 1976-77. I This will be my twel!fth and last report. On such occasions it is customary to take a reflective look backward,, attempti~ng some measurement of accomplishments against aspirations. My fiinal comments are directed towardia few of the lessons to be learned from events of the past dozen years and an assessment of how well situated Harvard Medical School is today to respond to the changed conditions and fresh challenges it will confront in the years ahead. Some of these thoughts I have shared previously with the Visiting Committee and alumni, and I welcome the opportunity for a fuller statement here. The fundamental issue I wish to explore is whether the organization of the Medical School needs drastic revision in order to adjust satisfactorily to new demands and regulations. It is an appropriate q,uestion, for the structure of this institution differs'marked'ly from most, and in the organization of its faculty and! in its relationships with affiliated:hospitals lie both strength and vulnerability. THE ORGANIZATION OF HARVARD Unlike Harvard, the majority of American medical schools either own or operate a:university hospital or have a special relationship with a private hospital which is designated as the university hospital. A variation in this patternlis the "medicali center" with a presiding vice president and a potpourri of institutional members, including hospitals, nursing schools, schools of allie&health professions and the like. Whatever the organization, one general' hospital usually dominates and'control's the academic appointments in the other hospitals of,-he medical center. In contrast, H'arvard'has never designated any of 0 1

I MEDICAL SCHOOL its affiliates as the single university hospital, but has fostered~development of equals. This policy has given the School far greater depth in its clinical faculty than any other medi.cal school can boast. Competition among the teaching hospitals has clearly encouraged'the emergence of multiple centers of excellence. Each of the hospital'.s starts with the proposition that the care of the patient is its primary purpose and that teaching and research are secondary. This might appear to be a problem for the university, but it is in fact an asset, for a hospital dedicated to the care of the patient provides the best teaching environment for students and house staff. The sharp separation of the principal functions of hospitals and the Medical School means also that Harvard is not involved in the operation of any of the hospitals and bears no responsibility for any of the operating costs. Professional fees collected by the clinical services contribute to the support of these services, obviously, but they are administered entirely at the discretion of the individual hospitals, and the Medical School has no claim on them. This is an important difference, for professional fees represent 25 per cent of the total support of all American medical schools today. Three things distinguish the organization of the Harvard Faculty of Medicine from most other medical schools. First is a structure which permits multiple departments in a single clinical discipline. There are, for example, four departments of medicine and~ anaesthesia, five departments of surgery, six departments of psychiatry. This means that no head~of a clinical service in one teaching hospital is automatically the head of other hospital departments in the same discipline, and it means that Harvard can attract the very best people for all the clinical services. Secondly, the executive authority of the faculty resides not in the heads of departments, as in many schools, but in an elected Faculty Council. Finally,, the Faculty of Medicine includes all of the faculty of the School of Dental Medicine. The fact that the business of the faculty is carried~out, for the most part, by standing committees and'ad'hoc committees rather than by a tightly organized executi;ve committee of department chairmen facilitates this relationship. THE ABILITY TO INNOVATE Such a structure has allowed!a strong teaching and research capability to develop. It has also, in my 2 ~ ~ ~ -'- - °-- -- J ~ r

0 MEDICAL SCHOOL experience, tolerated the expression of radical ideass and the introduction of controversiaL programs far better than other institutions with which I have had some acquaintance. The Harvard Community Health Plan is an example. The concept of prepaid health care had long seemed'to me to offer an attractive alternative to traditionaL mechanisms for the delivery of health care. Yet I had not found it possible to develop a model prior to coming to Harvard. Here it could be done because of the many teaching hospitals to which~an appeal coul!d be made, none of which was possessed of an absolute veto. Here also was familiarity with how to develop an independent corporate structure which could assume direct responsibility for the Plan:3part from~the Medical School. The university's willingness to delegate significant authority to:the deans of the various faculties was a helpful factor as well. And finally, Harvard would not be d'eterred by fear of what others might think; timidity is not one of our faults. The Harvard Community Health Plan now has an enrollment exceeding 60,000 subscribers who are cared for in two centers, one in Boston, the other in Cambridge. During the year just past the Plan's Long Range Planning Committee made public a series of recommendations to guide operations over the next ten years. Principal among these is immediate expansion of enrollment and a new multi-specialty health center to provide ambulatory care to 50,000 members at the Kenmore Health Center. If approved by the Greater Boston Health Systems Agency and the Public Health Council of the Massachusetts Department of Health, the new center could open in the fall of 1978. Plans include the renovation of 88,000 square feet in an existing building located two blocks from the present health center at a cost of approximately $7.9 million. The new center would continue to provide services in primary care and~12'specialty referral areas, laboratory and x-ray services, while adding audiology and expanding,ambulatory surgery and oral surgery. The Long Range Planning,Committee also addressed! HCHP's involvement with research, program innovation, education, and the community, recommending continued~ emphasis on health education and'resid'ency training and an extended commitment to the low-income Mission Hill community where an outreach center now operates. Clearly, HCHP is no longer a promising experiment, but a well accepted, financialily selif-suffi~cient,, established element withimthe health care system. HCHP exemplified one strategy for exploring i~ssues 3

MEDTCAL SCHOOL relatingito provisionlof health care. The Center for Community Health and Medical Care was a second -- a focus for inter-disciplinary teaching and research im health services. Since its organization in 1967 under the joint auspices of the Medical School and School of Public Health, the Center has undertaken a broad series of studies of delivery systems, costs, manpower utilization, health~policy, and'has designed methodolog,ies for the setting of standards and the evaluatiiomof service programs that have won wide acceptance and approval. In pursuit of these activities a staff has been assembled who have expertise in a wide range of biological, social, and administrative disciplines and interest and experience in applying the principles and concepts developed in the academic setting to problems of delivering health services to the population. The scholarly contributions of the staff and the technical assistance they have been able to provide have made the Center an influential resource for the development of national' l~egislation andithe planning and assessment of health services at the state and liocal community levels. The Center's responsibilities have included education as wel'1i as research and consultation. The major effort has been directed toward the training of post- doctoral fellows -- 39'had participatedlinithe program as of June, 1977 -- for positions of lead'ershiplin the manag,ement of the healthicare system. In a sense, however, nearly all activities of the Center, and especially those involving technical assistance, have anieducational component in the opportunities afforded for interaction between the Center staff and those who seek advice and help. Although the Center has demonstrated success in health services research, it has suffere&from a lack of money, both the stable, long-term funding that provides security for the core staff and "risk capital" that can underwrite development of an idea to the stage where project support can be sought. Funding arrangements may also have been a factor in the Center's inability to bring together all of the varied Harvard resources for coordinated work in health policy, as had been planned originally. Although created as a joint program of the Medical School and School of Public Health, financing has been a;responsibility of the Medical School alone. Perhaps if all parties to such joinii agreements are at risk financially as well as in principle, this would'help to counter tendencies toward ind'epend'ent, separate action among groups that are interested in basically similar issues. 4

MEDICAL SCHOOL An outstanding model of inter-disciplinary cooperation and-innovation is the Program in Health~Sciences and Technology, established jointly by Harvard'andiMass- achusetts Institute of Technology seven,years ago. Physical scientists, mathematicians, and engineers have become increasingly interested in applying their skills and insights to health probl'ems, and Harvard and M.I.T. have long pursued areas of mutual concern in education and research, but until 11970 there was no organizational core to whi!ch faculty and students could relate, and colilaboration was generally limited to piecemeal ad hoc arrangements, largely the result of chance encounters among scientists involved in work on common problems. Among the earliest efforts of the Program in Health Sciences and Technology was introduction of a new preclinical curriculum in biomedical sciences designed and taught by faculty of both institutions to medical students with special abilities in the physical and mathematical sciences. There are now 100 students enrolled in this curriculum, and the third class to complete it graduated in June, 1977 with the M.D. degree. A second degree program in medical engzneering and medical physics that will lead to a Ph.D. degree from M.I.T. or Harvard will be inaugurated in September, 1978. Investigative teams involving faculty of five M.I.T. schools together with members of Harvard''s Faculties of Medicine and Arts and~Sciences and the Division of Engineering and Applied~Physics are collaborating on research projects in biomaterials science, rehabilitation engineering, nuclear medicine, radiation therapy, clinical instrumentation, radio- pharmaceutical development, and toxicology. A fiunding, campaign for $101million in endowment to support the Program had reached $7.8 milLion in gi~fts and pledges by June, 1977. In addition, since 197,0 $2.3 million has been raised~for operations and facilities, and $11 million inisupport of research and development. So productive has been this reliationshi~p between Harvard'and M.I.T. that the two universities agreed in the past year to establiilsh an iinter-uni!versity Division of Healith Scisnces and Technology as an integraL part of each. The Division will provide a framework both for teaching and research and for development of new professions within the health field. It wilili facili~tate appointment of new faculty and creation of new facilities, foster career opportunities for those committed to working in the field, and provide visible evidence of the importance the two unilversi~ties attach to the enterprise. Director of the Division will be Dr. Irving M. London, who has been 5

MEDICAL SCHOOL director of the Programisince its inception. Dr. London hol~d's appointments as Professor of Medicine at Harvard University and Professor of Biology at M.I.T. It has not been easy to mount a common effort of the size, scope, and complexity of this program. It was possible to do so in part because of the flexibility of Harvard's structure, an6in part because the Medical School has considerable experience in forming relationships with other autonomous institutions, and it was able to move rather q,uickly to develop close working relationships with M.I.T. once mutual needs and complementary resources had been id'entified. Because the Medical School is not tightly bound to one teachiing hospital and not rigidly controlled by an executive committee, new organizational forms can be introduced without the need to alter the basic fabric of the institution. PROBLEMS OF AUTONOMY On the other hand, it is only fair to point out that Harvard's structure can hinder as well as promote progress. The cherished principle that insists, "every tub on its own bottom," leads more often to creative competition than to docile cooperation within the university. Th~is is especially apparent in the problems we have faced withiregard to the biological sciences. Three separate and distinct groups in the Faculty of Medicine, Faculty of Arts and Sciences, and Faculty of Public Health had, unti!1' recently, no formal relationship one to another. Each Faculty plans its departments on the basis of its own needs and without regard to those of the other schools and faculties. Although there is growing recognition of the need for more cooperation and joint planning, progress has been slow because the commitment to autonomy is so deeply ing,rained~ini the habits of all. Once these differences:are overcome,, however, agreements arrived at freely by equals are likely to be more worthwhile an&more durable than solutions imposed by a:central authority. A tradition of autonomy canialsolbe more obstructive than helpful inifostering cooperation among the several hospitals with,which,Harvard Medi~cal School is affiliated. The tortuous history of the Affiliated Hospitals Center is a prime example. More than a decade and one-half were required to achieve a merger of the three hospi;~als -- Boston Hospital for Women, Peter Bent Brigham Hospital, and Robert Breck Brigham Hospital -- and to~develop satisfactory mechanisms permitting trustees, hospital administrators, and service chiefs tolwork together toward a common goal. And as if the 6 ,

0 MEDICAL SCHOOL problems involved in the sacrifilce of a degree of each institution's autonomy were not sufficiently difficult, the plans for building a new hospital complex met sharp and sustained'opposition from the neighboring community an unwarranted complication it seemed at the time. As it turned'out, however, the need for unity in facing, and'resoliving these objections probably did more to hasten agreement on a merger than prolonged~negotiation among the hospitals. In the last year, fortunately, progress in con- struction has beenimad'e. The site has been cleared and excavated,, a building permit has been obtained, financing,has been assured, and work on the foundation has beg,uni. OUTLOOK FOR THE FUTURE On balance, then, the present structure, though not without flaws, has prove&to be adequate. But what off the futuze?' The years ahead will bring profound changes, especially in the form of stronger, more pervasive influence by government in the affairs of this and aLl, medical schools. We can look forward to increased governmental regulation, decreased support for research, curbs on the number and distribution of residencies among various specialties, and'controls on costs and on the introduction of new and'expensive technologies. I believe that Harvard Medical Schooli can respond to the need~for change not by altering the basic structure, which iis fundamentally sound, but by developing a number of umbrella organizations which attempt to coordinate the various independent units that make up the university and its affiliated institutions. This approach has been tried with success recently in two areas of expanding,academic importance. I In recent years strong,residency programs in primary care have been developediby the Harvard'teachimg hospitals. Althoughithere are common elements among them, eachiprogram has been deliberately shaped to reflect the particular character and orientation of the parent institution. As they have matured, opportunities have increased to offer educational programs in primary care to medical students, interest in collaborative research grows among the various hospital groups, and the need to exploit all of the resources of the university becomes more compelling. Rather than create a new department in the Medical School to further these efforts, a Division of Primary Care and Family Medicine, which will act as a coordinating body for the several 4 7

,T MEDICAL SCHOOL programs, was proposed and approved~by the faculty on November 5, 1976. Organized as a unit of the Medical School, but with no power of appointment, the Division is head'ediby Dr. Robert S. Lawrence, who has held appointment as Assistant Professor of Medicine and Preventive and~ Social' Medicine at Cambridge Hospital. Its goals and objectives are to be established, reviewed, and: modi~fied as necessary by a policy board chaired by the Dean of the Faculty of Medicine and composed of the chiefs of service in the participating hospitals, the chairman of the Department of Preventive and Social Medicine, the Director of the Family Health Care Program, the chairman of the Department of Health Services of the School of Public Health, the Dean of the School of Dental Medicine, the Dean of the School of Public Health, ex officio, and the President of the University, ex officio. An Operations Committee guides day-to-day activities. The responsibilities of the Division include: --development of elective courses or programs for medical students and residents, --approval of all elective courses in primary care and family medicine before submission to the Curriculum Committee, --evaluation of all educational programs in primary care and family medicine, --exploration and development of relationships with other institutions which may provide appropriate settings and/or personnel for primary care and family medicine training, --assistance in identification of individuals for appointment to appropriate departments for primary care teaching and research, --solicitation of funds and development of grant proposals, --review with and advice to the dean(s) on all solicitations, --identification and coordination of the use of scarce university resources. A related~effort has involved a re-evaluation of the organization and'mission of preventive medicine, a discipline that has been the subject of more or 8