State of the School
Philip Pizzo, MD
Dean, Stanford University School of Medicine
Some Challenges for 2008
As the New Year begins we can look forward to the continuation of many wonderful accomplishments and successes by our faculty, students and staff. But to foster and enrich opportunities for the future, it is important that we be cognizant of looming challenges that arise from both internal and external forces and events. Some of these are controllable, whereas others present obstacles that may be more difficult or even impossible to surmount. When I was planning my arrival as Dean in January 2001, I felt strongly that the best way to respond to change was to take charge of it and plan accordingly. That view led to the development of our initial strategic plan, entitled "Translating Discoveries," and has accounted for many of our advances in our integrated missions of education, research and patient care during the past nearly seven years. Integrated planning has also guided our approaches to long-term facility and finance planning, the development of our professoriate, the role of information technology and related resources, our approach to communications and public affairs and our efforts in fundraising and medical development.
We have continuously renewed and revised our institutional strategic planning efforts and have revisited them in the aggregate each January at our Annual Strategic Planning Retreat. The theme for this year's retreat is "Quality and Balance," which we will explore across the dimensions and domain of the medical school, medical center and university. We are a small research-intensive school of medicine aligned with two major teaching hospitals and co-located on the campus of an outstanding university. In this context it is imperative that we establish choices and priorities that optimize our uniqueness and permit our greatest future success despite constraints, limitations or challenges which inevitably arise -- whether they emerge from within Stanford or from forces and events that occur locally, regionally, nationally or globally.
For example, a continuing challenge for us is sustaining and enhancing quality in a medical school that, compared to its peers, is comparatively small in size and constrained in space. In addition, we, like other academic centers, face reductions in research funding and a national climate that has increasingly tended to pit religion against science in the political arena. I have highlighted and discussed many of these issues in prior Newsletters and will more briefly highlight here some of the concerns that are high on my list for the next year. In doing so I am fully cognizant that they might easily be superceded by unanticipated events or by ones that are now viewed as less immediate. But I also believe that unless we anticipate issues and plan around them we run the risk of being reactive rather than proactive, letting events shape us rather than our shaping our institution and its future. The listing below is not prioritized and is hardly complete. But it does present a reasoned sampling of issues.
Challenges arising within Stanford
- Size and focus of student and education programs. During the past several years we have made considerable strides in better defining the guiding principles of medical education at Stanford. Our New Stanford Curriculum, initiated in the autumn of 2003, is one major result of these efforts. The new curriculum, which focuses on training physician scholars, scientists and leaders, has quite naturally impacted the students seeking education at Stanford as well as the types of students we select. While there is a purposeful direction to our medical education programs, it is also important that they remain balanced and that we weigh equally excellence in clinical education and professionalism, on the one hand, with scientific reasoning and proficiency, on the other. We still have work to do in achieving this balance, especially on the side of the equation dealing with clinical training. New programs such as Educators-4-Care are being designed to improve clinical teaching and mentoring for medical students.
As I have also noted in prior communications, assessing the impact of our new curriculum on the gender and ethnic balance of our student body is important. These concerns have influenced our discussion about emphasizing a Flexible Five-Year Program and will also impact our discussion about increasing the size of the medical school class from 86 admitted per year to perhaps 100 students per year.
We remain fortunate in attracting incredibly talented PhD graduate students, and we want to sustain the excellence of the bioscience programs at Stanford, which encompass the Schools of Medicine, Humanities & Sciences, and Engineering. The major challenge we face is the financial support of graduate education, especially given the limitations that the NIH has placed on tuition costs paid from grants. These, when coupled with the cost of tuition at Stanford, present an increasing burden and challenge to our basic science faculty. We have been working to address this issue by examining novel ways of using our restricted education endowment to cover graduate students as well as other key programs such as the Masters in Medical Science and the Advanced Residency Training at Stanford. It appears that we may be able to develop some options that have been unavailable heretofore, and this should provide some relief. We will be working on the details of how this can be accomplished in the coming months.
Continuing to support an environment that fosters the Stanford experience for our postdoctoral scholars remains an important challenge. As I have previously commented, postdoctoral scholars are among the most important individuals in our program and yet they seem to get less attention -- and likely feel less respect -- than other colleagues. While we have made some strides and are benefited by excellent leaders and a committed Office for Postdoctoral Affairs, much work remains to be done.
- Size, scope and satisfaction of the faculty. I have commented frequently that our full-time faculty is small compared to peer institutions (less than 40% the size of UCSF and less than 10% the size of Harvard). There are benefits from being relatively small. For example, our size forces us to choose faculty with greater care than at larger institutions and to emphasize quality and excellence. And we benefit from having to prioritize our areas of focus and effort. These choices and priorities can be more easily made for basic science programs than for the clinical programs. There we face an ever- increasing challenge, since the complexity of patient care makes it imperative to have both depth and breadth of services and expertise.
As I see it, we have several major issues on the horizon. The first is that we will be running up against the faculty billet cap of 900 during the next 1-2 years. We have now crossed the 800 threshold of full-time faculty in the Investigator (University Tenure Line [UTL]), Clinician Scholars/Scientist (Medical Center Line [MCL]) and non-tenure (research and education) lines. Given the recruitment of new departmental leaders in recent years, the pace of clinical programmatic development is accelerating -- which is a good thing -- but this will also mean that the timing for breaking through the cap is at least a year ahead of prior projections. We have been engaged in broad institutional planning across the medical center during the past several years and have been attempting to project the number of full-time faculty we will need during the next decade to fulfill our missions in basic and clinical research as well as education and patient care.
To date, thoughtful planning exercises project an ultimate faculty size between 1030 and 1060. This does not include our Clinician Educators, who are enormously important to our missions but who do not count against the billet cap. We understand that the billet cap and the size of the medical school faculty represent an important issue for a university that prides itself on excellence across each of its schools and that places a premium on quality over size. We certainly respect that point of view, but we face the challenge that delivering outstanding clinical care requires greater programmatic depth and breadth. Clinical programs, unlike other academic ones, are interdependent, making it impossible to cut out services to adjust to a fixed program size. That said, I am well aware that the faculty size and billet caps will be an increasing issue for the medical school in the coming year(s).
In tandem with faculty size we also need to better address the unfortunate perception that Clinician-Educators are not as valued as other members of the medical school professoriate. I view Clinician Educators as essential to our future success in patient care. Notably, many of these physicians are also highly valued by our students as outstanding educators in clinical medicine. We need to do more to break down barriers of perception and bias. This will require the leadership and engagement of our clinical chairs and division heads, and I am counting on their efforts and commitment.
In many ways the overall satisfaction of our faculty is tied to the work-life balance issues they face on a personal level. Surveys and assessments we have carried out continue to demonstrate that clinical faculty experience greater stress than their basic science peers -- and that women feel this stress more acutely than men. While we have put programs in place to help ameliorate some of these challenges it is clear that more efforts and creativity are needed. We need to do more to foster career development of women and underrepresented minorities so that they, like all our faculty, may fully achieve their goals and aspirations.
An additional challenge is assuring that we sustain a meaningful balance between our missions in basic and clinical research. There is no doubt in my mind that we are distinguished as a school of medicine because of the contributions and excellence of our basic science faculty. As we assess faculty size it is imperative to also achieve balanced growth in basic science as well. This is important for many reasons -- not the least of which is sustaining our pre-eminence as a research-intensive school. Ironically, despite their excellence, survey data indicates that members of our basic science community feel undervalued and overlooked. I am sure this feeling is not helped by the serious challenges many investigators are now facing in securing competitive grant support from the NIH. But it also may reflect the fact that their voices may appear to be less heard in institutional decision making or that they may not be listed among the priorities for programmatic or philanthropic support. I am committed to doing my best to change these perceptions -- and the realities of support -- but there is little question that these feelings impact the morale and wellbeing of our community. This represents yet another challenge we must address in the coming year.
- Quality and Balance across our missions. These days when "quality" is mentioned in medicine it is generally associated with patient care and clinical service activities. But clearly "quality and balance" extend across our missions and require continued emphasis to assure that we achieving the highest levels of success in our programs in education and research as well as patient care. Defining metrics for quality is a challenge for even local use and becomes more complicated when standards are applied across institutions. In the current era, however, quality metrics are increasingly becoming an expectation and are being used to publicly rate hospitals as well as physicians -- whether it be scores by the University Health Consortium (UHC) or Leapfrog or the recently announced "Zagat- like" guide for doctors (see January 12, 2008 New York Times "Rating of Doctors Now a Business Unto Itself."
Achieving quality requires more team-based collaboration, and it requires independent minded physicians to adopt a different approach to medicine. I recently wrote about this in the December 2007/January 2008 issue of Compass, a publication about Quality and Patient Safety at Stanford Hospital & Clinics (I published this in the November 5th issue of the Dean's Newsletter. And if you haven't read it, I would strongly recommend that you review the article by Dr. Atul Gawande entitled "The Checklist" that was published in the December 10th issue of The New Yorker.
We have clearly crossed a threshold in public access, awareness and perception about the quality of medical care. Whether rightly or wrongly, regional and national metrics will be used to guide payments to hospitals and doctors and will impact the referral of patients to providers and institutions. While one doesn't want to simply play to the polls (like our colleagues in politics) it is imperative that we be aware of the metrics being used and responsive to their assessment and that we take a leadership role in helping to define the most accurate metrics possible for future use. Of course, our ability to be change agents will be influenced by how well we are seen as leaders in this important area. While I am pleased that the close collaboration of SHC, LPCH and the School of Medicine has resulted in significant progress in our national rankings on quality metrics, we have much more work to do in this area. And without doubt it will remain a continuing challenge that requires constant vigilance and effort for the future. This will certainly be an area of major discussion at our upcoming Leadership Retreat at the end of January.
- Integration of programs within the medical center. While the School of Medicine, SHC and LPCH are separate entities, we are closely joined in our missions and the success of one is closely dependent on the success of others. It is safe to say that at many academic medical centers there are constant strains and struggles between the medical school and teaching hospitals and between faculty and administrators. Of course such strains and challenges exist at Stanford but I must quickly add that we have all worked hard to overcome them and to engage, as much as possible, in integrated planning and collaboration. There are inherent differences between an academic enterprise like a medical school and a business such as a hospital. But the interconnections are highly significant and must be unifying wherever possible. Accordingly, we have engaged quite thoughtfully in integrated financial, programmatic and facilities planning activities.
For example, we have worked collaboratively to define the projected size of the clinical faculty and how that will impact on the projected bed size capacity of both SHC and LPCH. We have also worked collaboratively to determine which clinical programs should remain on the current medical center footprint and which would be more optimally developed at the new SHC Redwood City North Campus site. Additionally, we are working collaboratively to develop a shared website between the School and SHC that will serve our broad Stanford Medicine community. We are working collaboratively as well on the implementation of the electronic medical record systems at SHC (i.e., EPIC) and LPCH (i.e. Cerna) -- and their implication for faculty performance. We are working collaboratively on improving efficiency, throughput and service.
That said, there will be important challenges as the issue of balance between hospital investments in program versus those in capital becomes more evident during the coming years. The needs involved in priority setting are nearly always multi-faceted, and there seems little doubt that tensions will surely arise as resources become more constrained. This will require transparency, communication, trust and leadership. But I do think that the next several years, especially during the period of hospital and school facilities developments and growth, will test our boundaries and fortitude. Many of the issues and their dividing lines are already evident but their solutions will be challenges.
- Coordination of programs across the university. One of the areas I am most pleased with is the better integration of the medical school with the rest of the university that has occurred over the past several years. The period during the Stanford-UCSF merger and de-merger created considerable distraction, and the financial debacle that ensued created major tensions and misperceptions on both sides of Campus Drive. Thankfully, we have been successful in bridging a number of these gaps, and the medical school has increasingly close relationships and interactions with each of the other six schools that comprise Stanford University. These are of enormous value and importance since one of the medical school's greatest strengths is the interaction of faculty and students in research and education in various interdisciplinary efforts.
The well-established Bio-X, Bioengineering, the Bioscience Programs as well as the evolving interactions with the Schools of Business, Law and Education are all notable and important. At the same time, sustaining and enhancing these interactions require shared efforts and cooperation. Thankfully the current leadership provided by the President, Provost and various Deans has helped considerably. But I would predict that tensions will arise as the need for medical school faculty growth becomes more evident, or as the needs of the hospitals for additional resources come to the fore, or as the competition for fundraising reaches greater heights. There is no denying that these tensions are natural and predictable. But their management will be an important challenge during this year and those that follow.
- Facilities. One of our greatest challenges for the next several years is the availability of space for academic programs and patient care. The medical school and the hospitals have spent considerable time and effort in the development of master facilities plans for each entity that will unfold during the next 10-15 years. The scope of these projects is enormous and represents the largest building effort ever undertaken at Stanford. The renewal and expansion of hospital facilities at SHC and LPCH will add approximately 1.3 million gasf (gross available square feet) in Palo Alto, with additional clinical sites being developed in Redwood City, Sherman Avenue (Palo Alto) and elsewhere. During this same time period the medical school will add approximately 982,000 gasf at onsite and off-site locations.
As you might imagine, the costs of these new facilities are enumerated in multi-billion dollar projections that will require judicious financial planning, coordination and fundraising. While we have determined the optimal size of the hospitals and the projected needs of space for wet and dry research, we have work to do in determining the size and location of space for clinical faculty. Needless to say, the staging of the facilities projects will require considerable flexibility -- but there will be a time when choices will become more limited and we will be locked into decisions. That makes it all the more important to test and retest our assumptions about the major drivers for these projects, whether that be the projected needs of faculty or the capacity requirements of the hospitals. We are currently reviewing these issues (among others) for the third time. While doing so, we also recognize that the pace of the growth and development will ultimately need to be adjusted according to what is affordable and doable.
For the medical school, we anticipate the initiation of two major projects during this next year. The first is the groundbreaking for the Learning and Knowledge Center (LKC1), which is currently slated for late winter of 2008. The second is the groundbreaking of SIM1 (Stanford Institutes of Medicine 1) now slated for late 2008 or early 2009. The timing of these projects will be influenced by the completion of our fundraising goals and the final financial plans for construction. As we continue with the next stages of the LKC and SIM1 we are also engaged in the programmatic planning for FIM1 (Foundations of Medicine 1) and are beginning to stage our plans for the Freidenrich Center for Translational Medicine (to be located at 800 Welch Road) as well as planning for LKC2 and SIM2. In addition to these on-site projects we are also engaged in plans for offsite facilities as well. So, these efforts are quite broad and will require us to balance a number of converging (and some diverging) goals and objectives.
- Financial resources. In the December 17th Dean's Newsletter, I highlighted our financial performance for the past fiscal year and stated then that "we must also be cognizant of the many challenges that stand before us. The need to support faculty through difficult times in research funding, to cover the increasing costs associated with graduate student education, to recruit and retain outstanding faculty, to renovate and build new facilities, and to develop exciting new programs are just some of the challenges we face. While we won't be able to accomplish everything we want, we can continue to make progress on supporting key investments, albeit in a prioritized manner. And while the years ahead will be challenging, we face them with the recognition that we are strong in the key components for success: we have outstanding faculty, students and staff, and we have a strong financial platform from which to build the future."
For the medical school and the hospitals, it will be important to ascertain the balance between programmatic and capital investments needed to optimize our future. But as I also noted in the December 17th Newsletter "looking at our consolidated budget and results, the School (as a whole) increased its bottom line by $32 million in FY07. While the departmental reserves rose, the central School accounts declined because of significant investments in space, technology, recruitments (particularly in basic science departments) and various programmatic initiatives. These are all good things, of course, and it is terrific that we have been able to accomplish them. And while we are in a strong financial position compared to many peer institutions, we do have a number of challenges. Among these is the fact that the majority of our funds are restricted for specific purposes or are fully committed. In addition, while we have reserves, they are unevenly distributed, which creates, almost by definition, a ‘have and have not' portfolio. Obviously this is an issue deserving increased scrutiny. One way of addressing this is through transparency -- which is why we shared the detailed financial data with the Executive Committee at its December 7th meeting, even though we acknowledged that it would raise questions and sensitivities."
Understandably these will be difficult challenges to address, and doing so will undoubtedly pit the needs of individuals, departments and schools against one other from time to time. But our collective success is interdependent and we will need to proceed with that in mind. This becomes more apparent as we look to our multi-year financial planning and projections that will guide the rate and nature of our investments -- and help to define their sources as well.
- Medical development. The past fiscal year was a record for the medical school with $246 million raised in pledges and gifts (see: http://news-service.stanford.edu/news/2007/november14/med-fundraiser-111407.html). This is a great testament to the wonderful individuals and foundations that resonated to Stanford proposals and plans and stepped forward to help support our dreams and goals. It is also a testimony to the dedicated work of our faculty and the members of the Office of Medical Development. And while this is a great success, the challenge will be doing as well or better in the current fiscal year and those that will follow. As noted elsewhere in this communication, our programmatic and capital needs are considerable and our resources are limited. Continuing to identify individual donors who have the capacity and commitment to make major gifts will be a continuing challenge --and one that will be heightened by the concurrent needs and aspirations of our hospital partners as well as our university colleagues. While we -- and I -- are putting considerable resources and time into medical development and fundraising, this will surely be a continuing challenge in 2008 and beyond.
Challenges coming from our local, regional, national and global communities
- Entitlements and GUP. I discussed the medical center expansion project and especially the ongoing entitlement negotiations with the City of Palo Alto in my December 5th Newsletter. During 2008 the entitlement review as well as the architectural review will be conducted by the City Council. While one would naturally think that a city would be proud to have a world class medical center in its backyard, the views of at least some of the members of the City Council are remarkably narrow-minded in their reluctance to see the benefits that come to the community from the medical center. Thankfully this view does not seem to be shared by the public, who generally favor and support the hospitals and their needed expansion and renewal. That said, this next year will pose many challenges about these projects from the City of Palo Alto.
It is not generally appreciated that the medical center is bifurcated between two jurisdictions -- the City of Palo Alto and County of Santa Clara. While decisions regarding the hospitals and the current Grant, Alway, Lane and Edwards Buildings reside in Palo Alto and are governed by the City Council, as noted above, other medical school projects (e.g., LKC1, SIM1) are governed by the rules of the County's General Use Permit (GUP), which delineates the amount of space that can be allocated to these or future projects. One of our challenges is that, when summed across the entire university, we are approaching the limitation of available GUP space. This means that future buildings in the County (e.g., SIM2) will require a further allocation of space. This too will be a challenge.
- The political climate in California. We are fortunate that California is a progressive State regarding science and medicine. The fact that in November 2004 the citizens of our state passed Proposition 74, which established the California Institute for Regenerative Medicine (CIRM), has helped us to become a leader in embryonic stem cell research. Stanford has been highly successful in competing for grants and awards from CIRM, and a number of important opportunities and challenges will unfold during the next year -- including for major facilities as well as individual and team based awards.
While the funding for stem cell research has been exceptional in California, the investment of the State in Medicaid (aka MediCal) is among the lowest in the nation and has impacted significantly on the care for children and the financial stability of children's hospitals -- including LPCH. With the recent announcement of budget cuts by the Governor and the uncertainty of healthcare reform, it is likely that 2008 will bring additional strains to the medical care system. Of course, much of this is a national problem, but the impact of entitlement programs, particularly MediCal, is particularly challenging in California and represents an ongoing challenge.
- Academic-Industry relationships. I have communicated frequently about the continuing challenge of academic-industry relations (see: http://deansnewsletter.stanford.edu/archive/11_19_07.html#b) - another topic we will also be discussing at the upcoming Leadership Retreat. While we have taken a number of leadership positions on these issues, it is not unlikely that national attention will cause us to focus on this more deeply as Congressional investigations proceed. I am also expecting to learn the results of the School Task Force that we established in 2007 to evaluate industry support for Continuing Medical Education here at Stanford-- which I am certain will evoke some debate and discussion. While we clearly want to foster interactions with industry to bring discoveries to development, we also want to do all we can to assure that doctors and scientists avoid becoming marketing agents for industry or develop conflicts of interest that would threaten their integrity as individuals or as members of the Stanford community. Clearly this issue will be a continuing challenge for 2008 and beyond.
- National agendas and politics. Numerous issues are converging on medicine and science at the national level. The sometimes rancorous and often unfortunate debate on the boundaries between science and religion has created a number of fracture lines around topics like evolution and creationism, stem cell research and abortion, among others. In addition, the support for science has become problematic to say the least. The final 2008 budget for the NIH ($29,456 billion) increased by only 1.1% from FY07 -- resulting in the fifth year that the NIH budget increase has been below inflation. This problem is now worsened by the increasingly challenging economic situation and is not helped by the general loss of broad congressional support for the NIH. While major efforts by a coalition of academic and industry leaders resulted in an increase of 4.4% research funding for the NSF, the overall portrait for sponsored research in the biomedical sciences is extremely worrisome. Reversing these trends will require continued efforts by coalitions of academic leaders, professional and disease based societies, advocates and industry. But even that may not overcome the limitations of discretionary funding that has been made so much worse by the policies emanating from Washington during the past several years.
The New Year has of course heightened all of our awareness of the march toward the United States' presidency. It is incumbent that we learn as much as possible about the views of Democratic and Republican Party candidates about science and medicine. The January 4th issue of Science presents the views of nine of the candidates, including those who have emerged as leaders following the Iowa caucus and the New Hampshire primaries. You can review the viewpoints of these candidates at http://www.sciencemag.org/content/vol319/issue5859/index.dtl#n-focus.
In addition to understanding the position of candidates on science, it is equally important to understand where they stand on healthcare reform. To date the Republican candidates have been relatively silent on their views and while the Democratic candidates have offered more robust perspectives, none are bold or far-reaching. A reasonable comparison of these positions is described by Jonathan Oberlander in "Presidential Politics and the Resurgence of Health Care Reform" N Engl J Med 2007; 357: 2101-2014.
There is little question that policies regarding science and health care reform will impact our nation and academic medical centers, including Stanford. Thus anticipating some of these changes -- and ideally influencing them -- is important for our future.
- Thinking globally. While whatever happens on the national front has an impact, global changes in everything from climate to economics, including of course poverty and war, and disease and social justice, have an increasing impact on who we are as individuals, communities and nations. Through the Stanford Challenge, the university has decided to become more proactive in international issues and challenges, including global health. This year we are recruiting a leader who will work across the university to help lead this initiative and shape our future efforts. Given the increasing interest of our students, trainees and faculty in global issues, one of our important challenges is to further nucleate our efforts by identifying an internationally recognized leader. That search is now commencing and, I hope, will have a positive outcome in 2008.
Of course this is just a sampling of some of the issues and challenges I envision for 2008 and beyond. As I stated above, I am certain that others will arise as well and of course there are numerous topics I am already aware of that I haven't listed. That does not mean they are unimportant or that we won't address them. I simply wanted to highlight some that I felt would be of general interest. We will do our best to help address them -- and I am counting on your support as well. Happy New Year!
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January 14, 2008
