Administration Dean's Office

The Dean's Newsletter:
April 5, 2010

Table of Contents

v We Value and Appreciate our Adjunct Clinical Faculty
v A Juxtaposition of Healthcare Realities
v Moving Toward Improved Clinical Effectiveness
v The Respectful Workplace – An Ongoing Issue
v International Academic Medical Centers Seek Innovation
v Call for Judges and Volunteers for the Intel Science & Engineering Fair
v Notable Events
 
v Mini-Med School Begins its Third Quarter
v Frontiers in Medicine
v Upcoming Events
 
v Medicine and the Muse: Malcolm Gladwell, April 8
v Healthcare in the US: A Work in Progress, April 14
v Awards and Honors

We Value and Appreciate our Adjunct Clinical Faculty

I want to begin by thanking our Adjunct Clinical Faculty (ACF) for their valued and much appreciated contributions to the education of our students and trainees. We are the beneficiaries of over 650 ACF who volunteer their time and expertise to enhance and enrich our educational programs. In doing so they bring a breadth and depth of clinical and life experiences that are quite special and important and that span the entire domain of adult and pediatric medicine.

Over the last weeks an issue has arisen that may lead some of our respected ACF colleagues to question whether we value them and their autonomy and independence. Specifically this relates to the decision to extend our Stanford Industry Interactions Policy (see: http://med.stanford.edu/coi/siip/policy.html) to everyone who holds a Stanford title – including our ACF. When we first initiated our SIIP policies that banned gifts, free meals, speaker bureau participation and a number of other important issues, we decided to exclude our ACF colleagues. Since 2006, when those policies were adopted, there has been ever increasing attention on the financial interactions of physicians with industry, and this has become a topic of considerable scrutiny in the print media and elsewhere.

In fact the recent healthcare reform legislation includes provisions requiring major pharmaceutical and device companies to publicly list payments to physicians. Such reporting has already begun on a voluntary basis. Indeed, quite surprising to me was a report in the New York Times in January that noted that the physician receiving the highest amount of industry payment for lecturing was at Stanford. This individual turned out to be member of the ACF. Not surprisingly the media does not distinguish whether a faculty title is associated with a voluntary or university-employed individual. The association is with the university or medical school – thus creating a panoply of institutional risks and queries.

I certainly make no value judgments about the right of a community physician to be part of an industry speakers’ bureau and to give lectures and presentations on behalf of industry for which the individual is compensated. That is of course his or her right and personal decision. But when an individual holds a Stanford title, an association with an industry speakers’ bureau is highly problematic and creates risks for individuals and for the institution. It is not possible to turn a Stanford title on and off. And it is likely that a pharmaceutical company is interested in having an individual speak or act on its behalf or because of the Stanford title. These factors create overlapping interests and conflicts.

Given this situation and the importance of protecting and valuing our Stanford name – as well as the individuals who hold Stanford titles – we have made the decision to extend our SIIP policy to everyone with a faculty title, whether voluntary or otherwise. This is an evolution of our original 2006 SIIP policy – but is consistent with our institutional goals and, in many ways, with the changes that have unfolded in academic-industry interactions over the past several years.

I apologize to our colleagues if the extension of our SIIP policies poses new and perhaps unexpected (and even unwanted) challenges. And I do recognize that some of our current Adjunct Clinical Faculty may decide to give up their Stanford appointment. Of course I hope that this does not take place. In time I do believe that the expectations we are setting will be established throughout the nation – and the feedback I have had from leaders around the country affirms that perspective. As a major academic medical center we have an obligation and a mandate to gain the public trust – and the changes we are making are one more step toward that important goal.

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A Juxtaposition of Healthcare Realities

On April 1st I participated in two quite different events on healthcare. The first was the “Stanford Health Policy Forum: The Future of Health Reform” (http://healthpolicyforum.stanford.edu/), in which I participated in a panel discussion led by Dan Kessler, Professor in Management, Law and Health Policy and Policy, along with Alain Enthoven, Professor of Public and Private Management in the Graduate School of Business, Emeritus, and Dr. Alan Garber, Director for the Center of Health Policy and the Center for Primary Care and Outcomes Research and the Henry J Kaiser, Jr. Professor of Medicine and by courtesy, of Economics and Health Policy and Research. We had a spirited debate on the historic healthcare legislation signed by President Obama last week in which there was a wide range of opinion that went from gloomy to optimistic.

While I recognize that there are many imperfections in the recently passed legislation, I am on the more optimistic side of the debate, and I underscored that, at a minimum, the new legislation recognizes that health care should be extended to all USA citizens and that protection of healthcare benefits from private insurance also needs regulation. That said, we all acknowledged that the new legislation does little to control the cost of healthcare and that this will need to be a dominant focus going forward. While some of the panelists argued that they would not have “voted” for the reconciliation bill, I underscored that doing nothing was not an option given the ever-rising cost of healthcare in the USA – where the amount spent on healthcare is more than twice that of any other developed nation. At least the new legislation will serve as a beginning for healthcare reform that will surely evolve, be refined and even significantly changed over the next decade or more. But it is a historic beginning and that is worth recognizing and celebrating.

While I described the debate on the reform of the US healthcare system as ranging from gloomy to optimistic, I gained an important perspective on this issue during the presentation later that same day by members of the Stanford Medicine community who had traveled to Haiti to take part in the relief efforts there following the horrendous earthquake that occurred on January 12th. (see: http://stanfordmedicine.org/communitynews/2010winter/haiti.html). The Haiti presentation was sponsored by Stanford Hospital & Clinics, the Lucile Packard Children’s Hospital and the Stanford School of Medicine. Eight incredible individuals from Stanford Emergency Medicine shared their experiences, reflections and lessons learned from their weeks in Haiti. They described what they encountered on their arrival in Haiti and the conditions in which they worked and cared for incredibly injured and impaired adults and children. It was truly both extraordinary and devastating.

As a physician who spent decades caring for children with catastrophic illness I found myself struggling to imagine the incredible human suffering that occurred in Haiti in a dramatically compressed time and space. This was the experience that our Stanford colleagues and other members of the medical community from around the world encountered. The Stanford team who presented on April 1st represented only a portion of the overall contributions by Stanford doctors and nurses. But the nurses and physicians who spoke openly, honestly and compellingly at this event deserve our profound admiration. They included Paul Auerbach, Ian Brown, Jonathan Gardner, Gaby McAdoo, Anil Menon, Bob Norris and Julie Racioppi. They are each medical heroes, deserving of our deepest respect for their selfless contributions to relieve extraordinary suffering during the incredible and horrible disaster in Haiti.

For me the incredible juxtaposition of these two events during a five-hour period of my day was striking in a deeply personal way. Going from the economic arguments about healthcare in the world’s wealthiest nation to the devastation and near absence of healthcare in one of the world’s poorest nations gave deep meaning to the role of health professionals. It was a stark reminder of what is really important and also of the value of health professionals committed to relieving human suffering rather than economic gain or loss. That focus has been absent from much of the US healthcare debate – but it is the sole focus of the citizens of Haiti. That too is a lesson for all of us.

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Moving Toward Improved Clinical Effectiveness

During the past several years we have had a concerted and joint effort among the School of Medicine, Stanford Hospital & Clinics (SHC) and the Lucile Packard Children’s Hospital (LPCH) on the quality of the patient care we are delivering. This has been both a top-down and bottom-up effort, and it has resulted in significant improvements in our quality performance when compared to peers on a national level. Considerable and continuous improvements are needed, but there can be little doubt that these have been made – and will continue to be made. More recently, a joint effort between Stanford Hospital & Clinics and the School of Medicine to improve clinical effectiveness was launched. The organization and governance of this effort includes a Clinical Effectiveness Leadership Team that works in conjunction with a Clinical Effective Data Committee and a Clinical Effectiveness Council.

At the SHC Board of Directors’ Quality Performance Committee meeting of March 24th, Dr. Kevin Tabb, Chief Medical Officer, gave an update on ongoing efforts of the Clinical Effectiveness program. Of interest, he highlighted a number of projects that were proposed directly by medical staff and nursing professionals and that are currently underway. They represent a range of activities and issues and share in common the goal of improving clinical effectiveness. Examples include:

This list is not inclusive and is part of an expanding effort to improve clinical effectiveness throughout SHC. Some of these projects are specific to a discipline or clinical service while others are broad and more comprehensive. They are each important in weaving a more integrated effort to improve clinical effectiveness step by step.

Dr. Tabb also announced the initiation of a new Technology Assessment Committee (TAC) that will focus on new medical devices, surgical procedures, diagnostic tests and new pharmaceutical and clinical programs and evaluate them according to their clinical, financial and operational impact. Given the impact that technology and drugs play on increasing healthcare expenditures, this is an extremely important effort. Importantly, the work of the TAC is multidisciplinary and includes input from physicians, nurses and administrative leadership.

As healthcare reform evolves, efforts to control cost will be an imperative for SHC. But controlling costs should not be at the expense of innovation and development. Nor should technology and new developments be embraced or deployed without assessing their utility and costs. So the TAC is likely to be an important committee – and one whose charge, scope and impact will surely evolve in the years ahead.

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The Respectful Workplace – An Ongoing Issue

On May 14, 2002 I announced in the Dean’s Newsletter (see: http://deansnewsletter.stanford.edu/archive/05_13_02.html#1) the initiation of a series of seminars and workshops on the “respectful workplace.” These programs were launched about a year after I joined Stanford to address the many behavioral and personal interaction difficulties and communications challenges that had impacted faculty, staff and students. The kinds of issues for concern included raised voices, heated language, name-calling, belittlement and intimidation; displays of anger, rage or threat; rude, offensive or abusive conduct; public criticism of an employee; inappropriate description of employees by those in charge of programs; racism and discrimination; and disparagement of employees with diverse backgrounds or lifestyles.

While these may sound like extreme examples, they were not infrequently reported behaviors in 2002 and, while progress has been made, they still exist today. Each of us has a responsibility to help assure a respectful workplace in our communications with each other, regardless of whether these occur with the spoken or written word, or with email or other forms of interaction.

In 2002 we established a School goal regarding the Respectful Workplace. I would like to reiterate that goal again: “Stanford University School of Medicine is committed to providing a work environment that is conducive to teaching and learning, research, the practice of medicine and patient care. Stanford’s special purposes in this regard depend on a shared commitment among all members of the community to respect each person’s worth and dignity. Because of their roles within the School of Medicine, faculty members, in particular, are expected to treat all members of the Stanford community with civility, respect and courtesy and with an awareness of the potential impact of their behavior on staff, residents, fellows, students and other faculty members.”

Over the past several years “Respectful Workplace” presentations and discussions have been given to all School of Medicine departments and have been discussed during the orientation of new faculty and staff appointments. While we have not experienced some of the significant challenges that existed in the 1990’s and early part of this decade, I am well aware that challenges and problems still persist. Some have taken new forms, one of the most notable being email communications. The topic of email etiquette has been much discussed, especially the fact that the lack of face-to-face contact permits some to offer comments that are inappropriate or even libelous.

What is missed is that email communications are virtually always retrievable during an investigation. Further, using “confidential” does not assure that email cannot be used in a legal discovery. So it is incredibly important for everyone using email to do so with “respect” and with the recognition that whatever they communicate can become public knowledge. I am aware that faculty, students and staff communicate in ways that create individual and institutional liabilities – an issue that needs further discussion and education.

There are many additional examples and issues – all of which underscore the need to rekindle our focus on assuring a “Respectful Workplace.” Over the next months the Human Resources Group will be seeking your input regarding your own experiences and observations. We will use this to help guide future programs that will heighten, inform and engage all of us in being part of a Respectful Workplace.

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International Academic Medical Centers Seek Innovation

Academic medical centers comprised of schools of medicine, teaching hospitals and varying constellations of other professional schools (e.g., nursing, public health, pharmacy) have been part of American medicine since early in the 20th century – especially since the 1910 Flexner Report, which defined medical schools and centers. In other parts of the world, academic medical centers are new entities that are endeavoring to overcome the challenge of split alignments between Ministries of Education and Health. As these international centers have evolved, they have begun to explore new funding mechanisms – not dissimilar to those of American Academic Health Centers (AAHC). This was the topic of discussion at the recent International Forum sponsored by the Association of Academic Health Centers on March 22-23rd.

The models being pursued are quite different. In Canada, for example, a member owned and unified entity has been created in which the Intellectual Property from all member medical centers comes to a single entity under the umbrella of the MaRS Discovery District (see: http://www.marsdd.com/index.html). Other models are being explored in The Netherlands, and Singapore among others. Most are looking toward ways to bring products of discovery forward to industrial partners. They vary in their intent to commercialize and, in some instances, they get close to the borders of conflict of interest. Understandably there was considerable discussion about how academic medical centers in the USA are redefining their relations with industry to create partnerships that seek to avoid conflicts of interest. This is a major topic in its own right and one that organizations like AAHC are seeking to evaluate. It seems clear that there is much to learn in this area as different models are pursued in the USA as well as worldwide. Sharing what is working and not will be important as this new territory is explored.

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Call for Judges and Volunteers for the Intel Science & Engineering Fair

We have received a request for scientific judges and volunteers for the Intel Science and Engineering Fair that will be held on May 11-12 at the San Jose Convention Center. This education event will bring together some 1500 high school students from around the world to compete for $3 million in awards and scholarships. Currently there is a shortage of qualified judges in a number of areas where the School of Medicine has expertise – especially animal science, biochemistry, cellular and molecular biology, medicine and health. Judges should have an MD or PhD degree or an MS with 5-6 years of experience. To learn more about this opportunity to volunteer and support the future of science and engineering see http://www.isef2010sanjose.org. You can apply on-line. Thanks for considering this request.

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Notable Events

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Upcoming Events: Malcolm Gladwell

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Awards and Honors

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A downloadable Microsoft Word version of the newsletter is available. If clicking on this following link does not initiate a download, right-click (Windows) or click-and-hold (Mac), then use the command most similar to "Download Link To Disk" or "Save This Link As" and save the Word file to your disk.

Microsoft Word version: DeanNews04-05-10.doc

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