The Chancellor's Journey

Ralph Snyderman, MD, first came to Duke more than three decades ago as an intern in medicine. He was on the faculty through much of the 1970s and 1980s. But he will be remembered most for his most recent years here -- those spent as chancellor for health affairs, a position from which he will step down in June 2004.

Snyderman recently spoke with INSIDE editor Marsha Green about his passion for Duke University Medical Center (DUMC) and Duke University Health System, his pride in its people and programs, and his plans for his final 15 months as chancellor for health affairs and as CEO and president of the health system.

INSIDE: Our first question is rather obvious. Why are you stepping down?

Snyderman: As you know, I am nearing the end of my third five-year term. I have given it lots of thought, and I think this is the right time for me to step down. Duke is in a strong position and is widely acknowledged as one the nation's premier academic medical centers. The quality of the leadership team is strong, and I can leave with confidence that our Medical Center and Health System are in good hands.

INSIDE:You actually have 15 months before you step down. What will you do during that time?

Snyderman: I want to maintain and even strengthen the leadership team so that our momentum doesn't stop. I also am committed to our initiatives to create new models of health care that have the ability to transform how care is delivered. Primary among these is the push for "prospective health care" -- care that uses scientific knowledge to assess each individual's health risks and anticipate and prevent disease before it occurs or intervene in early stages. I want to move this initiative forward on several fronts: at the federal level with the help of Health and Human Services Secretary Tommy Thompson, the Center for Medicare/Medicaid Services, and the Association of American Medical Colleges [AAMC], and through initiatives here at Duke and in our surrounding communities.

Key to successful prospective care is continuing the development of the Institute for Genome Sciences and Policy [IGSP]. Through this we will apply genomics to improve health risk assessment. I'd also like to help get Duke Translational Medicine Inc. [DTMI] started. This program is a new way of focusing venture capital investments in an academic institution's research programs. Another budding initiative is the development of an affiliated medical school in Singapore. These initiatives are all evidence of our medical center's leader-ship nationally and internationally. They also are exciting to me because they support the overarching effort to effect prospective health care.

The recent tragic events surrounding Jesica Santillan's death bring the nationally recognized issue of medical errors right here to Duke. This issue is not new. It was clearly articulated by the Institute of Medicine [in 1999]. We need to become a leader in patient safety. We need to establish best practices and assimilate new technologies that can help prevent errors, such as the computerized physician order entry we are implementing throughout Duke Hospital. We have the ability to develop and put in place systems that allow us to be a national model for patient safety and then share that knowledge broadly with others so we can improve safety for everyone.

INSIDE: Shortly after becoming chancellor, you began a strategic planning process. I believe it was the first in the history of DUMC. How has that initial planning influenced your time as chancellor?

Snyderman: Back in 1990, we identified the areas we felt were most important to invest in over the next five years. In terms of research, we planned to strengthen high-impact fields such as genomics, neurosciences, immunological sciences, and structural biology. They were, I believe, exactly the right areas to emphasize, and still are today. Building strength in those areas has allowed us to be very competitive for funding from the National Institutes of Health [NIH]and has helped our institution increase NIH funding from $85 million in 1989 to $203 million last year. The development of the Duke Clinical Research Institute also was instrumental in enhancing our research capabilities.

As we evaluated our core missions of education, research and clinical care, what really struck me was the capability we had to combine these three core missions into an overarching one -- to improve the nation's health. We added this mission to the Medical Center's mission statement: "To develop the means to solve regional and national health care problems."

Very often mission statements get put on the shelf and mean nothing. But this societal mission actually drove our institution in a whole new direction. I think the most concrete example of its impact was the creation of the Health System in 1998 and the drive to develop of new models of health care. We reorganized the way we deliver care using a multidisciplinary concept called a clinical service unit (CSU). Putting together teams that look at the whole continuum of care, from research to wellness, in a single clinical area such as heart disease or cancer produces more coherent care. We also created the DCRI [Duke Clinical Research Institute] to give Duke the capacity to perform large multinational clinical trials. This allowed us to develop skills and amass information for evidence-based medicine through creative clinical research.

At present, these initiatives are all coming together and enabling the creation of prospective health care -- combining discovery research, the sequencing of the genome, the ability to identify an individual's risks for disease, practical ways of organizing providers in effective teams to deliver health care, and the ability to amass huge amounts of clinical data on outcomes. We can pull all this together to create better working models of health care that can constantly be observed and improved. Without taking anything away from the individual components of the medical center, we bring them all together to make something even greater.

INSIDE: In the early days when you were helping to set up programs like the DCRI, were you thinking along the lines of integrating all of this into prospective care?

Snyderman: I wish I could say that I had a great epiphany back in 1991, but the answer is no. We simply felt that there were important building blocks that needed to be put into place to allow us to make a positive impact on the practice of medicine.

One of the principles that drives me is the need to utilize the medical center's resources to enhance the quality of health care through our various core missions.

The DCRI seemed to be an obvious opportunity for the Medical Center to get involved in clinical research, an area largely neglected by academic medicine. It also gives the medical center access to large clinical databases and outcomes research. It allows the medical center to create practical value for discoveries that occur in research labs. We felt that the DCRI was the right thing to do and this has proven to be true. In a similar way, the development of IGSP clearly seemed the right way to get practical value from the emergence of genome science. Before IGSP, not a lot of attention was being paid to how we were actually going to make the theoretical science of genomics useful to human-kind. The IGSP can help shape those answers.

And the creation of the Health System was clearly the right thing to do. When we created the Health System we had a vision of creating a broadly distributed capability of delivering comprehensive health care in the Research Triangle area. We have accomplished this.

INSIDE: How have the changes in economics of health care affected your position as chancellor and dean?

Snyderman: When I started in 1989, it was very much the job of a conventional medical school dean. For the first two or three years I focused on being an academic dean -- recruiting basic science chairs, for example. At that time, the clinical world took care of itself. In 1992-93, that world as we knew it began to crash down as managed care swept in from California. No longer could we depend upon having a financial margin from the clinical practice, which was needed to subsidize the education and research missions. We knew that unless we changed how we practiced medicine we were going to have serious problems and could even conceivably fail as a leading academic medical institution. We needed to be more market-relevant -- to deliver the kind of health care people wanted at a price they were willing to pay.

We went through major changes in the mid to late '90s. As the health care market evolved, we learned and tried to stay ahead of the changes. As time went on, we found that some of the components of the health system weren't necessary, and indeed, became distractions. For example, in 1995 we partnered with New York Life to create a managed care HMO [Wellpath] when it seemed inevitable and needed to care for the University's employees. We ended up leaving managed care when it was no longer a compelling force for delivering care. In hindsight, we should have sold Wellpath earlier than we did.

Other things we created as part of the Health System are the network of three hospitals, physician networks, and home infusion and hospice capabilities. I'm very pleased that these entities are part of DUHS. If we had to do it all over again, we'd certainly do some things differently. But through the creation of DUHS we have ended up in a tremendously powerful place as a regional health care provider.

I like to think about things in terms of biological systems, as many sociological systems seem to evolve in similar ways. During the time I have been chancellor, DUMC has developed an increasingly effective nervous system. As an institution, we are now able to perceive the environment better and respond to it quickly and effectively -- to try things and see whether they work, to do more if it works well, and to pull back if it doesn't. Opportunities sometimes develop piece by piece, but I've always felt it was important to put all the pieces together to have a more coherent entity that functions as an institution. And I think we have done that here at Duke and in doing so are in a unique position to improve the very basis of how health care is delivered.

INSIDE: A large part of your time has been given over to guiding the academic side of DUMC. From that perspective, what gives you the most pride?

Snyderman: The School of Medicine has gotten much stronger -- we are one of the most desirable medical schools in the country today. Part of this is because we have maintained the third year as a chance for students to do creative work. More and more students use that year to pursue an advanced degree, so we are truly developing the health care leaders of the future. And our faculty have focused on teaching the curriculum in a more integrated, holistic way.

I also am proud of the diversity within our school. We are a national leader in training underrepresented minorities.

A major recent change has been to make the position of dean independent from the chancellor. This has allowed our deans, first Ed Holmes and now Sandy Williams, to concentrate on the School of Medicine while I focus more strategically as the chancellor and as president and CEO of the Health System. This has been very positive for everyone.

The School of Nursing also has made great strides during the time I have been chancellor. When I came, there was a very small faculty, with many near retirement. Now we have a vibrant graduate school of nursing that is developing a national reputation, has developed creative programs such as the accelerated Bachelor of Science in Nursing (BSN) degree to address the nursing shortage, and is working toward developing a doctorate in nursing. Dean Mary Champagne's leadership of the School of Nursing has been exceptional.

We also have added a doctoral program in physical therapy. We know that health care is changing, and that we need to have not only great physicians, but strong nurses, nurse practitioners, nurse leaders, physician assistants, physical therapists, and allied health professionals of all types. They are all needed on the health care delivery team of the future, and we are committed to providing excellent training for them all.

INSIDE: Have you given much thought to what you will do after June 30, 2004? Snyderman: It is my intention, when I step down as chancellor, to become increasingly energetic in certain initiatives I have helped initiate -- dealing with prospective health care, helping with the DTMI, the IGSP, the development of the Singapore Medical Center. And I also want to get back to my other professional loves, research in inflammation and teaching rheumatology. INSIDE: When all is said and done, what would you like to be remembered for? Snyderman: I haven't spent much time thinking about that yet. I still have 15 months to go. Someone recently asked what my legacy will be and I said "It's a work in progress." When I took the job of chancellor, I had the vision that Duke could and ought to be one of the leading academic institutions in the world. I started at Duke as an intern, so I knew the strength of the institution from the bottom up. I wanted to be a part of enabling the Medical Center to achieve its proper prominence and leadership role. As I now walk through the Medical Center, I am more proud than ever to be part of this great institution. The way we have gotten where we are is by committing to excellence and trying to think ahead. I have enjoyed having as many people as I could think about that with me: what are the currents of change in medicine and how do you ride those currents so that you are growing from them, rather than responding? I think a fundamental change in the nature of our Medical Center has stemmed from our attention to societal relevance, finding the practical value for what are otherwise academic missions. We have truly moved toward applying all of our academic core missions to improving the health of our society. And because of that I believe the Medical Center is on the threshold of being able to accomplish things that really haven't been possible before in any academic medical center. That is, to transform how health care is delivered so that it continuously improves in its ability to predict and prevent disease. ‚ Inside DUMC 2002:March 25, 2003 Duke University Medical Center Office of Publications