Governance of Teaching Hospitals: Turmoil at Penn and Hopkins (review)

In his recent book Governance of Teaching Hospitals: Turmoil at Penn and Hopkins, Dr. John Kastor presents the results of 105 interviews that he conducted in connection with much publicized changes in governance that took place over the last few years at two of America's greatest centers of academic medicine. The narrative that he has fashioned from this extensive research is long on descriptions of the so-called turmoil and what many observers thought about it, very short on a presentation of the external contexts in which the events took place, and even shorter on analysis. As a result, the lessons to be learned—to the extent that there are lessons to be learned—from the much-discussed Kelley era at Penn and the aftermath of the Heyssell era at Hopkins are not to be found in this book.

In the first part of the book, Kastor follows the meteoric rise of Dr. William "Bill" Kelley from his professional beginnings as an academic rheumatologist, through his brilliant tenure as a department chairman at the University of Michigan, to his becoming Dean of the School of Medicine and Vice President for Medical Affairs at the University of Pennsylvania at the age of 50. In this position, Kelley was responsible for all academic, scholarly, and clinical matters relating to the life sciences at Penn, reporting only to the President of the University.

It is clear from the book and all outside reports that Kelley was a powerful and charismatic leader. He demanded and received absolute loyalty and support from the members of the faculty and staff within his domain and often paid little more than lip service to the authority of the President. When he needed authorization for major expenditures, he apparently often dealt directly with members of the Penn Board of Trustees. Kelley's unified and integrated control over the medical research, education, and clinical enterprise at Penn became widely known as the "Kelley model."

Kastor's rather passive recitation of the results of his interviews does not allow the reader to get much of a feeling for Kelley, the man. In describing his personality, Kastor simply reports (more alphabetically rather than in any order of importance) the results of his research:

Frequently used descriptions of his characteristics include ambitious, brilliant, charismatic, effective, efficient, energetic, forward-thinking and willing to take risks, imaginative, optimistic, tenacious, an activist with unusual drive, truly committed to academic medicine, even heroic and awesome, a giant of a man. . . . Many found him aggressive commanding, dominating, controlling everything, and always pushing the envelope. Others described him as autocratic, arrogant, imperious, impetuous, inflexible once he makes up his mind, intense, intimidating and inconsiderate of other people's feelings, mean spirited, even megalomaniacal with grandiose ideas.

However, Kastor does describe in considerable detail the way in which Kelley, early in his tenure, harnessed the then-powerful money-making capacity of the Penn clinical enterprise and invested much of the proceeds into building Penn into one of the top five medical research establishments in the country. Kelley was a controversial figure in a controversial structure, but no one can argue with his dramatic success in catapulting Penn into a position in the very top echelon of American medical research universities.

As he was building the research establishment, he was building the size of the Penn clinical enterprise as well. Primarily through a series of acquisitions, Penn built a large network of medical practices, community hospitals, and related enterprises that was intended to channel patients in need of intensive medical care to the mother ship, the University of Pennsylvania Hospital. While some of these acquisitions and expansions were controversial at the time, Kelley used his considerable power, charm, and persuasiveness to obtain funding and authorization to build a large health care system. During the early part of the 1990s, the Penn medical enterprise was seen as among the most powerful, far-sighted, and successful efforts in the country. Like him and...