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

In his book Governance of Teaching Hospitals: Turmoil at Penn and Hopkins, John Kastor compiles the results of many interviews to tell his tale of two Academic Medical Centers (AMCs). His writing style, basically a series of descriptions and facts linked via a chronology rather than through a central theme, reminded me of what I read as a Second Lieutenant in the Marine Corps when reviewing the transcripts of Unit Diaries, daily logs of men in combat. Unit Diaries are not particularly helpful for understanding a strategy, but they are fascinating at the tactical level. Through a review of individual events, you could certainly get a sense of the daily drudgery, boredom, and terror on the front lines. All of those elements exist in this book. Just as it helped to be in the military to appreciate the value of the Unit Diary, it greatly helps if you are somehow connected to academic medicine to appreciate the anthropological field notes in Kastor's book. While he does not provide much detailed analysis, there is a story to be told. I thoroughly enjoyed the voyeuristic peek into two of our great academic medical centers.

Kastor undertakes his study to answer the following question: "To what extent do permutations of governance among medical schools and their principal teaching hospitals affect how well the school and the teaching hospital conduct their work?" Unfortunately, he cannot adequately answer this question with an account of only two institutions that faced unusual problems in special times and environments. Nevertheless, by reading accounts of the personal observations of many of the participants at Penn and Hopkins, the reader can deduce some apparent lessons to be learned and things to think about. Still, Kastor's key question is answered only in a limited way.

In many ways, the most important audience for this book is current or potential trustees of teaching hospitals, AMCs, or universities that have affiliations with teaching hospitals. From the lessons learned at both institutions, it is clear that there are legitimate, useful, and important functions for trustees—even if those who are governed don't particularly like it. The book does a good job of conveying the difficulty in balancing the demands arising from the core missions of teaching, research, and clinical care in a context in which external market forces play an important part. These demands require oversight and a degree of separation so that the balance among research, teaching, and clinical care can be rationally considered, negotiated, and maintained. Governance structure should enable trustees to help members of leadership figure out the best use of resources, a challenging task even when resources are plentiful. A board of trustees, moreover, should help the CEO stay grounded in reality, face the brutal facts, and provide a forum to resolve issues. (In today's world, there are other great hierarchical institutions that are painfully learning the value of external lay involvement and oversight.) Nevertheless, as Kastor notes, "in the most frequent relationship, however, the medical schools and their principal teaching hospitals are governed by different entities."

Unfortunately, as we see in the case studies, trustees themselves can become entangled in the fight for control and in protecting their particular leader's interests. Up to a point, this is not necessarily bad, but taken to an extreme, it does get in the way of problem solving and can divert focus away from external pressures and dangers. At both Penn and Hopkins, decisions were not being appropriately vetted and serious mistakes were made. Two miscellaneous points are worth noting. First, blue ribbon committees always seem to recommend change, and such recommendations are often accepted and then ignored. Second, a leader's legacy needs to be judged in its entirety. There is a human tendency for a successor to minimize the achievements of the predecessor.

Another important audience for this book would be the leaders at universities, hospitals, and medical schools. There are helpful leadership lessons to be learned. As the early tenures of the leaders at both organizations were described, it was interesting to note the attention to the fundamentals...