Academic Medicine Deploys a Logical Fallacy to Avoid Disclosing Inconvenient Truths

We recently discussed a simultaneous retreat from aggressive regulation and enforcement applied to big health care corporations by US government agencies.  Now a story published by Bloomberg (currently available without a subscription here on PharmaGossip) showed that the push for less disclosure of relationships with industry that generated conflicts of interest for academic medicine came not from industry, but from ... academic medicine:

The lobby for Harvard University and other research institutions drove the Obama administration to weaken draft rules for scientists to disclose potential conflicts of interest, according to U.S. records and watchdog groups.

In particular,

Universities objected to draft rules in a letter to NIH and in meetings with officials at the White House Office of Management and Budget, approver of the final version, said Carrie Wolinetz, associate vice president for federal relations at the Association of American Universities that represents 61 research universities.

Also,

The letter was co-signed with the Association of American Medical Colleges, American Council on Education and Association of Public and Land-Grant Universities.

The one example of the universities' reasoning to justify their objections to greater disclosure of conflicts of interest was striking.

Wolinetz’s organization wrote in the letter that 'there is a paucity of evidence that the disclosure and management of financial conflicts of interest affect objectivity and integrity.'

Recall that the disclosure to which they objected would be by federally funded researchers, and of financial relationships with organizations that had vested interests related to the particular research projects. The Institute of Medicine's landmark report, "Conflict of Interest in Medical Research, Education and Practice,"  stated:

Disclosure of financial relationships with industry is an essential, though limited, first step in identifying and responding to conflicts of interest.

One could also argue, as did Senator Grassley, (see here) that disclosure is owed to the tax-payers who support the research.

On the other hand, I do not think anyone would argue that disclosure and the ill-defined "management" proposed by the NIH would be sufficient to guarantee "objectivity and integrity" of the research.

In fact, the IOM report called for going far beyond disclosure.  Specifically, it called for banning most conflicts affecting most clinical research:

researchers should not conduct research involving human participants if they have a financial interest in the outcome of the research

This goes far beyond what the original NIH revision of its conflict of interest rules mandated. However, I am sure that banning such relationships was the last thing that the AAU and AAMC wanted.

So the academic institutions' argument seems to be a variant on the false dilemma logical fallacy. If the only alternative to doing nothing about conflicts of interest is disclosure, and if disclosure is really a poor solution to the problem, than perhaps doing nothing makes sense. However, if disclosure is just a necessary first step, as the IOM asserted, then it is a first step that should be taken in preparation for other steps to come.

Note that the academic institutions' argument also seems to be a version of what has been called the Nirvana fallacy, or the perfect is the enemy of the good fallacy. That is, if what one can do does not result in Nirvana, then one should do nothing.

Finally, in this case the academic medical institutions' argument seemed too extreme even for their pharmaceutical industry supporters. As the Bloomberg article reported,

Researchers have been lax making financial disclosures and there’s been an absence of oversight, said Peter Pitts, president of the Center for Medicine in the Public Interest, a nonprofit research institute in New York. 'When you don’t properly disclose, you give the impression that you’re trying to hide something.'

Institutes should instead disclose all financial interests without trying to judge whether they are conflicts, Pitts said.

As we have discussed previously, Peter Pitts' main occupation has been as a leader in public relations for the pharmaceutical industry. He is currently a senior partner, director, global regulatory & health policy for Porter Novelli. Even though we have previously criticized Pitts for deploying logical fallacies in support of industry positions, in this case the academic medical institutions' argument was too much for him to support.

So we have come this far. Universities are ostensibly about finding and disseminating the truth. Yet universities' academic medical subsidiaries now deploy illogic to avoid revealing particular truths that they find uncomfortable, and which might raise questions about relationships with industry that are increasingly lucrative. Universities seem now willing to jettison their mission to make more money.

True health care reform would require academic medicine to put its mission ahead of its revenues.

Dr. Silverstein and Dr. Poses in WSJ: "The Literature Is Hardly Pristine"

I have considered Dr. Roy Poses' Dec. 14, 2010 post "The Lancet Emphasizes the Threats to the Academic Medical Mission" (with its hyperlinks to source posts and articles) an excellent summary of many of the pathologies we address at Healthcare Renewal, especially with regard to the academic mission and the disruption of the integrity of the medical literature by commercial interests. His post is consistent with what might be considered our mission statement:

Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

The Wall Street Journal published the following letter to the editor authored by me today in which I cited and summarized Dr. Poses' accounting of the medical literature's ills.

Unfortunately, the print version cannot contain the hyperlinks as in the aforementioned source post, but I have included them in the reproduced letter below in [brackets]. They are worth reviewing, along with additional links at the aforementioned source post "The Lancet Emphasizes the Threats to the Academic Medical Mission":

April 8, 2011
Wall Street Journal
Letters to the Editor

The Literature Is Hardly Pristine

I find it unfortunate having to inform reader James Reichmann, (Letters, April 1) who prefers his physician to recommend only treatments proven in the "synthesized medical literature," that the very literature on which he wishes his life to depend may be tainted.

As Dr. Roy Poses points out on the Healthcare Renewal Blog, numerous factors common in today's culture can and do corrupt the literature.

The factors include but are not limited to: rampant commercialization of medicine [here, here, here and here], research universities with lax conflict of interest policies [here], faculty as de facto employees of industry through grants [here], academics paid to be "key opinion leaders" to stealth-market drugs and devices [here], control of clinical research given to commercial sponsors [here], conflicts of interest allowing manipulation and suppression of clinical research [here and here], academics taking credit for articles written by commercially paid industry "ghost writers," [here and here], whistleblowing discouraged [here and here], leadership of academic medical centers by business people [here] and medical school leaders becoming stewards (as members of boards of directors) of for-profit health-care corporations [here, here, here and here].

As for me, until the medical literature can be freed of these contaminants, I'd rather trust a well-trained personal physician's good judgment in my own medical care.

Scot Silverstein, M.D.

Drexel University

Philadelphia

I believe it's also worth reviewing my own views on the subject, that the degree of contamination of medical literature is unknown and may be unrecoverable, due to spread of the contaminant vectors to the "experts" who then propagate the disease.

See my Aug. 2009 post "Has Ghostwriting Infected The Experts With Tainted Knowledge, Creating Vectors for Further Spread and Mutation of the Scientific Knowledge Base?" where I raise these questions.

At that post I suggest that while the damage might not be easily recoverable, the practices that lead to contaminated literature must be stopped going forward if true evidence-based medicine is ever to be a reality.

-- SS

4/12/2011 addendum:

Almost predictably, some anonymous person, this time over at the Respectful Insolence blog in commenting on a post there that attacks "naturopathic" medicine, proffered strawman arguments about my piece above in comment #26.

... So Dr. Silverstein thinks that the defects he cites (many of which have been revealed by and hotly debated within the scientific community) are ample justification for tossing out the entirety of research in favor of the sort of "clinical intuition" that's repeatedly been found false over the years

This binary, two-dimensional thinking is quite sad to read, if real. I'll be charitable in saying that the comment does have the "feel" of something contrived, such as received before from corporate sockpuppets.

-- SS

4/13 addendum:

The proprietor of Respectful Insolence assures me that "anonymous" quoted above is not a sockpuppet. My response was basically that before attacking non-anonymous authors by name on the web who in fact (as is clear from my writing here) share similar views on medical quackery, one should contact them first to ensure you truly understand their views.

(In my case, my view is that the "well-trained physicians" of good judgment I wrote of consider the literature critically but are not bound to it, in consideration of the unknown level of its commercialization-based contamination and the variability of individual patient situations. They treat the patient, not the guideline.)

-- SS

The Lancet Emphasizes the Threats to the Academic Medical Mission

We just discussed an important article in the Lancet calling for major global reforms of health care education.(1)  An accompanying editorial(2) argued for the critical importance of upholding the mission of higher education, because that mission is critical to human civilization:

Louis Menand has investigated the current role of the modern university in his startlingly powerful book, The Marketplace of Ideas. Menand argues that: 'The pursuit, production, dissemination, application, and preservation of knowledge are the central activities of a civilisation.' More importantly still, 'the ability to create knowledge and put it to use is the adaptive characteristic of humans'. The goal of the university is 'to make more enlightened contributions to the common good'.

The editorial argued strongly for the revitalization of the university's mission:

'It is the academic's job in a free society to serve the public culture by asking questions the public doesn't want to ask, investigating subjects it cannot or will not investigate, and accommodating voices it fails or refuses to accommodate.'

The education of doctors, nurses, and public health workers must seek to: strengthen the overall intellectual culture of a society; define principles for public aspiration; give life to and enlarge the best and most proven ideas of the age; refine the grounds for the private exchanges that take place in our lives; facilitate the exercise of political power; and enable professionals to detect what is important and discard what is irrelevant, accommodate oneself with others, have common ground between colleagues across societies, ask good questions and find the means to answer them, and have the resources to adapt to national and global circumstances. Some readers might recognise that these words are adapted from John Henry Newman's On the Scope and Nature of University Education.

In England, Newman argued for the university as a centre of intellectual liberty, a vital force for progress in society. Menand writes about the university as a 'zone of autonomy'. The importance of tertiary education as a means to advance health, reason, democracy, and justice needs to be rediscovered.

But arguing so forcefully for upholding the academic mission makes sense only if that mission is under threat. The Lancet editorial only briefly alluded to why this might be:

What this Commission argues for is nothing less than a remoralisation of health professionals' education. For decades, health professionals have colluded with centres of power (governmental, commercial, institutional, even professional) to preserve their influence. The result? A contraction of ambition and a failure of moral leadership.

While the original article by Frenk et al suggested that health professionals' education has shortcomings, it did not argue that the academic mission is threatened.  Although the message of the accompanying editorial is that the mission needs a strong defense, it did not clearly explain the extent of the threat to it. 

However, this blog, Health Care Renewal, is largely concerned with threats to health care's core values, including threats to the mission of academic medicine, largely from concentration and abuse of power.  The largest set of threats come from the ascendancy of financial goals amidst the commercialization of health care (mentioned briefly both in Frenk et al and the editorial).  We have discussed the nature of the threats in detail.  For example,

• Abandonment of traditional prohibitions of the commercial practice of medicine - In the US, a Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  After then, it ceased trying to maintain this prohibition.  The result was increasing, now rampant commercialization.  See posts  here and here.
• Making money takes precedence over education -  A recent survey showing that more than half the faculty at multiple US medical schools felt they were valued more for how much money they brought in than their teaching or patient care abilities (here), confirming previous anecdotal reports (see here). 
• The medical school re-imagined as a biotechnology company -  In 2000, a Vice President of the American Association of Medical Colleges(3) wrote that research universities must respond to "societal demands that they become engines of economic development…."  Many universities now defend lax conflict of interest policies with similar arguments.  For more details, go here.
• Faculty become employees of industry - For numerous examples of this and other kinds of conflicts of interest, go here.  A survey by Campbell et al suggested that approximately two-thirds of medical academics get significant payments from industry.(4)
• Academics become "key opinion leaders" paid to market drugs and devices - Marketers regard "key opinion leaders" as salespeople who appear more credible because of their professional guise.  See anecdotal evidence here.  
• Control of clinical research given to commercial sponsors - A study by Mello et al showed how universities' grant administrators are willing to sign contracts giving commercial sponsors control over key aspects of human research studies.(5)  See post here. 
• Conflicts of interest allow manipulation and suppression of clinical research - Commercially sponsored research design, implementation, and dissemination are often manipulated to favor the sponsor's interests.  When such manipulation fails to produce favorable results, the results may simply be suppressed.
• Academics take credit for articles written by commercially paid ghost-writers - Such ghost-writing is often part of organized stealth marketing campaigns. 
• Whistle blowers are discouraged, or worse, and academic freedom is damaged.  Discussion of some examples of what may happen to whistle blowers is here.  The survey mentioned earlier (here) showed that about one-third of faculty fear they may be punished for speaking  out. 
• Leadership of academic medical centers by businesspeople - Ill-informed management may result from leaders who have no background or training in actual health care. 
• Leaders of teaching hospitals and universities become millionaires -  A recent example is here, and more may be found here.  Leaders of academic medical centers and the parent universities of medical schools often make more than $1 million a year in the US.  When such amounts are in play, executives may focus more on short-term measures that lead to even more pay than on upholding the mission. 
• Medical school leaders become stewards (as members of boards of directors) of for-profit health care corporations - A recent example is here, and a summary of how we discovered this phenomenon in 2006 is here.   The conflict of interest is severe because directors of for-profit corporations are supposed to have unyielding loyalty to the interests of the corporation and its stockholders, although they are frequently accused of acting mainly as cronies of the top hired executives (see here and here).
• Leaders of failed finance firms become stewards of academic medicine - We have found numerous examples, recently here, here, and here, of top executives and/or board members of the finance firms who helped bring on the global financial collapse also being trustees of medical schools, academic medical centers, or their parent universities.  Such "stewards" may bring to the academic environment the "greed is good" culture now pervasive in finance. 

So the threats are real and substantial.  However, their scope generally generally gets little attention.  Even when specific threats appear in the academic literature, their importance may be soft-pedaled, and their confluence with other threats ignored.  Of course, trying to discuss the full breadth and depth of these threats, as we endeavor to do on this blog, threatens in turn those who have personally profited from the current system.  Hence, we frequently cite the anechoic effect, the phenomenon that important threats to health care's core values are often just not discussed in polite company.

Therefore, we applauded the article by Frenk et al for concatenating some of the most important challenges to health care professionals' education, and we now applaud the Lancet editorial for emphasizing the threat to the academic medical mission.  We hope that these two articles, appearing in one of the most prestigious and well-read medical journals, will help to combat the anechoic effect.  Meanwhile, we will continue to blog about threats to core values in the hope that discussing them will lead to solutions.
References

1.  Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.  Lancet 2010; 376: 1923-1958.  Link here.
2.  Horton R. A new epoch for health professionals' education.  Lancet 2010; 376: 1875-7.  Link here.
3. Korn D. Conflicts of interest in biomedical research. JAMA 2000; 284: 2234-2237. Link here.
4. Campbell EG, Gruen RL, Mountford J et al. A national survey of physician–industry relationships. N Engl J Med 2007; 356:1742-1750. Llink here.
5. Mello MM, Clarridge BR, Studdert DM. Academic medical centers' standards for clinical-trial agreements with industry. N Engl J Med 2005; 352: 21.  Link here.

Deceptive Marketing, For-Profit Universities, and Health Care Education

Last week, reports about deceptive marketing and other questionable practices used by the growing for-profit higher education industry in the US appeared in the news.  For example, per Bloomberg:

Recruiters at U.S. for-profit colleges lied to entice students and encouraged them to commit fraud to qualify for aid, a report by the Government Accountability Office found.

Recruiters at all 15 colleges studied by the GAO, Congress’s investigational arm, misled potential students about the costs, duration and quality of their programs, according to a report obtained by Bloomberg News....

Other deceptions include:

“'college representatives exaggerated undercover applicants’ potential salary after graduation and failed to provide clear information about the college’s program duration, costs, or graduation rate,' the report said. 'Admissions staff used other deceptive practices, such as pressuring applicants to sign a contract for enrollment before allowing them to speak to a financial advisor about program cost and financing options.'

Also,

In one case cited by the report, a GAO investigator posing as an applicant was told to lie on an aid application about the number of household members to qualify for grants. When the investigators told college employees that they had $250,000 in savings, officials at three colleges told them to hide their savings in order to qualify for financial aid.

In addition,

For-profit colleges overstated the quality of their programs and the organizations overseeing their accreditation, the report said. One recruiter told an investigator posing as an applicant that his school was accredited by the same one that accredits Harvard University.

'It’s the top accrediting agency,' the recruiter said, according to the report. 'Harvard, University of Florida --they all use that accrediting agency.'

Recruiters exaggerated their colleges’ benefits and graduation rates, the report said. A beauty college recruiter said barbers earn as much as $250,000 a year, while the Bureau of Labor Statistics said 90 percent of barbers make less than $43,000 annually, according to the report.

A later report by the Dow Jones news service named some of the corporate players whose educational "institutions" were involved in dubious schemes.

Colleges operated by Apollo Group Inc. (APOL), Corinthian Colleges Inc. (COCO) and Washington Post Co.'s (WPO) Kaplan Higher Education unit were among the schools the U.S. Government Accountability Office found provided 'deceptive and otherwise questionable information' to agents who posed as prospective students in an undercover investigation of for-profit student recruitment tactics.

It is tempting to look for parallels with health care, once a calling like higher education, but now increasingly an "industry," often run, as we have documented endlessly, by people with little experience or knowledge about how health care is actually done on the ground, with little sympathy for the values of health care professionals, and given strong incentives to maximize the money coming in, whatever it takes.

However, the issue goes beyond these parallels. In fact, many of the bigger for-profit education corporations provide considerable health care education, including the three named above. The University of Phoenix, a subsidiary of the Apollo Group Inc, offers a Masters of Science in Nursing degree. Several of the "brands" of Corinthian Colleges Inc offer offer "diploma and/or degree programs in health care." Kaplan University, a subsidiary of Kaplan Higher Education Corporation, has a School of Health Sciences.  So it seems likely that many health care professionals, or would-be health care professionals, have been enticed by the sorts of sales practices documented in the report. 

There are no known for-profit US medical schools.  However, as we have discussed, many US students go to for-profit "off-shore" medical schools, often in the Caribbean, who mainly "educate" US citizens who want to practice here (as opposed to all the schools in countries other than the US whose main goal is to educate doctors for their own countries.)  Some of these off-shore schools are owned by big US corporations.  One can only wonder whether their recruitment tactics are similar to those of the for-profit "universities" located in the US. 

We have discussed deceptive marketing of hospitals, drugs and devices, but now it seems that deceptive marketing is even more widespread in health care than we originally thought, along with the take the money and run ethos that has infected so much of the business world.

If we truly want to reform health care to improve quality and access, and control costs, we need to restore the focus to care, the care of the patient, and away of the false pursuit of economic efficiency that only seems to benefit the quick buck artists. 

Members of the Board of Now Bankrupt Lehman Brothers as Leaders of Health Care?

In our own Providence Journal, Michael Hiltzik commented about the Valukas report on the fall of the once proud Lehman Brothers.  He asserted that one of the lessons learned from the case is the "folly of relying on self-discipline and self-regulation in the financial markets," particularly given the irresponsibility of the top leaders of financial corporations. In particular,

I’d love to hear an argument for allowing any of Lehman’s independent directors, who seem seldom to have asked a penetrating question, ever to serve on a corporate board again.

As I write, those 10 directors, who pulled down better than $100,000 cash a year to sit jointly in the driver’s seat for Lehman’s race to disaster, still boast at least 15 company directorships among them. Does this make you confident that corporate America is in good hands? Me neither.

It also should not make us confident that health care, and academic medicine, in the US and elsewhere, are in good hands. Hiltzik declined to name the members of the Lehman board, or identify the other organizations that they lead.  One can find a list of the directors who presided over the demise of Lehman in the company's 2008 proxy statement. It turns out that while they were presiding over Lehman's collapse, they also were presiding over the direction of some major health care organizations, to wit:

MICHAEL L. AINSLIE Director since 1996

Trustee of Vanderbilt University [including the School of Medicine]

JOHN F. AKERS Director since 1996

ROGER S. BERLIND Director since 1985

MARSHA JOHNSON EVANS Director since 2004

Ms. Evans served as President and Chief Executive Officer of the American Red Cross from August 2002 to December 2005.

RICHARD S. FULD, JR. Director since 1990

serves on the Board of Trustees of ... New York-Presbyterian Hospital

SIR CHRISTOPHER GENT Director since 2003

Non-Executive Chairman of GlaxoSmithKline plc.

JERRY A. GRUNDHOFER

Mr. Grundhofer is a director of Ecolab, Inc ["As a leader in infection prevention, Ecolab provides products, tools, training and service to healthcare facilities to help prevent the spread of healthcare acquired infections.]

ROLAND A. HERNANDEZ Director since 2005

HENRY KAUFMAN Director since 1995

a Member of the Board of Trustees of New York University [including the School of Medicine]

a Member of the Board of Governors of Tel-Aviv University [including the Sackler Faculty of Medicine]

JOHN D. MACOMBER Director since 1994

[Also, a member of the board of directors of Warren Pharmaceuticals, "a privately held biotech company, incorporated in 2001 for the purpose of developing proprietary tissue-protective technologies."

So, collectively, the confidence uninspiring members of the board of the now defunct Lehman Brothers also were on the boards of two major US and one major Israeli university that include well-known medical schools, one major health care related charity, one major British multi-national pharmaceutical company, a prestigious academic medical center, a large public for-profit US company with major health care interests, and a small, privately held biotechnology company. 

We have another vivid illustration in the aftermath of the global economic collapse, and in an ongoing health care crisis, how some of the problems of health care, and academic medicine in particular, may have been at least enabled by leadership more used to working in an increasingly amoral marketplace than to upholding the academic mission. All health care organizations, for-profit and not-for-profit, those in the US and those in other countries, need leaders who value their health care and academic missions more than simply the money they may bring in.

Everything is Up to Date in Kansas City, Except the Health Care University CEO's Knowledge of Her Own Budget

They say everything is up to date in Kansas City, so maybe it should not be a surprise that it is the source of a new and colorful tale of how leaders of health care organizations are different from you and me.  The Kansas City Star reported about the professional life of the recently fired CEO of Kansas City University of Medicine and Biosciences:

Hiring the CEO

There’s an often-told story about how Karen Pletz, the fired president of the Kansas City University of Medicine and Biosciences, got her job in the first place.

On a flight from Phoenix to Kansas City in 1995, a stranger sat next to her: Jack Weaver, then chairman of the university’s board of trustees.

Pletz, with a law degree and a career in banking, so impressed Weaver that he proposed she join the board. When the trustees met her, they asked her to apply for the president’s job.

The CEO's Compensation

Big paydays: Pletz’s compensation skyrocketed from $261,000 in fiscal 1999 to nearly $1.2 million — about $250,000 more than the president of Johns Hopkins University made.

Also,

Pletz’s million-dollar compensation package put her among an elite group of university presidents.

A review of the latest available tax records — for the fiscal year ending June 30, 2008 — shows that the leaders of other osteopathic medical schools in the region were being compensated far more modestly.

While Pletz was making $1.2 million, the CEO of the larger Des Moines University received $347,000. A.T. Still University of Health Sciences in Kirksville, Mo., where osteopathy got its start, changed CEOs nine months into the year. Both were paid about $50,000 a month; their combined compensation was $609,000.

The last time the Chronicle of Higher Education included free-standing medical schools in its survey of compensation of private college and university presidents, in 2006, Pletz was one of only seven making seven figures.

The CEO's Spending Decisions

She spent disproportionately on administration versus education:

Spending on the university’s primary mission — educating medical students — didn’t keep pace with the school’s rapidly growing administrative costs. From fiscal 1999 to 2008, the amount spent on educating students and other program services rose 59 percent. At the same time, administration expenses jumped 384 percent.

Other executives were paid well:

For Douglas Dalzell, executive vice president for institutional development, the compensation was $437,000 in fiscal 2008, more than double his pay in 1999. For Richard Hoffine, chief financial officer, it was $616,000, more than triple.

Dalzell’s compensation frequently rose in five-figure increments. Hoffine’s pay increased by as much as $127,000 in a single year.

The board fired Dalzell on Dec. 31, and Hoffine resigned over the New Year’s weekend.

She spent copiously on entertainment and items less well defined:

Along with the generous compensation paid to Pletz and her top lieutenants, the university was spending large sums on special events and other activities.

Shortly before a retreat for university managers in 1998, the university spent $15,000 to have 26 members of the Kansas City Symphony play for faculty and department heads at the Folly Theater. The object was to demonstrate with music how teamwork and good leadership produce the best work.

Records show that expenses for graduation activities jumped 47 percent in just three years, from $199,000 in 2005 to $294,000 in 2008.

Entertainment costs averaged $84,000 a year.

In fiscal 2002, the university spent more than $197,000 for various services at the Fairmont hotel — now the InterContinental — on the Plaza.

Even 'miscellaneous expenses' exploded, according to the university’s tax forms: They were about $81,000 in fiscal 2001 and $1.4 million in fiscal 2005, the last year they appear on tax reports.

The university also was spending as much as $739,000 a year on expenses for 'healthcare leadership,' tax records show.

Pletz defended the spending on graduation and other ceremonies because of their importance to medical students and their families.

Graduation is 'a whole weekend of events,' Pletz said. Many homecoming activities were held at the Fairmont, she said.

As to what the healthcare leadership spending entailed, Pletz said she didn’t know.

Executives hired their relatives:

Family members and friends, including Pletz’s daughter and a top associate’s daughter-in-law, were added to the payroll in administrative positions. The university’s nepotism policy allowed a lot of leeway.

And then there was the mysterious Health Policy Institute (as reported separately by the Kansas City Star):

After HCA, Inc., acquired the large, nonprofit hospital group Health Midwest in 2003, opportunity came knocking for Health Midwest executive Barry Seward:

An appointment as president of the Kansas City University of Medicine and Biosciences’ new Health Policy Institute.

It was an unpaid position, but Seward didn’t have to work for free. He received consulting fees of as much as $177,300 a year from the university, tax records show.

Seward’s son, Michael, became the institute’s unpaid vice president. The younger Seward also has a paying job as the university’s director of grant development.

Along with his consulting income, Barry Seward has had the fringe benefit of extensive travel for the institute.

The Health Policy Institute’s budget was $62,909 in 2008, tax records show. A few thousand dollars of that went to office overhead. The rest was spent on travel and meals.

Ms Pletz justified the Health Policy Institute thus:

Pletz said the institute’s position papers are widely distributed.  Eight are posted on the institute’s Web site

However,

they average about 240 words. Stem-cell research took five paragraphs; pandemic flu got three.

Neither the Health Policy Institute web-site nor a Google search revealed any experience or expertise in health policy on the part of its President.  I would note also that Institute's position paper on "healthcare workforce" failed to note the shortage of primary care physicians, and the paper on integrative medicine advocated for more access to, more insurance coverage for, and more medical school training in complementary and alternative medicine without acknowledging the lack of evidence supporting many "CAM" treatments.
The Role, Such As It Was, of the University Board

Current board chairman Danny Weaver, who also is the university’s acting president, won’t discuss why she was fired. Pletz, who says she’s proud of her work for the school, won’t get into specifics.

Danny Weaver, son of Jack Weaver, will say only that more than one person in September brought 'extremely serious' issues to the board’s attention that led to Pletz’s termination.

University administrators kept the governing board in the dark for months at a time about important issues, Weaver said.

But it was the board Weaver has led since 2004 that approved Pletz’s salary and incentive package. The board, which met just twice a year, approved the university’s budget, but it did not monitor the way money was actually spent. And it did not routinely review key filings the university made to the Internal Revenue Service.

How the board justified Peltz's compensation:

Questions about her salary and incentives, Pletz said, should go to the university’s trustees.

'Compensation was a board decision,' she said. 'It was the board’s responsibility.'

She said she thought the board was interested in retaining top managers.

'It was a very team-oriented approach,' Pletz said. 'If the performance was there, the compensation was there.'

In addition,

Weaver defended the compensation the board granted Pletz.

'Based on her production and what she brought to the university, her compensation was within reason,' he said.

However, apparently none of her production had to do with familiarity with her own university's budget:

The spending figures are all line items in tax documents called 990 forms that nonprofit corporations, such as the university, must file each year with the IRS. The forms are available to the public.

Pletz could not say what the line items on the 990 forms represented.

'Any questions about the 990, I would not be able to answer for you,' she said. 'You’re going back a number of years, and I really don’t have direct knowledge about those line items and what they would have been comprised of in any given year.'

Of course, the board might not have caught that problem, since they seemed equally unfamiliar with the budget:

Weaver, who has been on the board since 2001, said he has never reviewed the documents.

'I never see the 990s as the chairman. … The board never saw the 990s,' he said. 'That’s the business of the president and the CFO.'

Weaver said he had no idea how the university could run up $1.4 million in miscellaneous expenses. He 'couldn’t even gather a guess' on the entertainment costs.

And Weaver said he could only speculate on what 'healthcare leadership' expenses were: Perhaps they were expenses Pletz and her vice presidents incurred in their work with community organizations.

Summary

So here we have a particularly colorful example of how the leaders of health care organizations are different from you and me.  The CEO of one osteopathic health care university got more than one million a year despite her lack of any experience or expertise in health care, and her unawareness of her institution's budget, which apparently included lavish spending on administration and other expenses unrelated to the educational mission.  She nominally reported to a board of trustees which seemed completely clueless about her activities, but happy to pay her for "production" of what they did not know. 

So, as I wrote last week about out-size compensation given for no clear reasons to CEOs and other top executives of not-for-profit hospitals in three US states...

Although the executives of not-for-profit health care organizations generally make far less than executives of for-profit health care corporations, collectively, hired managers of even not-for-profit health care organizations have become richer and richer at a time when most Americans, including many health professionals, and most primary care physicians, have seen their incomes stagnate or fall. They are less and less restrainted by passive, if not crony boards, and more and more unaccountable. In a kind of multi-centric coup d'etat of the hired managers, they have become our new de facto aristocracy.


Or as we wrote in our previous post, executive compensation in health care seems best described as Prof Mintzberg described compensation for finance CEOs, "All this compensation madness is not about markets or talents or incentives, but rather about insiders hijacking established institutions for their personal benefit." As it did in finance, compensation madness is likely to keep the health care bubble inflating until it bursts, with the expected adverse consequences. Meanwhile, I say again, if health care reformers really care about improving access and controlling costs, they will have to have the courage to confront the powerful and self-interested leaders who benefit so well from their previously mission-driven organizations. It is time to reverse the coup d'etat of the hired managers.

A final note - we have heard a lot from health policy "experts" in this time of interest in health care reform, and millions of words about health policy have been dispensed by such "experts" during the continuous health care "crisis" of the last 30 years.  This case demonstrates how little one needs to know about health policy to run a university "Health Policy Institute" to churn out health policy position papers, especially when the university CEO and board of trustees are equally unkowledgeable.

Hat tip to Prof Margaret Soltan on the University Diaries blog.

BLOGSCAN - Accountable Academic Governance Under Threat

On The Torch blog, hosted by FIRE (Foundation for Individual Rights in Education), this post by Kyle Smeallie summarized the travails of "petition candidates" for the boards of trustees of two elite American universities (Dartmouth and Harvard). As we have noted, at most universities, the boards of trustees, the bodies ultimately responsible for upholding the universities' missions, are closed shops. At most universities, the boards appoint new members to replace departing ones, without input from alumni, parents, students, faculty or anyone else who might be considered constituents. Thus, at most universities, even though the boards are ultimately responsible for the stewardship of the institutions, and upholding the institutions' missions, practically, they are accountable to no one. At very few universities, there may be contested elections for a few board seats, and an opportunity for those outside the board, usually alumni, to place candidates on the ballot. However, even at those somewhat more enlightened universities, those candidates face an uphill battle. Thus, while Dartmouth and Harvard have somewhat more transparent, accountable, and representative governance than do most academic institutions, even that is under threat.

We're Only In It for the Money: the Disproportionate Funding of University Administrators by Academic Medicine

We have previously discussed how academic medical leadership seems to care more about how much money their faculty bring in than their clinical, teaching or research performance. Why academic medicine came to put money ahead of mission has never been clear. However, a little bit of insight has been (probably inadvertently) provided by an announcement of a new university president.

After the early resignation of President Trani, under fire for his coziness with tobacco money (see post here and links backwards), Virginia Commonwealth University (VCU) just announced its new President, Michael Rao. The official announcement of his appointment included:

The VCU Board approved Rao’s salary of $488,500, $176,113 of which is paid by state funds and $312,387 from VCU Health System and private funds, for the positions of VCU president and president of the VCU Health System. His total compensation package, approved by the board, also includes $66,500 in deferred compensation, a $60,000 housing allowance, and use of a car, all paid by private funds. Separate from the compensation package, Rao will receive a signing bonus of $275,000, paid by private funds. He will be required to repay $200,000 if he leaves the university within five years.

This announcement is unusual, perhaps unique, in that it breaks down the sources of a university president's salary. Very few universities publish any details about their budgets, and hardly ever explain money flows among their different sub-divisions.

What is striking is that 63% of President Rao's salary will come from the health center. However, the health center only accounts for about one-eighth of the university's students. (Total university enrollment is more than 32,000, and 2008 Health Sciences enrollment was 4278.) So, the president of a university will derive approximately five times more of his funding from the health sciences division of the university than would be expected by the size of that division.

I suspect that this situation is not unique, or even uncommon. What is unique is that VCU has made it public.

(Note also that President Rao's total compensation, while far more than that of the average faculty member, is nowhere near as outrageous as that of some other university presidents. Finally, in the interests of disclosure, I should note that I was a full-time faculty member at VCU from 1987-1994, and still serve as an adjunct faculty member there.)

In my experience and humble opinion, it seems that the pressure academic leaders put on their faculty to bring in ever increasing amounts of money is out of proportion to the needs of academic medical centers or medical schools, or even the greed of their leaders. Instead, it may be that academic medical centers and medical schools, in turn, are under pressure to be the cash cows of their universities.

Many universities have expanded their administrative staffs and budgets, and raised the salaries of their top leaders far more than inflation or increases in enrollment would justify. They have also erected palatial buildings, funded extravagant sports programs, and provided students luxuries unheard of when the baby boomers went off to college.

University leaders may well have taken advantage of the abundant money flowing through health care, especially that supplied by pharmaceutical, biotechnology and device companies to generate research and "education" to market their products, and that supplied by a physician and hospital reimbursement system rigged to pay handsomely for an ever increasing number of procedures (see post here). But having become accustomed to this money to fund expansive administrative budgets, it is no wonder that university leaders have pushed for more and more financial production from medical school faculty, no matter what. And funded by their cash cow academic medical sub-divisions, it is no wonder that university leaders have turned a blind eye towards, if not actively encouraged financial entanglements by faculty and administrators that would dull their scruples about the sources and reasons for their outside financial support.

If we want universities and their academic medical components to go back to putting their mission before their margins, we need to wean university leaders off the narcotic of surplus funds provided by their academic medical sub-divisions' external financial support.

BLOGSCAN - Car Allowances and Country Club Membership for University Executives

On the University Diaries blog, Margaret Soltan posted on the perks afforded to top leaders, including the medical school dean, at the University of South Florida(USF). These included country club memberships, and car allowances at $650/ month. The rationale seemed to be that the administrators need to appear to be rich in order to hob-nob with the sort of rich folk needed as donors. The perks have continued even though the state-supported university is facing budget cuts.

I would comment that these perks might also be based on university executives' sense of entitlement to being at least on the fringe of the power elite, or superclass. This sense might truly be fed by their contact with even more wealthy people who might be prospective donors, and the sorts of masters of the universe who seem to have gravitated to university boards (see our posts about the Dartmouth board here and the Harvard Corporation here). But I would suggest that the perks handed out at USF might be bush-league compared to those found at the more supposedly elite universities.

I am afraid the main effect of such perks is to further isolate academic leaders from the people they are supposed to serve. After all, academic institutions are supposed to serve truth-seekers and learners. (Academic health care is also supposed to serve patients.) Country club memberships, or having a fully-staffed house and a car and driver might tend to make one feel apart from the common folk in the student body, or the patient population.

Silverglate on How Corporate Academic Leaders Try to Control the Message

In the US, and most countries, academic medicine, including medical schools and teaching hospitals, are situated within larger universities. The leaders of academic medicine report to university presidents, who in turn report to university boards, who are ultimately responsible for upholding the universities' mission.

Perhaps one reason that universities, and their academic medical components seem to have worsening difficulties upholding their missions is that their top leaders increasingly are people to whom the academic mission may be a foreign concept. For example, we recently discussed how the board of trustees of one prominent university with a prominent medical school has been taken over by leaders from the finance sector, the same sector which brought us all the global financial collapse.

In an article in the Boston Phoenix, civil liberties expert Harvey Silverglate discussed some other aspects of academic integrity failures, that is, how academic institutions now operate counter to their fundamental mission.

Harvard is accustomed to turning other universities green with envy. So it comes as no surprise that its alumni publication, Harvard magazine, which is largely financially self-sufficient and editorially independent of the university, has become a model to which other universities aspire. But rather than take pride in the bi-monthly’s stellar 108-year-old reputation, university administrators effectively declared war on Harvard magazine earlier this year when they brought out an in-house competitor. The new rag, The Yard — which Harvard sends four times a year to alumni, big donors, and parents of students — strikes a decidedly more self-flattering tone than its independent counterpart.

Why the change, and why now? In a word, the answer is: fundraising. As the Wall Street Journal reported in June, 'fund-raisers determined that Harvard magazine was no longer serving their best interests.'

In an era when corporations and politicians pay public-relations consultants big bucks to control the 'message,' one would hope that universities, devoted to the 'free marketplace of ideas,' would resist the trend. Yet in recent years, Harvard, like almost all universities, has been eager to limit how much the public in general, and alumni in particular, learn about what’s really happening on campus. This is especially true as many universities continue to sacrifice traditional academic values — free speech, academic freedom, and fair disciplinary proceedings — in favor of censorship and closed administrative proceedings that function as kangaroo courts, in a misguided attempt to avoid controversies that might gain public attention.

The reality is that alumni fund a major portion of private universities’ budgets, and even public institutions are increasingly dependent on former students to supplement stagnant or decreasing state education budgets.

Growing increasingly anxious, officials at public universities turned toward upbeat alumni mags to buoy fundraising efforts. Over the past 15 years, schools that had never previously published alumni mags began cranking out thousands of the things....

The image-above-all mentality is part of a lamentable trend 'Freedom Watch' has long identified as 'the corporatization of higher education.' Increasingly, university presidents operate more like CEOs than academic leaders: they emphasize the bottom line, large endowments, U.S. News and World Report rankings, and highly visible campus construction (and donor-naming) projects, while they neglect or marginalize academic excellence, intellectual inquiry, academic freedom, and students’ rights.

A sampling of local [to Boston] alumni glossies reveals a near-universal practice of praising the university, even if it means demeaning the intelligence of alums.

As Alan Charles Kors and I pointed out in our 1998 book, The Shadow University: The Betrayal of Liberty on America’s Campuses, academic freedom is being sacrificed so that academic administrators can play-act as empire-builders and careerists rather than serve as educators. The typical modern college president’s goal is to have no controversy, no trouble 'on my watch,' we wrote.

This article suggests several important points.

First, there is a growing realization that academia's mission is being increasingly subverted as the leadership of academic organizations, including, in particular, academic medicine, increasingly resembles corporate leadership. (We, of course, have repeatedly discussed the prominent movement in health policy in the 1980s that advocated breaking the "medical guild" while handing power over health care to bureaucrats and managers.)

Second, there is a growing realization that academic leaders who ape their corporate peers have a penchant for propaganda promoting their interests, and for suppressing discussion of their faults. Clearly these are causes of the anechoic effect. Never mind that controlling speech and communication in this manner is antithetical to the fundamental academic mission to discover and disseminate the truth in the spirit of free enquiry.

A practical lesson for those interested in what is going wrong with academic medicine. Do not expect to find much out about what is going wrong from academic medical institutions themselves, and particularly from the publications and media they sponsor. Just because academic medical institutions are supposed to promote discussion of important issues in medicine, health, and health policy, do not expect them to allow discussion of issues that reflect baldly on their fearless leaders.

But Silverglate warned administrators intent on controlling the message:

For administrators to think that they can mold alumni opinion by monopolizing the universities’ messages sent to grads ignores the growing realities of our increasingly sophisticated and informed electronic-media-saturated culture.

Now that no-nonsense alumni are seeing through the smoke and mirrors, cutting off donations and asserting control of alumni associations and boards of trustees, colleges may have no choice but to pay attention to the rising chorus of voices saying 'enough!'

We hope that Health Care Renewal and some of the blogs to which we link are part of an "increasingly sophisticated and informed electronic media" which will help people see through the "smoke and mirrors," and encourage them to say "enough."

What is Not Taught About "Leadership in Healthcare"

One of our scouts forwarded me a link to the curriculum from an MBA program from the distinguished Yale School of Management designed especially for would-be health care leaders. The program is entitled "MBA for Executives: Leadership in Healthcare."

Here are the required courses, in alphabetical order:
- Competitive Strategies
- Corporate Finance of Biotechnology
- Economic Analysis
- Enhancing Negotiation Skills
- Entrepreneurial Business Planning
- Field Studies in Healthcare Management
- Financial Accounting
- Financial Management
- Financial Reporting
- Healthcare Policy, Finance & Economics
- Hypothesis Testing and Regression
- Independent Study
- Integrated Leadership Perspective
- Law & Management
- Leadership
- Managerial Controls
- Marketing Management
- Operations Management
- Policy Modeling & Decision Analysis
- Probability Modeling & Statistics Estimation
- Quality Management
- Services Marketing: Strategies for Nonprofits & For-Profits
- Strategic Environment Management
- Valuation I and II
- Visiting Scholars Program

The link provides more detailed course descriptions.

So what is missing? There seem to be two obvious areas that are not taught.

The first is health care. There are only two courses in this curriculum on "healthcare policy" and "healthcare management." There descriptions are as follows:

Field Studies in Healthcare Management

The Field Studies Program is a year-long combination of integrative coursework and hands-on, faculty-mentored consulting to active healthcare organizations. It serves as a capstone for the MBA-E, bringing together skills learned in the classroom with knowledge and perspective gained from the Visiting Scholars to explore their application in a variety of healthcare settings. The coursework covers funds flow and value creation in the healthcare system, competitive and cooperative strategies in the world of healthcare, managerial controls in the healthcare setting, designing and refining operating processes in healthcare, current applications and issues in healthcare information technology, and managing transformational change in a healthcare setting. Past consulting projects have included reducing order-to-report cycle time for a diagnostic imaging department, coordinating and cross-checking diagnostic and therapeutic processes across different clinical departments, strategic planning for a community-based HIV/AIDS care program, developing a clinical quality management plan, capacity planning for a new nursing unit, and strategic and financial analysis of different adoption alternatives for a newly-introduced artificial vertebral disk.

Healthcare Policy, Finance & Economics
Teaches students critical skills in analyzing and working within the healthcare industry. The first portion of the course focuses on the Economic and Financial drivers of the domestic healthcare system, including private and public financing and delivery models. In the latter portion of the course, the students learn about current issues of importance to this $1.4 trillion industry. The course is part didactic/part seminar style and includes significant team projects and presentations.

Thus, these courses seem to have little if anything to do with the care of actual patients. Furthermore, there are no courses that seem to have anything to do with biology or biomedical science, or with the practice of medicine or nursing.

The second area missing is ethics, particularly the business ethics of health care. There are simply no courses even remotely related.

As we have discussed before, since the 1980s, the health care professions have been systematically dis-empowered, with the goal of breaking up the "physicians guild," while bureaucrats, managers, and executives have taken over health care. A quick perusal of the curriculum meant to train top level health care executives at an elite US university suggests that such executives may be completely untutored in biology, medicine and nursing, and of how patients actually receive care. Furthermore, such executives may not receive even rudimentary training in ethics, despite the severe problems we have documented on Health Care Renewal with the business ethics of health care, and the effects of such problems on patients and society.

We need to rethink the advisability of having health care controlled by bureaucrats, managers and executives, especially in an era marked by widespread arrogance, greed and foolishness among even the top executives of our most prestigious industries (finance in particular). If we must continue some control by such people, at the least they should be educated in biology, the values of health care professionals, the context in which patients actually receive care, and the ethics of business applied to health care.

Report Faults West Virginia University Leaders for Retroactively Granting Degree to Pharma Executive

The Charleston (West Virginia) Gazette reported on an unusual entanglement between a medical school's parent university and a health care corporation.

The article summarized the findings of a West Virginia University committee that investigated irregularities in the awarding of an MBA degree to Ms Heather Bresch. Ms Bresch is the daughter of the governor of the state, and is also Executive Vice President and Chief Operating Officer of Mylan Laboratories, a large generic pharmaceutical manufacturer. Also,

Critics of the university have long pointed to Bresch's political connections: The chairman of Mylan is a major benefactor of her father and the university.

In summary,

West Virginia University administrators showed 'seriously flawed' judgment in awarding Gov. Joe Manchin's daughter a master's degree she didn't earn, rushing to protect her and themselves from media scrutiny, a panel investigating the dispute says.

Failures of process and leadership were 'unique to this particular, high-profile case' involving Mylan Inc. executive Heather Bresch

Apparently, Ms Bresch was awarded the MBA degree although she had not fulfilled the requirements for the degree, under circumstances that suggested external pressure.

The damning 95-page report released today is harshest on Provost Gerald Lang and business school dean Steve Sears, who the panel said had no academic foundation for retroactively granting Bresch the 1998 degree.

'Mistake was compounded by mistake. An unnecessary rush to judgment, spurred in some measure by an understandable desire to protect a valued alumna and to respond to media pressure, produced a flawed and erroneous result. It didn't have to happen this way,' the panel concludes.

[The report] does, however, indicate a failure of leadership at high levels within the administration and suggest there was pressure from Lang and 'representatives of the president's office' to accommodate Bresch.

Lang, as chief academic officer, bears the brunt of the criticism for running the one-hour, Oct. 15 meeting where the decision to grant the degree was made. Also attending were Sears, WVU chief of staff Craig Walker, general counsel Alex Macia, communications director Bill Case and three educators from the business school.

'The panel believes the prevailing sentiment at the meeting, evinced by the actions and comments of the provost and the representatives of the president's office, was that a way should be found to justify the granting of the degree, if at all possible,' the report says.

Ms Bresch's official biography on the Mylan Laboratories web-site claims she "earned an MBA .. from West Virginia University."

It is beginning to seem like if one can imagine a possible connection between a health care corporation and an academic health care institution, somewhere, somehow such a connection already does exist.

"Mandatory" "Treatment" of University of Delaware Students

This case is already all over the web [starting here], but it has an unusual health care slant which has heretofore not been covered, so....

The University of Delaware, a large, state-supported US university, which includes a College of Health Sciences, recently instituted a new "treatment"program for university students, described in the draft of a detailed report. [Following page references are from that report.] (References to the program, also described as a curriculum, as a "treatment" are on page 8, 10, and 14) Subjects will be exposed to educational and behavioral interventions, the latter described in one document as that which will "leave a mental footprint on their consciousness." An example of one behavioral intervention requires subjects to line up, then step forward or backward in response to questions about their social identities [see p. 2 of this letter.]. The program will be subject to "action research" [p. 3], which "is generally distinguished by being practioner based, focused on actual existing practices, and using data to improve existing practices," [p. 4] and possibly also "summative, research style studies" [p. 3] Outcomes to be assessed include "behavioral changes in reaction to ... educational strategies." [p. 5] Data collection methods include "surveys, formal inteviews, focus group[s]" [p. 11] Subjects with the worst outcomes in particular groups would be individually identified, and subject to additional interventions [see p. 3 of this letter.] The investigators claimed the research "would qualify for an exemption from full [institutional review] board review." [p. 12]

So far, this sounds unremarkable, but, just has been extensively reported by the Foundation for Individual Rights in Education (FIRE), the subjects of this "treatment" program are all students living in all University of Delaware dormitories, not patients with any defined conditions or diseases. Furthermore, as the FIRE case file makes very clear, participation is mandatory. Not only is consent not required for participation, students must participate in the "treatment" and in the associated "action research" study whether or not they want to.

As FIRE noted in a letter to university president, there are a set of objections to all this based on the content of the intervention, which seems to designed to inculcate political beliefs, rather than to educate, and which requires students to affirm beliefs they may not actually hold. For a government institution to expose students to what seems to be mandatory political indoctrination, and to require students to express beliefs which are not theirs raise major constitutional issues.

Setting those aside, this program seems to profoundly violate some fundamental values of health care and of human research. Except in very particular cases of incompetent patients or patients who are at immediate risk of harming themselves and others, no one should be subject to a treatment without his or her consent. In such a situation, compelling subjects to participate in associated research is equally unethical.

Some may argue that the university's description of this project as "treatment" was metaphor or rhetorical excess. However, the repeated use of that term, plus description of the project in behavioral terms, and the clear human research component invite viewing the project as a treatment intervention and associated human research plan.

For an American state university to have gone so far in a plan for mandatory behavioral "treatment" of students without their consent is chilling. It is a reminder that something has clearly gone very wrong in health care and academia, and that the problems are clearly not at all limited to the for-profit corporate sector.

ADDENDUM (3 November, 2007) - the University of Delaware has cancelled its mandatory "treatment" program, as covered by FIRE.

For Halloween, Reports of Spooky Finances at UMDNJ and Other Academic Institutions

We have done a long series of posts about the troubles at the University of Medicine and Dentistry of New Jersey (UMDNJ), the largest US health care university. The university now is operating under a federal deferred prosecution agreement under the supervision of a federal monitor (see most recent posts here, here, here, here and here.)



We had previously discussed allegations that UMDNJ had offered no-bid contracts, at times requiring no work, to the politically connected; had paid for lobbyists and made political contributions, even though UMDNJ is a state institution; and seemed to be run by political bosses rather than health care professionals. (See posts here, and here, with links to previous posts.) A recent development (see post here with links to previous posts) was that UMDNJ apparently gave paid part-time faculty positions to some community cardiologists in exchange for their referrals to the University's cardiac surgery program, but not in exchange for any major academic responsibilities. Another was some amazingly wasteful decisions by UMDNJ managers leading to spending millions of dollars for real-estate that now stands vacant (see post here). Another was the indictment of a powerful NJ politician for getting a no-work job in the system, and the indictment of the former dean of the university's osteopathic medicine school for giving him the job (see post here). Most recently, we found out that UMDNJ had named one of its teaching hospitals for a pharmaceutical company in 2001 (see post here), and that the federal monitor accused the dean of one of the UMDNJ campuses of fixing students' grades (see post here).



In response to this debacle, the New Jersey State Commission of Investigation (SCI) investigated financial practices at multiple state institutions of higher education, including UMDNJ. As compiled from articles in the (central New Jersey) Home News Tribune, and the (North Jersey) Record, the main points were

• Even after all the scrutiny given to UMDNJ, the SCI found new problems there, for example, its report alleged "a contract for janitorial and housekeeping supplies wasted $1 million over six years at UMDNJ because of overbilling. The vendor also gave liquor, meals and Yankees tickets to key UMDNJ staff." [Home News Tribune] "The company even sprang for $800 in food costs for a 60th birthday party for ... [the head of ] UMDNJ's office of supplier diversity and vendor development." [Record] Also, a construction company founded by a former UMDNJ plumber billed more than $2.8 million over seven years. The work was overseen at UMDNJ by the former plumbing partner of the construction company boss. The company built the UMDNJ official "a 400-square-foot wooden deck on his Oxford, N.J. home, free of charge. Three years later, when [he] ... decided to convert the deck into a sunroom, [the company owner] ... paid the bill."


• There were "questionable payouts to employees, including $3 million in bonuses in 2004 to UMDNJ administrators and lump-sum payments to departing officials." [Home News-Tribune]


• However, similar problems were found at other institutions. For instance, the report alleged Rutgers University paid for expensive trips, meals, and alcoholic beverages. Also, "vast amounts of money were moved through 'emergency accounts' including a $5,000 liquor bill for an anniversary celebration at the Camden campus." [Record]


• The report found instances of excessive political influence on the academic institutions, even though they had been freed from centralized state supervision in 1994. For example, "One former trustee at The College of New Jersey said he was told then-Gov. James E. McGreevey wouldn't reappoint him because 'he criticized the administration's approach to the New Jersey business community concerning taxes.' A Ramapo trustee said he resigned after state officials tried to make then-Sen. Joseph Doria Jr., D-Hudson, president of the college. [Home News-Tribune]

Although some may argue that New Jersey has uniquely bad problems, this report raises the possibility that sleazy accounting and budgeting practices may be widespread at US academic institutions, particularly but not exclusively those involved in health care. The finances of US private not-for-profit academic health care institutions are generally completely opaque. Almost never do such institutions publish detailed budget, or subject themselves to outside audits. This opacity may make it easy for such practices to flourish.

(For those who don't believe that statement, try to find a clear, detailed budget for any local health care not-for-profit. Further, try to find the results of any outside audit of any such institutions. You may need to dig much deeper than the usual glossy institutional publications and their state-of-the-art web-sites. Let me know of any success.)

Given that tuition for higher education, including health care professional education, and the costs of health care have been rising much faster than inflation for a long time now, there is reason for concern that a good chunk of the cost increases are due to questionable payments and financial practices. But until the organizations involved make their finances public and allow detailed audit, that is all conjecture.

WHAT CAN BE DONE:

Insist that your local hospitals, academic medical centers, medical schools, and universities make public detailed budgets, and subject their budgets to periodic audits. "Sunlight is the best disinfectant." But expect lots of resistance...

Oceania in New Hampshire?

We recently discussed a proposed attempt to "reform" the governance of Dartmouth College, an elite US educational institution and home to a well-regarded medical school. As noted earlier, Dartmouth is unusual in that it allows almost half of its board of trustees to be elected by alumni. Furthermore, it allows candidates to be nominated by petition of the alumni. Many US colleges and universities' boards are entirely self-appointed. Those that allow elections usually restrict these to a few seats, and usually only permit candidates chosen by the board, university administration, or their agents. Thus, the top leadership of most US higher educational institutions is mostly self-appointed. Dartmouth was a partial exception to this pattern.

Now the Dartmouth board has decided to become more like its peers. The board just announced that it will expand its membership by eight. All the new members will be chosen by the current board. None will be elected. (See Dartmouth press release here.)

This is a setback for a nascent movement to make the governance of academic institutions more representative, accountable, and transparent.

What may be most notable about the current dispute at Dartmouth is how it has thrown some light onto the thinking of those who have been made uncomfortable by the college's modicum of democratic governance. At most colleges and universities, the leadership does not need to attempt to justify its power. When some Dartmouth leaders were forced to do so, the results were Orwellian.

First consider some assertions by the current Chairman of the Board, Charles E. Haldeman Jr, in a letter to alumni here.

• "The changes we are making preserve alumni democracy at Dartmouth by keeping eight alumni-nominated trustees. They expand the board with eight additional charter trustees...."
• "We are maintaining alumni trustee elections at their current level...."

But rather than making up 44% of the board, now the elected trustees will make up 31%. That clearly reduces the power and influence of the elected trustees, while increasing the power and influence of trustees appointed by other trustees. The current changes obviously reduce rather than preserve alumni democracy.

Then there was this,

• "We are expanding the Board from 18 to 26 to ensure it has the broad range of backgrounds, skills, expertise, and fundraising capabilities needed to steward an institution of Dartmouth's scope and complexity."
• "We also are giving the Board more flexibility to select trustees who offer the specific talents and experiences that the College needs, which elections don't ensure."
• "A larger group of trustees representing even more diverse backgrounds will help us enhance board engagement with key areas of the college."

But up to now, having the board appoint its own new members did not ensure that these appointed members would have "diverse backgrounds" or a "a broad range of backgrounds, skills, expertise." Of the current eight board appointed trustees:

• 6 are executives of investment or financial services firms,
• 1 is an executive of an advertising agency, and
• 1 is an academic physician.

Of the four alumni trustees who were not nominated by petition:

• 1 is an executive in an investment of financial services firm,
• 2 are a former or current executives of e-commerce firms, and
• 1 is a lawyer.

(See board membership here.)

Since in the past the board has used its power to select new members with homogeneous backgrounds, skills, and expertise, Chairman Haldeman's assertion that allowing it to select even more members would produce the opposite result makes no sense.

So Haldeman made two bald assertions that seem contradicted by facts. Orwell would have understood. In 1984, the protagonist, Winston Smith, wrote that "freedom is the freedom to say that two plus two makes four." The power of Big Brother and the Inner Party was to make two plus two equal to five.

Chairman Haldeman also revealed his intolerance for "divisiveness," that is, disagreement with him and the rest of the self-appointed Dartmouth leadership.

• "Dartmouth's trustee elections have become increasingly politicized, costly, and divisive."
• "But some of the recent rhetoric in this debate has become so harsh and divisive it is now doing harm to Dartmouth. "
• "Given the divisiveness of recent elections we did not believe that having more elections would be good for Dartmouth."

Apparently, Chairman Haldeman seems to believe that someone who disagrees with him is "divisive." Furthermore, he also believes that such "divisiveness" is bad for Dartmouth. The implication therefore is that anyone who disagrees with the Chairman is "doing harm to Dartmouth." Thus, Chairman Haldeman expects the orthodoxy of goodthinkers, even if this means, as Orwell put it, "a loyal willingness to say that is black is white when Party discipline demands this."

A final Orwellian theme emerged in a New York Times article about the run-up to Chairman Haldeman's assertion of power,

• "Now there is debate about whether all this democracy is such a good thing. Some in the administration, and some alumni, see the petition trustees as a throwback to the more conservative Dartmouth ethos of years ago, bent on undoing the liberalization of the campus ...."

Orwell would have recognized the notion that to defend "liberalization," one should attack liberal democracy. This is akin to one of the Party's slogan's, "freedom is slavery." Here is his explanation,

Oceanic society rests ultimately on the belief that Big Brother is omnipotent and the Party is infallible. But since in reality Big Brother is not omnipotent and the Party is not infallible, there is need for an unwearying, moment-to-moment flexibility in the treatment of facts.

Thus, the controversy about the administration's packing of Dartmouth's board of trustees brought out the Orwellian set of contradictions that those in power used to justify their actions. Although I fear the immediate future of Dartmouth's governance does not include much representativeness, transparency, and accountability, I believe there is a pronounced silver lining in these events.

First, those with loyalty to Dartmouth will realize that the college is not a province of Oceania, and Chairman Haldeman does not have the backing of the Inner Party nor the power of Big Brother. Although there may be no dissent permitted at the moment on the Dartmouth Board of Trustees, the Dartmouth Association of Alumni, purporting to represent 68,000 alumni, condemned the illiberal new way Dartmouth is to be governed. If a good fraction of alumni are stirred to action, they could exert sufficient influence to ensure that Dartmouth will never come any closer to being an outpost of Oceania.

Second, this episode may make alumni worry whether whether the endlessly upbeat missives from their institutions conceal a leadership closer to Ingsoc than Mister Chips. When alumni (and students, faculty, and parents) start to question how much power academic leaders have, and what they are doing with that power, universities may be tempted to teach more about 1984, and emulate it less.

Finally, in case this seems too remote from the issues we usually address on Health Care Renewal... Every US medical school is part of a larger college or university. All US academic medical centers and teaching hospitals are tied to US medical schools. Thus all of US academic medicine, and thus a good chunk of US health care, is tied to American universities. Many of these universities have governance that may be as Orwellian as that of Dartmouth. (For some examples, see the web-site of FIRE, the Foundation for Individual Rights in Education.) Such governance cannot help but have a major deleterious impact on health care. If this impact seems obscure, it is because we have not been looking for it.