November 2011
 
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Dean Lawley
Thomas J. Lawley, Dean

Adapted from the Dean's State of the School Address, October 11, 2011

Good afternoon. This is my 16th State of the School address, and let me start by saying unequivocally that the school has never been stronger. We have outstanding faculty, staff, and students. But—and it's a big "but"—we do face big challenges, and our responses to these challenges will determine how we continue our journey toward elite status as a school of medicine and a health sciences center. More about that later.

EDUCATION
We have a large commitment to medical education from undergraduates to postdoctoral fellows. We have more than 3,300 learners, including 531 medical students and 489 allied health students. We also educate 503 students from the Graduate Division of Biological and Biomedical Sciences. Our residency programs are among the largest and the best in the nation, with 1,192 house staff and 620 postdoctoral fellows.

Class of 2015
The class is 138 students strong, and as in the previous five years, women outnumber the men, 71 to 67. Nontraditional students are 63% of the class, meaning that they spent at least one year doing something after college before attending medical school.

The class is also diverse, with nine African American students, nine Hispanic Americans, one Native American, and 29 Asian Americans. As usual, Emory provided the largest number of students, followed by Georgia Tech, Duke, Harvard, UGA, William and Mary, Yale, Penn, MIT, Wash U, and so forth.

They also have very diverse academic backgrounds. Non-science majors make up 25% of the class, and 18% were double or triple majors. As usual, they're very bright. They have very high GPAs and MCAT scores, and 19 of our students entered the medical school already having received a postgraduate degree.

This year the largest number of M3s ever have chosen to complete an additional year in their studies. Thirty-four students have opted for a fifth year, which we believe is a result of the new curriculum. Our students are encouraged to reach beyond the usual traditional subjects in medical school and to expand their professional experiences.

The quality of the new curriculum also is reflected in the most recent resident match. Thirty-six students remained at Emory, seven went to Harvard, six to UCSF, five to UNC and the University of Colorado, four to University of Wash, and three each to Hopkins, Wash U, Yale, and UCLA. Bill Eley, the executive associate dean for medical education, and I believe this past match was the strongest in our history.

As you know, our students also have as part of the new curriculum a mandatory five-month discovery experience in which they perform research or pursue other scholarly activities. So far the first Discovery Phase resulted in 41 published papers, many of them in extremely well-known journals. A paper from Pete Lollar's lab with a student as first author made the cover of Blood. The success of Discovery speaks to the dedication of the faculty who design projects for the students and who allow them to join existing research teams. To all the faculty who have sponsored a student, many thanks for your hard work on their behalf.

There are several new courses this year. The ambulatory care block is a three-month course that allows students to spend half of their day in primary care for 12 weeks. This course is overseen by Joanne Williams, Danielle Jones, and David Lloyd. We also have a new critical care course created by Tim Buchman and now overseen by Eric Honig. And finally, we have a capstone course in which we have 108 contributing faculty. The course is overseen by Sheryl Heron and Jason Liebzeit and occurs one month before graduation.

Our students have the great advantage of being taught by outstanding teachers and role models. Each year the faculty and students choose six to eight individuals to receive the Dean's Teaching Award. This year's awardees are Nate Flacker, Sheryl Heron, Jaffar Khan, Patricia Nichols, Barbara Pettitt, Louis Rapkin, David Schulman, and Stefan Tigges.

RESEARCH

We are ranked 15th in NIH awards among medical schools in 2011, just a few million dollars shy of the University of North Carolina and Columbia University. To move into the top 10 would require an increase in awards of about $40-$50 million a year, which right now would certainly be a stretch. But—and I want to plant the seed—this would be attainable when we have the new Health Sciences Research Building completed.

To be a school of medicine ranked in the top 20 in NIH awards means that we have many highly ranked departments. A total of 14 departments are in the top 20 and six in the top 10, with the Department of Emergency Medicine ranked number one in the nation. Congratulations to department chair Kate Heilpern. The other departments in the top 10 are pathology, microbiology and immunology, biomedical engineering, surgery, and neurology. These accomplishments are wonderful, especially in this difficult funding environment.

Our faculty do a remarkable job in garnering grant funding, both large and small. We have 108 faculty this year with more than $1 million each in annual grant support, and 143 with more than $750,000 in awards in 2011. Again, this is testimony to the quality of our faculty.

Our total research funding this year of $428 million has continued to grow over the past several years even after ARRA (stimulus) funding has decreased. The medical school's funding accounts for about 80% of all grant funding in the university. Our departments increased their funding by $50 million in 2011, which lessened the impact of the drop-off of ARRA funding.

Emory University MilliPub Club
While research funding is important, it’s simply a surrogate for research quality and the importance of research. One example of our research quality is the MilliPub Club. Its members are from the medical school and elsewhere in the university. Each has published a paper that has been cited more than 1,000 times. This year our inductees include Paul Plotsky, Douglas Bremner, Arash Grakoui, Andrew Neish, Walter Orenstein, Dong Shin, and Robert N. Taylor. This year, for the first time, the MilliPub Club Committee decided to honor four postdoctoral fellows who have distinguished themselves by conducting outstanding science early in their careers. They are an impressive group, but there easily could have been another five or 10 awardees in addition to these four. We are growing outstanding young scientists in our halls.

Emory delivers very high-quality science for the funding our scientists receive and has done so for a number of years, as evidenced by the medical school’s bang-for-buck rating, which is the H-index—the number of times an article is cited in other scholarly writings—divided by the NIH grant figure. By this measure we exceed Hopkins, Penn, Pitt, Vanderbilt, Wash U, Duke, Yale, and UNC and are surpassed only by Stanford and Baylor. This is a remarkable achievement and confirms what we’ve known all along: Emory is a bargain, and you, the faculty, do a great job.

FACULTY
We have a relatively large faculty. It has grown substantially over the years, mainly in the clinical departments, and we have relatively few part-time faculty. The growth of our clinical faculty naturally has paralleled the growth of our clinical enterprise.

Our Faculty Committee on Appointments and Promotions was busy this year, considering 81 faculty actions, and I'd like to give special thanks to Jeff Lennox, who informs the chairs and me about the committee's decisions. This year 27 individuals were promoted to professor on the clinical, research, and tenure tracks. I congratulate all of you on your accomplishments and the hard work that resulted in these well-deserved promotions.

The Department of Biomedical Informatics was formally approved a few months ago, and Joel Saltz is the chair of the department. Tammie Quest from the Department of Emergency Medicine has been appointed director of the Emory Palliative Care Center. Laureen Hill is the new professor and chair of the Department of Anesthesiology. She joins us from Washington University. Mark Rapaport, professor and chair of the Department of Psychiatry, joins us from Cedars-Sinai and UCLA in Los Angeles.

I also want to emphasize that all we accomplish as faculty couldn't occur without the support of more than 2,000 excellent staff in the School of Medicine. Just a few of their accomplishments in the past year include increasing productivity in the admissions office and improving communication across the school in various forms of recognition. To all of our staff members, I want to thank you sincerely for all of the hard work that you invest on behalf of the faculty in the School of Medicine. We really appreciate you.

FINANCES
Now as we all know, this has been a financially challenging year, and there's every indication that the years ahead also will be financially challenging. Our E&G revenues total almost $156 million. The biggest chunk, research FAC recovery, is about $74 million and has grown dramatically over the years. Those funds have helped us be competitive as a leading medical school. The downside is that we are leveraging our future on our ability to get grants, and that's why our continued progress in this area is so important because two other revenue streams, our endowment income and the Academic Enrichment Fund, have remained flat.

So how do we spend the money we bring in? Support for our academic departments accounts for about $61 million; university overhead, about $64 million; debt service and space leases, about $10 million; and administration and non-academic units make up the rest.

Now I'd like to address some challenges that we face. It's been another great year of accomplishments on every front despite the repeated weather forecast that the sky is falling. So the natural question is how do we continue to hold up the sky? I can tell you that it's not going to be easy. Foremost, we're in the midst of the worst financial crisis since the Great Depression. Debilitating debts, deficits, and, unfortunately, partisan governmental dysfunction are going to be with us for the foreseeable future and will frame everything we do. Health care and related industries and services account for approximately 17% of the U.S. economy. Because major bipartisan efforts are being made to reign in these costs, we're looking at an environment ahead that at best will be austere and at worst will force us into some very painful choices across our system.

Here's a short list of significant challenges, in no particular order:

  • The cost of medical education keeps going up. Student debt is high, and tuition can't be raised much more.

  • The NIH budget is under tremendous pressure and will probably decrease.

  • Our university endowment payout is less than it was in 2003.

  • Because of the financial crisis, foundations have less money to distribute.

  • A flood of Baby Boomers are about to turn 65 and transition from traditional medical insurance to Medicare.

  • Regardless of the promises or the intent of the architects of health care reform, we know that per capita Medicare and Medicaid payments will likely shrink.

  • Traditional medical insurance will shrink in volume and payments, threatening revenue in our practice plan and in our hospitals.

So clearly the sky is drooping, if not falling. Again, how are we going to hold it up? I think we can take a few lessons from our own history. Some of you remember the financial crisis that The Emory Clinic faced in the 1990s. The clinic had for decades been a private partnership with more than 28 different sections. Each section operated with great autonomy. All scheduling and staffing were handled within the sections, and sections were responsible for their own bottom lines. This model had been extremely successful and profitable for several decades, and then things began to change in the early 1990s with the advent of managed care. In 1994, out of economic necessity, the partnership agreed to dissolve and be replaced by a not-for-profit entity overseen by a board. The new director of the clinic introduced some innovations, such as attempting to centralize and streamline a wide variety of functions. That, of course, created its own set of new problems, and physicians and staff alike found these new ideas and systems to be disruptive and difficult to master. Throughout this time of managed care, the clinic had to quickly transition from managing a few insurance contracts to more than 100.

I bet some of you can remember as keenly as I do the stress and strain and demoralization that resulted during that time. Now Emory was lucky at that time to have recently hired Michael Johns, who clearly saw the danger ahead for our clinical systems if we didn't change and adapt quickly. Then in 1997 the U.S. Congress passed the Balanced Budget Act, freezing federal budgets for the foreseeable future. A study was undertaken by our health sciences center projecting that the impact on our clinical system would be a reduction in clinical revenues of more than $100 million over five years. We started planning successful pathways forward into our future. Long story short, because of that crisis, The Emory Clinic was transformed into what it is now—arguably one of the best and most efficient faculty practices in the country.

I can't tell you how many planning and implementation meetings that took. I can't tell you exactly how many faculty were stressed and frustrated to wits' end nor how many records and computer systems and processes were tried and replaced. It was not easy, and it wasn't fun. But the fact is that we emerged far, far stronger than when we started the process. We developed a business model, IT, and a care delivery system that made us not just viable but a source of strength and growth in the university. We expanded and improved our relationship with community physicians and our many community partners. Our health professionals emerged as happier, more satisfied faculty members. And most important, we improved patient care and service.

We did this because we knew the sky was falling. We knew we couldn't just stand still. We were going to be proactive, and we were going to find leadership opportunities. When we put that kind of clarity of purpose behind a seemingly impossible task of holding up the sky, we found in every instance that there were at first dozens and eventually hundreds of people willing to dedicate themselves to finding those answers. So it is remarkable to look back on that time and remember the packed meetings where faculty were screaming with rage about proposed changes in IT systems or patient flow or whatever. Now we hold such meetings and everyone is so confident that things are on track and well managed that they often don't bother to show up at all.

I want to give you one more example of when the sky was clearly falling—the severe financial and leadership crisis at Grady Hospital. Grady is clearly not only an important element of our mission of training and service, but it's also a critical resource for the greater Atlanta community. Grady is an essential provider for thousands of area residents of everyday health services and is, in addition, a level one trauma center, a burn unit, a sickle cell center, and many other things. It was run by a board appointed by elected officials, and like many public hospitals, Grady had nearly always struggled financially because of its role in serving mostly very poor populations and maintaining expensive trauma and burn units. County support did not keep up with inflation for more than a decade. Essential equipment and infrastructure had steadily deteriorated. The CEO position turned over repeatedly.

Finally when debts and unaddressed physical plant issues mounted into the hundreds of millions of dollars, it looked like Grady would be forced to close. The sky was surely falling. So we asked some tough bottom-line questions about ourselves and our missions.

We knew how deeply Grady was rooted in the core of Atlanta. More than 25% of the physicians practicing in Georgia were trained at Grady. We had hundreds of faculty who couldn't imagine practicing medicine or delivering health care outside of this compelling population. We had improved the lives of hundreds of thousands of people in the communities who depended on Grady for their health care. So we realized we needed to help keep the sky from falling on Grady.

Our goal soon became not just to preserve Grady but to strengthen it as an essential resource. So we and our colleagues at Morehouse went to the state, to the counties, to the communities, to our elected officials, to our faculty. We went to our benefactors. The process was hard. It took endless meetings and planning and time. It took finding and appealing to a vast cross-section of professionals, politicians, community leaders, and benefactors. In this process we found a new consensus around a vision and a mission for Grady. We helped find outstanding leadership to enhance and implement that vision. Enlightened benefactors stepped forward and invested hundreds of millions of dollars and helped structure a board and a management and governance model that would work for all stakeholders. At the end of the day, Grady has gone through a transformative change, and we played a role.

I could talk about other changes we've brought about because of challenges, but suffice it to say that over the past 15 to 20 years there has been tremendous progress in adaptability and transformation at Emory. Despite the ominous circumstances of the moment, there are so many good things happening here in medicine and in health care. For instance, we have a tremendous track record of success and momentum in research, education, and clinical care. We are one system under the umbrella of the university. We don't have separate hospitals and practice plans like many academic medical centers do. Our patient care quality metrics are outstanding. We are in the top percentile in UHC rankings for both Emory University and Midtown hospitals. We have strong leaders in the university, at Emory Healthcare, in the Woodruff Health Sciences Center, in The Emory Clinic, and throughout the School of Medicine, who are actively meeting to plan for the impact of potential future revenue decreases. Our students are among the very brightest and most committed in the nation, but they don't see falling skies; they see blue skies and endless horizons.

So as we plan for the future, I don't know exactly what strategies will work for us. I do know that we will put our utmost energy into identifying and testing strategies that will foster the preservation and the advancement of our missions. But here are some thoughts. We need to enhance the efficiency of our research, teaching, and clinical operations. We will increase our focus on patient-centered care and student-centered education. We will emphasize the most important areas of research where we believe we can have the most impact. We will consolidate practices, and we will consolidate hospitals. We will place increased emphasis on allied health education and practice and allow health care professionals to practice at the top of their licenses. We will continue to push IT utilization and solutions. We will collaborate with other medical schools in areas such as research cores, libraries, and IT challenges. We will seek and pursue international opportunities, and we will leverage clinical and research success for increased philanthropic support. In short, we will transform ourselves and Emory into a more competitive and better institution, which will continue to blaze trails in education, research, and patient care.

Let me wrap up with a couple of observations. First, an important lesson learned is that either you can let the sky come tumbling down or you can set about the impossible task of holding up the sky and making the changes that make progress. Every generation has its particular challenges, and we're now facing the second phase of health care reform amidst the severe economic downturn. Our shared vision and strategy to overcome our challenges is critical to the success of this big complicated institution that we work in.

Second, we can't inhabit an ivory tower. We're part of a much broader community. Our fortunes will rise or fall with those of our friends and partners, including Children's, the VA, Georgia Tech, Morehouse, and Grady.

Third, our faculty, staff, and students are the greatest resource and blessing that Emory has. You are the ones who will be among the leaders of our efforts and who will help recruit more leaders and contributors to the cause. I can honestly say when I started thinking about this talk, I made a long list of challenges for our future and all I could think about was the sky was falling. But then I realized I had my own opportunity to be an emissary. In this case an emissary to all of the innovative and committed leaders who are in this room today to say that if we work together we will be successful. So to all of you, my esteemed colleagues, I bring you the news, the sky is falling, and I can't wait to see the amazing ways that we will work together to hold up the sky this time. Thank you very much.

 
 
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