The Teaching Hospital1

Dr. Robert Uric was the head of the Renal Medicine Unit at a large university medical school and teaching hospital. The teaching hospital, a regional medical center, had over 1000 beds and was considered a reasonably prestigious medical facility. There was a steady undercurrent of hostility and competition between the hospital and the medical school. The two institutions, a state school and a state supported hospital, had only one top official in common!the provost. "rom the provost down, the organi#ation split in half, with the medical school, its physician faculty, and its nursing faculty on one side, and the hospital administrator, nonmedical hospital employees, and ancillary service staff on the other $see "igure 1%. The physical plant, designed in the shape of an &, paralleled and accentuated the organi#ational structure. The medical school ran east west, ten floors high on the north side, and the hospital ran east west, eight stories high on the south. They were connected only by the bar of the &, an officeless corridor connecting the medical school and the hospital on each of the first si' floors. ( large part of the problem was the unusual nature of the financial arrangements. The physicians, as faculty members, received salaries, but no money for patient services. )atients were billed for professional services, but the revenues went into departmental funds which were disbursed at the discretion of the department chairs. The hospital, on the other hand, turned in every patient revenue dollar to the state and then had to turn around Provost and beg for, and account for, every penny of operating revenue it got. Teaching &ospital Medical 2chool *rant monies further complicated the situation, especially in the area of salaries. &ospital employees were civil service wor+ers, strictly regulated by ,ob classifications and &ospital wage scalesno e'ceptions were made. The medical school faculty, however, could Dean (dministrator fre.uently use grant money to supplement state salary scale, to hire people outright at 3onclinical higher salaries, or to4linical provide nonsalary per.uisites. /ecause of the financial fle'ibility, wor+ing conditions were also fre.uently better on the medical 8'ecutive school side, and medical (ssistant Director, (ssistant Director, 4ommittee )ersonnel Medical 2ervices school staff had money for more e.uipment, more travel, and even more parties. The inconsistencies between the operations of the hospital and those of the medical )ersonnel )hysician 3ursing 4linical school were highlighted 5age and /enefit by the integration of medical school faculty into hospital functions. Department Department &eads Department The situation was aggravated by the reports of technicians, patient floor employees, and 4hair 4hair (ssistant Director, clinical cler+s. These hospital personnel directly under the physicians and nurses Renalwor+ed Unit "inancial 2ervices from the medical school faculty, who were also administrative heads of clinical hospital 88* departments, and were in rather good positions to observe and hear of differences between 4redits and 4ollections 89* the hospital and medical school sides. $0ualified physicians were felt to be necessary in )atient /illing Radiology heading clinical hospital because of the technical natures of the departments1 6nsurance /illing departments :ther departments functions and from medical necessity.%
(ssistant Director, 2upport 2ervices
&ouse+eeping
1

(ssistant Director, (ncillary 2ervices )hysician Department &eads

"ood service This case was prepared by Roberta P. Marquette 4linics and Michael H. Smith under the supervision of Theodore T. 7aundry Herbert. The case is not intended to reflect either effective or ineffective administrative or technical practices it Maintenance :perating Room !rummer #raduate School of $usiness" Rollins was prepared for class discussion. !opyright Theodore T. Herbert" !ollege" %inter Par&" '( )*+,-.

)hysician Department &eads

"6*UR8 1 Teaching hospital medical school organi#ation chart

(ssistant hospital directors were in charge of most administrative matters, including administration of wage and benefit programs- department heads $physicians%, however, were responsible for supervising departmental activities, evaluating employees, and recommending raises and promotions. The dual reporting relationship left the employees in a situation of very divided responsibilities. "urther, the general disdain that the physicians felt for hospital administrators left the assistant directors in the position of mere figureheads in the area of clinical services. The hospital personnel, seemingly from the administrators down to the clinic cler+s, complained that the physicians were prima donnas, who considered themselves the ne't best thing to being divine. The medical personnel, on the other hand, complained that hospital personnel were civil service, time serving incompetents. :ne e'ception was Dr. Robert Uric, head of the renal unit. Despite the difficulty of his ,ob and his membership in the faculty group, Dr. Uric was roundly li+ed by the hospital employees with whom he wor+ed. :ne reason was that, whenever possible, he shared his grant monies with the hospital employees in his unit. "inancially and emotionally, the hospital renal unit, not the medical school department of medicine, was Dr. Uric1s home and favorite child. The Renal Medicine Unit at the teaching hospital, li+e many other renal units, received

what might be termedstepchildtreatment, banished to a subbasement where most of the other faculty and staff could avoid the painful realities of chronic +idney patients. 3evertheless, the renal unit was a cheerful place. The staff, under Uric1s leadership, maintained high morale, remar+ably high in view of the hopelessness of many cases and the fre.uent deaths of patients who spent years visiting the unit and who became, in time, almost members of a large family. The ,ob done by the renal staffersresidents, interns, and technicians ali+ewas sincerely appreciated by the patients and their families, and was a source of wonder to those outside faculty and staff who were familiar with the conditions of the dungeonli+e renal unit. (s a matter of fact, Dr. Uric himself was something of a wonder. :n nice afternoons he could be seen strolling the grounds, pop bottle and hero sandwich in hand, trailed by a half do#en students, teaching 2ocraticstyle among the birch trees and the s.uirrels. /rown bagging his lunch was not the least of Uric1s peculiaritiesmany stories circulated, including the tale of his being given a tic+et for speeding down one of the steep campus hills on his bicycle. (lso, through those who +new someone in the renal unit, other stories began to lea+ outtales of "riday afternoon parties fueled with grain alcohol and fruit punch, and worse yet, rumors of a monthly rabbit roast in which e'perimental animals whose transplants were not successful were put to death painlessly and then barbecued over a pair of /unsen burners. :ther faculty members found Uric to be a constant source of embarrassment and discomfort. &is actions wereundignified- for a research physician, he was entirely too involved with his patients. &e actually cried openly when his patients diedmost unprofessional; 2till, he was a fine director of renal medicine and a remar+able teacher, and he was, after all, an inside ,o+e. That all changed with "lower 7ife. Dr. Uric had several federal grants from the 3ational 6nstitutes of &ealth $36&% to pursue research on +idney transplantation. &e had begun doing active research within the first year after ta+ing over the renal unit. 3ot the type of man to become fascinated by academic .uestions, Uric had become almost obsessed with the need for answers when he saw his patients suffering and dying because treatments were not available. &e began by solving small, individual problems for specific patients and then generali#ing and publishing the solutions. *aining confidence from his initial successes, Uric applied for, and got, grant money and began wor+ing on the larger problems facing patients with chronic +idney failure. ( ma,or problem in transplantation is +eeping the +idney properly diffused $alive and full of fluid% between donor and recipient, and Uric was involved in this problem. 6n the course of his wor+ he discovered a fluid that was absorbed much faster than water at the cellular level. Testing showed it to be ineffective as a solution for diffusion, but it occurred to Uric that if plants absorbed it as well as human cells did, it might ma+e a good fluid for cut flowers, e'tending their life. (fter finding the right combination of fluid and an acid substance to +eep the cut stem end from closing, Dr. Uric decided he did have a substance superior to anything then on the mar+et. (s re.uired by the grant agreement, Uric reported his discovery to the 36&. 36& officials said they did not want the fluid. :wnership belonged to the university. /ut when Uric offered it to them, the university officials smiled indulgently and said he could +eep it. 3ot a man to be easily discouraged, Uric ne't offered his discovery to a large nursery

supply manufacturer. The firm bought it, named it "lower 7ife, and began ma+ing millions. (ll of a sudden 36& had a change of heart and filed suit. The story bro+e in the newspapers, first locally, then regionally, then nationally- needless to say, Dr. Uric madefuncopy. Uric and his peculiarities were no longer a private ,o+e, and the faculty became concerned about the reputation of the school. (t the ne't e'ecutive committee meeting, the heads of the clinical departments discussed the situation with the dean and suggested that perhaps Uric should be put in aless visible position until things .uieted down. The dean agreed. The e'ecutive committee felt it should move carefully- Uric was, after all, tenured and very popular with the students and house staff. 6t would not do to let this move loo+ li+e persecution. The committee finally settled on approaching the provost with a plan to establish a new research chair in medicine. /ac+ed by the dean, and financed by money donated from the chairs1 department funds, the plan was approved and Uric was hastily offered the position. (t first he refused, but it was subtly made clear that if he e'pected the university to bac+ him in the impending litigation, he would have to help out by surrounding himself with an air of respectability. Uric accepted and was given a big raise and transferred to a beautifully e.uipped new lab on the tenth floor of the main buildingthe chief resident of renal medicine, Dr. *eorge 4onrad, was placed in charge of the dialysis unit. The chief resident had a reputation for being hard nosed. &e had gone to medical school at a smaller university and had been very happy to get an internship and residency at a large teaching hospital. (n e'cellent student, 4onrad had also applied to /ellevue, the hospital arm of 3ew <or+ University, and to several other ma,or teaching hospitals. &is only acceptance came from his current employer, and the evaluation committee had loo+ed long and hard at his application before accepting him. 5hile his grades and aptitude tests shoed him to be an e'tremely bright and an e'traordinarily dedicated young man, his reference letters revealed him to be infle'ible and rather ruthless. /orn and raised in very poor surroundings, *eorge 4onrad was determined to become a doctor and to surround himself with that safe and apparently impenetrable aura of the physicianfinancially, socially, and professionally secure. &e had an image of the physician as being wise, aloof, self controlled, and as close to infallible as a person can get. 2omewhat insecure about his origins, 4onrad had long ago assumed a fa=ade of what he thought a physician should loo+ li+e- now it was hard, even for him, to tell whether the fa=ade had become reality. 5ith Uric1s removal, the members of the e'ecutive committee felt that 4onrad was the ideal person to assume the responsibility for the renal unit. They felt 4onrad would applya strong hand. The assignment was turned over to him by the chair of the anesthesiology department, a powerful and respected member of the committee. The chair told 4onrad that the committee was certain he could handle the renal unit, and that they did not e'pect to hear of any problems from the unit under his capable guidance. The chair also suggested that 4onrad be firm in as+ing Uric to stay away from the unit and thereby allow the transition of authority to proceed .uic+ly. The e'ecutive committee e'pected a period of ad,ustment, but disruptions of routine e'ceeded anything the members imagined. 2erious personnel problems arose in the dialysis unit, with increased absences and constant grievances about impossible wor+ing conditions. 5hile these complaints were pouring into the hospital personnel office through grievance procedures, few or no messages were coming through to the e'ecutive committee or the

dean. The hospital administration, unable to alter matters without the concurrence of the department head, in this case Dr. 4onrad, waited for appropriate authori#ation to investigate the matter and attempt to improve conditions. /y the end of the first month the turnovers had started- after three months ninety of the old employees were gone. Dr. 4onrad did not believe in becoming involved with patients on a personal basis, and he appeared to feel the same way about subordinates. 6nterns on rotation through renal medicine complained bitterly about 4onrad1s attitude toward and treatment of them- the roster of residents applying to the service dropped dramatically. Meanwhile upstairs, Uric1s research wor+ was stale, as was his disposition. &e failed to turn in a grant progress report on time, and the granting agency fle'ed its muscle and canceled the remainder of his funding. The dean was not happy and the e'ecutive committee was far from delighted, but everyone still believed the situation would straighten itself out. 3obody, however, believed the problem to be serious enough to investigate the effects on the +idney patients down in the subbasement. The dean and the committee might have even forgotten that the dialysis unit was down there. 5hen news did come out, it revealed that the effects were far more damaging than any tales of Dr. Uric1s weird habits could possibly have been. ( patient who had been on dialysis three times a wee+ for several years had given up her place and gone home to die. /ecause she had a rare blood and tissue type, the woman had been waiting a long time for a transplant. 2he had seen many other patients die waiting and even more patients get transplants while her odds appeared ever slimmer. 2ometime after Uric left the unit, she had made her decision- the story lea+ed out after she died. 2hoc+ed by the reali#ation of how bad the situation had become, the dean and the e'ecutive committee immediately placed Uric bac+ as head of the renal unit- they then began to analy#e what had happened, and what could be done to put the real unitand the hospital1s reputationbac+ together again.

1. 6dentify the barriers to communication in this case, and describe their impact on the hospital1s effectiveness. >. 4ompare and contrast the two doctors1 styles of management and the apparent reflections of Theory ? and Theory < assumptions of each of the doctors. @. Relate various motivational theories, such as Mc4lelland1s drives, &er#berg1s two factor theory, and the e'pectancy model, to this case.