Building a health empire

At a sprawling desk befit for a conqueror sits Dr. Ralph Snyderman. The man who over the past 15 years has annexed a medical school, three hospitals, a nursing school and dozens of research fiefdoms as parts of his empire sits in a chair and seems to survey his conquests for the first time ever.

"My style has always been to plow ahead," he says. "I'm just starting to really look back."

As of July 1, the rheumatologist will have plenty of time to look back upon both the high and low points of the decade and a half he served as chancellor for health affairs. This man from a working-class neighborhood in Brooklyn. N.Y., has led Duke's medical system at a time when many academic health care facilities folded under the strain of managed care.

Along the way, he has taken missteps that at times threatened his job, the hospitals' credibility and the institution's financial viability. But by all measures of growth, the Duke Medical System is both larger and stronger than it was in 1989 when Snyderman took the helm.

"That all happened under the leadership of Dr. Snyderman."

Getting ahead of the curve
  

In 1989, the medical complex that would become an empire was little more than a good hospital and a top medical school, and Snyderman was merely an impressive scientist who had a good eye for innovation and industry.

The doctor earned a name for himself as a researcher at Duke, where he worked for more than 20 years, serving as chief of the Division of Rheumatology and Immunology. He gained administrative experience during a two-year turn at Genentech Inc., a leading biomedical technology company. When Duke's top medical job opened, Snyderman came running back to the institution where he had forged his career.

Major changes were on the horizon in health care at the time, and Snyderman had the foresight to see the financial difficulties that lay ahead for medicine. The new chancellor of health affairs, who also served as dean of the School of Medicine, was charged with creating a cohesive unit out of the Medical Center and the hospital.

"He really did organize the Medical Center as more of an integrated organizational entity, with a strategic planning process that gave all of us within the Medical Center a clearer sense of where we wanted to make our choices, where we were going to try and go and how we wanted to measure success," said William Donelan, executive vice president and chief operating officer of DUHS.

To position Duke for the move from regional health care provider to international symbol of medical innovation, Snyderman had to step on some toes. Faculty members accused the chancellor of usurping authority traditionally given to chairs of the major medical departments.

Murmurs of disapproval of his style surfaced loudly at the time of his first five-year review. Spurred by a controversy about whether Snyderman was forcing two popular chairs out of their positions, more than 150 faculty members from the department of medicine signed a petition calling for the president to fire the chancellor.

Despite the objections, newly anointed President Nan Keohane appointed him to a second term. One of the chairs who was allegedly forced out was reappointed and faculty unrest fell beneath the surface again.

"Anybody who was in the process of making the change that he was making was going to stir up some controversy, and he did," said Ted Pappas, director of the Private Diagnostic Clinic. "When the power shift happened, he was at the center of that."

Keeping Duke's word

The wave of managed care hit North Carolina later than it did the rest of the country. That gave Snyderman, who is a scientist first and a businessman second, a chance to set up Duke to weather the financial crisis of American health care in the 90s.

Snyderman realized that in order to financially support academic research, Duke needed to branch out beyond just clinical work. Under his direction, Duke had created in 1993 the Office of Science and Technology, which was designed to connect clinical research and industry.

Duke also realized it needed to streamline its workforce, and in 1994, the hospital announced a staff reorganization that might eliminate more than 800 positions. Durham citizens rose up against the plan, fearing that the cuts would fall disproportionately on black and other minority staff members, but administrators in the hospital worked diligently to reassign workers and to eliminate only vacant positions. When all was said and done, only two dozen workers were laid off and the impact on the community was imperceptible.

The issues of race and Duke's accountability surfaced again in 1997, when a rapidly growing Duke emerged as the top bidder to take over Durham Regional Hospital.

After a hard-fought battle with several for-profit hospitals, Duke convinced the community that it would be the best administrator for the ailing hospital--but only after vowing not to lay off any employees for the first three years.

DRH turned out to be far more in debt than officials originally thought, and Snyderman came under some fire for overpaying for the hospital because he was overanxious to expand. But Duke and the chancellor have broken none of their promises to the community.

"In the beginning, I was a skeptic," said Dr. Robert Buchanan, the former president of Durham Regional's medical staff who vocally questioned Duke's motives during the negotiations. "But I'm a believer, and I can only say positive things about Duke and I can only say positive things about Dr. Snyderman. They've kept their word and are putting money into the hospital."

Building an empire

Over the next few years, Duke gradually expanded the Medical Center and hospital. In 1998, Snyderman helped split apart the financially volitile operations of the hospitals and other care entities from the educational enterprises of the Medical Center. The Board of Trustees created a separate Board for the newly created Duke University Health System and appointed Snyderman CEO of the Health System.

"DUHS is a model for ways to organize health systems," said Dr. Ed Holmes, former School of Medicine dean. "He's taken an integrated delivery system farther than any other academic institution in the country."

Several of the facilities Duke acquired became financial near-disasters that the institution rescued itself from just in time. No entity ever crashed Duke's Medical System, but dealing with the amorphous and enlarged DUHS did divert Snyderman's attention away from immediate matters.

Throughout the 90s, women and underrepresented minorities tried to gain ground, arguing that institutional barriers prevented their promotion within the Medical Center.

"A number of woman colleagues and I in the clinical and basic sciences served on an advisory committee in the early 1990s," Dr. Nancy Allen, professor of rheumatology, wrote in an e-mail in which she noted recent progress in the area. "Most of our recommendations were ignored."

Snyderman said statements suggesting he was unconcerned with diversity issues are "untruths."

"What I would say is that we are far from where we need to be," he said. "The motives have been pure. The activity has been at times frenzied, but the outcome has not been what I would have hoped for."

Facing the facts

Many current leaders in departments and research centers praise Snyderman for allowing them freedom of innovation.

"He basically said, 'I don't want to read in the papers about illegal activities and I want to know what's going on, but if you want to be an entrepreneur, then go ahead,' " said Dr. Henry Friedman, a professor of neuro-oncology and a key player in the Brain Tumor Center.

But several once-prominent administrators cite his constant interference and micromanagement as the primary reason they left Duke for other jobs. Current and former colleagues describe Snyderman as anxious to take credit for successes but unwilling to face problems until they explode.

In 1999, the national body which governs ethical standards for research shut down all clinical trials at Duke for four days after it deemed the review board was insufficiently run. The national organization said Duke failed to respond to several warnings, but Snyderman said earlier this month he was "surprised and dismayed" when the suspension came.

He and his team acted quickly, and since then Duke has become diligent in its ethical standards.

Dr. John Falletta, who runs the Duke ethical review board to this day, said Snyderman should not have been surprised by the government's move. "There was a failure to appreciate the need for a timely response," he said. "There was a failure to appreciate the need to recognize that the people at the federal government were serious."

Again in 2003, Duke acquired a spot on its record when surgeons at DUH transplanted a heart and lungs of the incorrect blood type into 17-year-old Jésica Santillan, Snyderman was noticeably absent from the media fray that ensued. He let his top officials speak for Duke, and several faculty members wished he had taken a strong role.

"I did feel there was a void when he did not take a leadership role in those early and critical days around the time of Jésica's death," Allen noted.

In the wake of the incident, Duke created a new position to address patient safety, and the institution is striving to become a leader in safety research. These measures are being well received nationally, but many within the Medical Center criticize the efforts as being a Band-Aid on a festering and deeply rooted problem.

Despite all the setbacks and backlash, Snyderman has positioned Duke firmly in one direction: forward.

 

"He's further developed and strengthened clinical research, basic research and organized the clinical program through the creation of the Health System to be successful in an increasingly environment," Donelan said. "He will be remembered for important changes that advanced the Medical Center from a simpler world in the 80s to a much more complicated world in the 90s."