On the day Dr. Victor Dzau was appointed the next chancellor of health affairs at Duke, he stumbled just a little as he spoke. He articulated his vision through a faint accent that betrayed his non-native English-speaking roots.
But what raised the eyebrows of several people in the room was a carefully chosen preposition.
"I look forward to working for Dick Brodhead," Dzau told the high-profile crowd assembled from the Medical Center, the Health System and the rest of the University.
That three-letter word, "for," seems minor, but it marks a subtle shift in the relationship between the chancellor and the president of the University. Colleagues said they never recall Dr. Ralph Snyderman, Dzau's predecessor, saying he worked for President Nan Keohane. Rather, he maintains that he has always worked with her.
At this rare moment when both Duke University and Duke University Medical System are about to inaugurate new leaders, their roles have been redefined to make sure that the University--led by President-elect Richard Brodhead--can have the final say over the amorphous, ever-growing medical entities at Duke.
By self-consciously waiting to appoint Dzau until Brodhead was firmly accepted as the head of the University, the Board of Trustees has set their relationship: Part of the president's job is to keep the Medical System in check.
"When we've done it in this way--first the president and then chancellor position--we have the best ability of having those strong relationship and trust-building that will accomplish the most in the long run," said Professor of Medicine Dr. Nancy Allen, who served on the search committees for both the president and the chancellor.
Building the wall
There has always been a chalk line drawn on the ground between the Medical System and the University. But in the mid-1990s, when Duke acquired several hospitals and health care subsidiaries, administrators realized that more than a line needed to shelter the University from the financial liabilities of a full-blown health system.
In 1998, the Board of Trustees created a separate board for Duke University Health System, a firewall against financial downfall.
As DUHS walled itself off from the rest of Duke, it inadvertently strengthened the barrier between the academic pursuits in medicine and in other areas of the University.
With a multidimensional health system, the chancellor's job became too extensive for one man, and Snyderman handed off his role as dean of the School of Medicine. Dr. Ed Holmes and then Dr. Sandy Williams took the job and the regular meetings with the provost that came with the position. The chancellor let his own communication with the provost lag, and Provost Peter Lange focused his time with the dean.
"I think on the balance," Snyderman said, "the relationships in some ways are even further differentiated than they ever were before--such as the far-flung aspects of the Health System--and many of the things we do are technically even more complex and differentiated in the practice of medicine."
Some areas of scholarship have always straddled the fence between medicine and the rest of science. Anatomy, for instance, will always be a relevant class for medical students; however, research frontiers evolve.
"How many times have you read in the newspaper that a Duke professor discovers a new organ?" asked Richard Kay, a professor of anatomy and chair of biological anthropology and anatomy.
Years ago, it was possible to do substantive research in anatomy; now, though, the field is set. Duke has responded to this development by hiring anatomists with research interests in anthropology and paleontology. As a result, several anatomy-teaching faculty did research with little connection to DUMC, further widening the gap between the University and the Medical Center.
Punching holes in the curtain
Meanwhile, the University and DUMC have forged partnerships where relevant knowledge refuses to remain strictly within the bounds of medicine. Administrators have tried to remove the obstacles, many of them financial, that once blocked those paths.
"There are always problems about dividing resources in a fair and appropriate way," Lange said. "We put in place some rules about sharing indirect costs and grants that go across the schools, which has facilitated faculty on both sides feeling more comfortable."
The Levine Science Research Center houses Medical Center and other University departments. Similarly, the Center for Interdisciplinary Engineering, Medicine and Applied Sciences is primarily devoted to the needs of the Pratt School of Engineering, but it includes lab space for Medical Center researchers.
The Institute for Genome Sciences and Policy draws scholars with appointments in all areas of the University even though it primarily lies within the purview of the Medical System. On the reverse side, nearly half of the 50-plus scholars working with the Institute for Care at the End of Life, founded through the Divinity School, hold appointments in DUMC.
"There's a lot of goodwill there and the administration is doing the best they can to foster that, but there are a lot of institutional issues still," Kay said. "Still something exists that Bill Anylan [former chancellor for health affairs] used to call the 'gauze curtain,' which was a line drawn across campus that kept things somewhat separate... but people are poking holes in it."
Administering a connection
If it weren't for a coincidence of timing, the gauze curtain might remain in place as it has for more than two decades. Institutes and individual collaborations could continue to poke holes in it until it looked like netting, but without the leadership shifts it would still delineate a boundary between the Medical System and the University.
A steadily growing percentage of research is leading back to collaboration between medicine and basic science, medicine and public policy, and medicine and ethics. Still, the fear that DUHS might spiral too far away from the rest of the University nags at trustees and administrators.
"Across the whole history of Duke University and every university, academic medical centers have a strong penchant for a certain degree of independence, and that will certainly continue," Keohane said. "But I think some of the unnecessary drivers for it that we unwittingly built up over the last few years, we've tried to work through this past year."
The personal relationship between the president and the chancellor has contributed to the strain. Keohane leads by consensus; Snyderman often invokes a stronger voice, which, on occasion, has overpowered Keohane. The chancellor also boasts a longer tenure, having arrived four years before.
"It's complicated," Allen said of the sometimes-strained relationship between the Medical System and the University. "I think there probably are a number of factors, including the fact that [Snyderman] had been in place for those years before Nan became president. I think she had a learning time where there were a lot of big decisions to be made."
Seizing the moment
But Duke has a serendipitous moment at hand. Coincidentally, both the chancellor and the president picked the same year to step down. This allowed the Board of Trustees to first pick Brodhead, then the let Brodhead help select Dzau.
At the same time, the Board redefined the chancellor's position, which also includes responsibilities as chief executive officer of DUHS, so that he will report to the president for all matters--including the financial aspects for which he previously reported only to the DUHS Board. The wall that the Health System Board intentionally established still stands for financial protection, but it can no longer serve as a way to circumvent the president's authority.
"The intimate relationship between the University Board, the Health System Board, the involvement of the president in the Health System Board and being involved in interaction weekly with me is far greater than ever before," Snyderman said.
On both the University and Medical System sides of the line, administrators are doubling efforts to unify Duke.
Dzau has advocated intraschool partnerships, noting that Duke is one of only a few schools where the academic medical center, the health system and the rest of the University share geographic space.
"At many universities, I think there isn't such a relationship with the health system," Dzau said. "There's so much opportunity to collaborate."
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