Nationally ranked DUMC draws local criticism

David and Ricky Beck are well aware of Duke's reputation in health care.

Chatting in the waiting room of Durham Regional Hospital, the two brothers say Duke University Health System's 10-year-old partnership with the community hospital does make a difference-if only in name.

"Duke sounds more popular-everybody says Duke," explained David, 56. "The Duke name carries better than Durham Regional."

But it was less about the name affiliation than the hospital's proximity that led the brothers from Granville County-30 miles from Durham-to check their mother into Durham Regional for a broken hip. Considering whether they would pick a Duke-affiliated hospital over one that was not, the Becks said they would be equally happy with either, unable to differentiate the quality of services each provides.

It is no secret that Duke University Medical Center has a shining national reputation, as evidenced by consistently high rankings and the ability to recruit physicians and surgeons that draw the likes of Sen. Edward Kennedy, D-Mass., to seek their care.

Some, however, say the Medical Center's local prestige may be less strong in comparison despite, or perhaps because of, its efforts to reach out to the local and rural communities.

"The national and local reputations are based on different things, and yes they diverge," Frank Lombard, associate director of the Health Inequalities Program at Duke's Center for Health Policy, wrote in an e-mail. "What I hear from people in and around Durham is that Duke is elite-[it] provides amazing expertise-but is a huge behemoth with unfriendly structures around billing, etc."

Maintaining a national reputation

The Medical Center was ranked the seventh-best hospital in the 2007 U.S. News & World Report, putting it once again in the top 10 in the nation-a ranking it has held since 1989-and making it the only hospital in the Southeast to earn a top-10 rank in 2007.

Dr. Allan Friedman, Guy L. Odom professor of neurological surgery and the neurosurgeon-in-chief at Duke Hospital who successfully operated on Kennedy, said he was attracted to doing his residency at Duke 34 years ago because DUMC was considered to have the best neurosurgical training in the country.

He emphasized the collaboration between DUMC's various departments as a factor that sets it apart from other medical centers.

"One of the things that makes us so terrific and better than so many other medical centers with more prestigious names is people love to collaborate," said Friedman, who is deputy director of the renowned Preston Robert Tisch Brain Tumor Center. "Work in basic science is very likely to end up in clinical trials-that's unique."

Part of DUMC's rise to excellence can be explained by its leadership in the area of research, said Kevin Sowers, Duke Hospital's chief operating officer. The Medical Center received the second-highest amount of research funding-$388 million-from the National Institutes of Health in fiscal year 2006.

As a name, Duke University exudes a reputation that, unlike at some other prestigious universities, its Medical Center has seized the opportunity to parallel, said Rick Wade, the American Hospital Association's senior vice president for strategic communications.

He described DUMC as a pioneer in care and added that for decades, it has been drawing praise and attention to the South, despite a conglomerate of high-quality medical centers in the Northeast and media agencies there that keep them in the limelight.

Challenges in community care

Lombard, a Duke researcher who has worked closely with the local community in identifying its health needs, explained that just as the Duke name draws patients, it also drives some locals away.

For instance, he said Durham Regional's partnership with DUMC as a branch under the Duke name was considered by many to be a loss to the community.

A number of locals are intimidated by the Medical Center's emphasis on research, he said, afraid that Duke would only provide them with good care if they "have a disease that is interesting enough to get adequate attention." He said others sometimes felt like guinea pigs at Duke.

"I remember attending a meeting with a rural-based community health center, and having one of their leadership tell me that they only work with [the University of North Carolina at Chapel Hill], that some of the experiences they had with Duke's clinical research practices were disturbing-the words she used were 'reminiscent of Tuskegee,'" Lombard said. "[I] do not believe this was based in reality, but in this world, sometimes perception is as important as reality."

The perception may stem from Duke's private status, as Lombard said Wake Forest University Baptist Medical Center has similar town-gown strains. But DUMC's strengths and weaknesses vary across departments, as evidenced by rankings within the School of Medicine.

The School of Medicine was rated in the top 10 of 126 schools in the 2008 U.S. News & World Report for family medicine, internal medicine, geriatrics and AIDS, but did not appear in the top 10 for rural medicine, women's health, drugs and alcohol abuse and pediatrics.

Duke's comparative lack of leadership within academic disciplines regarding rural health and drug and alcohol abuse-issues that affect the Durham and North Carolina communities, according to county and state health departments-may corroborate a weakness in the Health System.

Dr. Victor Dzau, chancellor for health affairs and president and CEO of DUHS, said the disparity can be explained by the fact that each school and medical center has an individual area of focus.

"Different schools have to have [a] different emphasis-it can't be everything," Dzau said. "I don't think we need to figure if it's a shortcoming or not.... Duke has a great reputation and is cutting edge, and I think we bring together the research, clinical care and education-and we provide community care."

The Health System has been a leader in providing some of the highest-quality specialty care in the nation, with expert physicians, equipment and resources to boot. Patients from all over the country and world seek the Medical Center for innovative higher-level care.

Indeed, Duke provides community care through two hospitals-Durham Regional and Duke Health Raleigh-as well as its local clinic, the Private Diagnostic Clinic. Each has a patient base with more than 80 percent from the home and surrounding counties or North Carolina, providing much of the care Duke Hospital may not accommodate.

A balancing act

Although Duke receives greater recognition for its national name and specialty care, leaders within the Medical Center emphasized that Duke's local and national reputations go hand in hand.

"Really, it's the work you're doing locally that gets you the national reputation," Friedman said.

Duke's Private Diagnostic Clinic offers private care to the local community from faculty members in the School of Medicine. John Robinette, assistant director of the PDC, said the clinic maintains a local reputation simply by respecting patients and balancing resources between the community, county and state.

Duke began a partnership with other hospitals July 1 to increase coverage of uninsured Durham residents under Project Access. As part of the program, Duke has pledged to provide 2,000 physician visits to the uninsured-a move that will greatly increase access to specialty care for the bulk of patients at Durham's Lincoln Community Health Center, said Dr. Evelyn Schmidt, the center's director.

Lombard said Project Access is a good example of how Duke can reach out to community members by sharing and ceding power in a meaningful way.

"That was the one gap. Not the education, not the collaboration-the access to specialty care," Schmidt said. "The big gap is now hopefully going to be covered for the most part with Access."

The Medical Center's Division of Community Health has more than 30 outreach programs providing care and management services to the local community, said Susan Yaggy, the division's chief. The programs assist patients in multiple stages of the health care process, from prevention to helping patients follow-up with their treatment. The division has 16 outreach locations throughout Durham County.

Lombard said the Medical Center should also provide resources to improve the health and wellness of the community on a more holistic level, such as through safety, nutrition and improved quality of life.

"This allows a full range of response more in the form of stewardship-nurturing the community that hosts us, supporting the community through increased resources and increased understanding of the community in which many at Duke find themselves for such a brief time," he said.

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