A year at the helm

Since he arrived at Yale in 2004, Dean Robert Alpern has led faculty to a new vision of the medical school, with a focus on clinical expansion and the application of great science.

By Michael Fitzsousa

It’s 8 a.m. on a Wednesday morning in late July, and Robert J. Alpern, M.D., has assembled his senior leadership group for its weekly meeting. About halfway through today’s agenda, the five people at the table are discussing options for an electronic medical record, or EMR. The computer-based patient chart is becoming a must-have in medicine’s transition to the digital age. Computerized record-keeping lessens the likelihood of a mistake being made—preventing a medication from being prescribed at a dangerous dosage, for example, or ordered for an allergic patient. It also holds promise for clinical researchers hunting for patterns in the illnesses, interventions and outcomes of patients, to determine which treatments work best for which groups of individuals.

The problem is that the medical school and its affiliated practice and hospitals do not yet share an EMR or a data repository, the computerized warehouse where data from medical visits, tests and surgical procedures are stored. There are competing software products, a still-shifting technology platform, major costs to implement and maintain a system and many questions remaining about how to get doctors to adapt to new ways of charting patient information and ordering drugs and tests. A central dilemma, Alpern notes, lies in the trade-off between ease of use and specificity: the systems that are most practical for physicians are the least useful for researchers, while those that standardize data entry in a way that makes sense for research are unwieldy for busy doctors.

This issue is just one of eight or nine broached at today’s weekly meeting, unusual in that the agenda is fairly short. Some weeks it grows to as many as 25 or 30 items, all of which need to be moved forward during the three-hour session. Today’s topics include the potential reorganization of one of the academic departments, planning for a new center for clinical research, two or three new fund-raising opportunities, a review of the medical school’s website, the retreat for department chairs in the fall, a proposal for a student-run free clinic and renovations to the school’s day care facility. Alpern, a nephrologist and Ensign Professor of Medicine, moves things along but allows the discussion to meander enough to pull in many points of view. From time to time, he takes an index card out of his shirt pocket and jots down a few words on the back of his schedule for the day.

The talk eventually leads to the perennial space crunch at the medical school and the constant juggling of lab, office, clinical and teaching space inherent in managing a growing institution of 1,787 full-time faculty members, 1,150 students and more than 3,000 full-time employees. Two years ago the 457,000-square-foot Anlyan Center opened on Congress Avenue, and a new, smaller building on Amistad Street is almost complete, but still there is not enough room for new programs and people. Space is at such a premium that Alpern holds a weekly meeting to work on the ever-changing puzzle. “Everything is so dependent on facilities, and you always have to think years in advance,” he says. “I still think we’re one building away from where we need to go.”

Before the discussion draws to a close, Alpern excuses himself to take a call, a rare interruption of the weekly meeting. As it turns out, the occasion is anything but ordinary: a successor to Joseph Zaccagnino, M.P.H. ’70, the president and CEO of Yale-New Haven Hospital (YNHH, the school’s primary teaching hospital and clinical partner), has been named and will be announced later in the day.

Opportunity in New Haven
Alpern came to Yale the summer before last from the University of Texas Southwestern Medical Center. Dallas is a world away from New Haven in its geography, politics, culture and climate, but it shares a rich tradition in science with the medical school. It was a young Yale medical graduate, Donald W. Seldin, M.D. ’43, HS ’46, who transformed the Southwestern campus from a compound of Quonset huts in the 1950s to the powerhouse in basic science and medical research that it has become. Alfred G. Gilman, M.D., Ph.D., the Nobelist who succeeded Alpern as dean there, is a Yale College alumnus and son of one of the Yale pharmacologists who developed the first chemotherapy treatment for cancer in the 1940s.

Alpern was recruited to Yale not only to lead a world-class medical school with an annual budget of more than $750 million, but also to counter several unsettling trends, including a mounting operating deficit ($35 million in fiscal 2004) and a general perception that the school was beginning to slip in relation to some of its peers. Third in funding to medical schools from the National Institutes of Health in 1993, the school still brings in more than $260 million in federal grants, but gradually dropped to eighth place during the 1990s and early 2000s as other schools were expanding their campuses and research capacities. Its ranking in the U.S. News & World Report annual survey of research medical schools dropped from third in 1996 to 11th this past June. Many academicians dismiss the rankings, arguing they lack scientific rigor and rely too heavily on subjective assessments—reputation in particular. Alpern understands that view but is enough of a pragmatist to know that a higher ranking will help the school attract the best faculty and students.

He also has two giant tasks ahead of him: leveraging Yale’s formidable strength in the basic sciences to translate knowledge about molecules and cells into new ways of treating illness, and putting those treatments to work in a much larger patient base. Yale has long been known as a powerhouse in biological science but has not had the same scope and depth in clinical practice, despite a handful of subspecialties that attract patients from outside the region, a few of them internationally. Alpern wants to expand the medical school’s programs in cancer care, cardiovascular medicine, organ transplantation and other key areas of practice to raise Yale’s profile nationally.

His honeymoon period as dean may still be in effect, but many faculty members are pleased by what he has done in his first year. Robert Udelsman, M.D., M.B.A., the Lampman Memorial Professor of Surgery and Oncology and chair of surgery, says Alpern is “available, approachable and affable, and he appears willing to delegate to others and empower them.” With the appointment of a new hospital CEO—Marna P. Borgstrom, M.P.H. ’79 (See “Marna Borgstrom Named to Lead Yale-New Haven Hospital and Health System”)—and a new dean at roughly the same time, Udelsman says, the medical center is presented with an unusual opportunity.

“Here is the entrée for Yale-New Haven Medical Center to make a fundamental decision about what it wants to be, whether it wants to be the best [medical center] in the world—not just in the top 10, but number one,” Udelsman says. “The hospital can’t do it alone, and the medical school can’t do it alone.”

David L. Coleman, M.D., HS ’80, the interim chair of the Department of Internal Medicine, says that Alpern worked hard during his first year on the school’s relationship with YNHH, the recruitment of department chairs and the launching of a strategic planning process that occupied 70 faculty members on three committees from last December until August. Throughout the planning process, Alpern dropped in on meetings and participated in the discussion, helping guide it at times but mostly listening. “I would say the key word to my management style is consensus building,” he says. “I don’t try to force people to do things. I try to think things out so that I have a vision for where we should go, and then I try to build a consensus.”

Planning for the future
Alpern sees the strategic planning effort, which was shared by three committees evaluating basic science, clinical practice and clinical and population-based research, as a major contribution to the healthy functioning of the medical school. (A fourth committee has been evaluating the educational mission in a separate process.) “Two of the best things that have come out of it are communication and the creation of a common sense that the institution has a direction,” he said in an interview in late summer, as the final reports were being circulated among the planning groups and edited into final form. “In a university, you have each faculty member marching to the beat of his or her own drummer, and if you get the best faculty, that works. But an institution should also have a sense of direction, and people felt we didn’t.”

Among the recommendations to come out of the planning process was the establishment of large multidisciplinary programs in stem cell biology, cardiovascular medicine, cancer, genetics and the neurosciences. The planners also identified areas of infrastructure that needed strengthening, as well as strategic “cores,” or pooled resources, to provide the latest technology and expertise to faculty conducting research. One example, discussed at the dean’s group meeting, is a center for clinical and population-based investigation bringing together the statisticians, study designers, computer scientists, regulatory professionals and others who are essential to the conduct of large studies evaluating new drugs and medical procedures.

From the basic science committee, the dean received recommendations for expanding or starting academic programs as well as bolstering certain portions of the academic infrastructure. For example, the group urged expansion of the Combined Program in the Biological and Biomedical Sciences (which has unified graduate education across the medical school and central campuses) and investment in animal facilities, X-ray diffraction equipment for structural biologists, laboratories for drug development and testing, small-molecule screening systems, RNAi screening (a hot technology that promises to identify potential new drug targets many times more quickly than previous methods) and advanced biomedical imaging.

The clinical committee focused on even more basic infrastructure: mechanisms for improved planning, communications, marketing and support services, as well as an EMR and a central scheduling service to standardize the way appointments are made. Like many medical schools, Yale saw its clinical departments grow quickly in the 1970s, ’80s and ’90s with an autonomy that would surprise many outsiders. For years, each ran its own ship and handled its own scheduling and administrative operations. Now the challenge is to make sure the system as a whole works in a way that is effective and convenient for patients without dampening the entrepreneurial spirit that has driven progress in the specialties and subspecialties.

“The faculty at Yale in general are all excellent doctors, but in many cases we don’t have enough of them to provide good service to our local and more national constituency. In addition, we don’t have the mechanisms in place to provide such service,” Alpern says. Patients should be able, with ease, to make appointments, schedule tests, obtain results, see multiple specialists and count on good communication among them and their referring physicians—things that cannot always be taken for granted, Alpern says. “We need to become a very user-friendly medical center that patients can navigate easily and where they can uniformly receive the highest level of care.”

That task has been entrusted to David J. Leffell, M.D., HS ’86, the newly appointed deputy dean for clinical affairs, who has been the driving force behind the 750-member Yale Medical Group since 1996. Other members of the senior leadership team are Jaclyne W. Boyden, M.B.A., the deputy dean for finance and administration; Carolyn W. Slayman, Ph.D., the deputy dean for academic and scientific affairs; Martha E. Schall, M.B.A., the university’s associate vice president for development and director of medical development and alumni affairs; Mary J. Hu, M.B.A., the director of planning and communications; and Julie B. Carter, J.D., an associate general counsel of the university.

Alpern cites the formation of the leadership group as one of the most important accomplishments of the past year. The group provides a structure for dealing with the complex problems the medical school must deal with, the EMR being just one example from this week’s meeting. “The problem is, it could be very easy. We could go real fast and do it wrong,” he says of the EMR process. To make good decisions, Alpern does what most corporate CEOs would do and works closely with a small group of senior leaders in whom he has complete confidence, delegating authority to them. There is a twist, however.

“Most people would tell you that you should have no more than about six direct reports, and unfortunately, that’s where the system breaks down in academics,” he says. Such a business model would have the 27 academic departments reporting to one of the deputy deans, but Alpern says, “I couldn’t stand that model. It removes the dean from the academic presence of the medical school, and it would frustrate any good chair. Plus it would take me out of what I consider some of the most enjoyable parts of the job.” Instead, Alpern meets weekly with his core group and at least biweekly with the department chairs. If something comes up, he adds, “any chair can get on my calendar within a week.” A newly formed dean’s advisory group of senior faculty will assist in major decisions affecting the school. In addition, Alpern has scheduled regular meetings with the departmental faculty so that he visits with each department once a year.

A long commute
Alpern is married to nephrology researcher Patricia A. Preisig, M.S., Ph.D., who remained in Dallas for the first year of his deanship, while their daughter, Rachelle, finished high school (she entered Yale as a freshman this September, and their son, Kyle, is a sophomore at the Hopkins School in New Haven). Alpern spent the first year commuting home on the weekends to Dallas, where he held his weekly lab meeting—he moved his nephrology lab to Yale in August—and took up tennis again after many years, joined by his son. Originally from Long Island, N.Y., where his parents and his sister and her family still live, Alpern says he was happy at Southwestern but was attracted both by the opportunity to come to Yale because of its position as a leading medical school and by the chance to help solve its problems.

“I wouldn’t have moved for a school that wasn’t as good as Yale,” he says, “and I’m not sure I would have come if it was not a chance to really put my fingerprint on Yale.”

He sees empowering the clinical faculty as one of the most important tasks before him. He and Leffell speak daily about clinical issues and have put a great deal of effort into building up the Yale Cancer Center (more than a dozen cancer clinicians have been recruited in the past year), relaunching the school’s liver transplant program and placing faculty who are primarily clinicians on an equal footing with their counterparts in research. Getting promoted at a top medical school traditionally has hinged on prowess in the lab, for scientists and clinicians alike, but in recent years Yale and some of its peer institutions have introduced new faculty tracks that reward clinical excellence. Last year, Yale lifted its cap on the number of faculty in one of these categories, the clinician-educator track, because Alpern felt the clinical practice could not grow otherwise. “I told the provost, there’s no choice here. We must lift this cap, and [then-Provost] Susan Hockfield said okay,” he says. “Anyone who’s really an outstanding clinician and educator who has a national reputation will be promoted to professor. And when you’re a professor here, your title doesn’t say what track you’re on. All people know is that you’re a professor. I really believe all the tracks are equal.”

Teaching is also of critical importance to the school’s future, and Alpern says Yale has one of the best educational programs in the world. “The Yale System, I think, is great, in that it allows the students to focus on learning rather than on grades and to explore their own unique interests through the thesis. It’s just terrific. It’s how you create the leaders of tomorrow.”

Alpern says the least pleasant parts of the dean’s job are the schedule—he has meetings from 8 a.m. to 7 p.m. most days, is out several evenings a week, answers e-mail late into the night and works through the weekends—and getting and dealing with bad news. For example? “Faculty who want to leave,” he says. “That’s probably the most unpleasant and the most important to deal with. When you have a great faculty, they’re constantly under attack” by competing schools wanting to recruit them. He is also under pressure to balance the budget while making major investments in the school’s future. Those two goals might seem contradictory, but Alpern says they go hand in hand. Cost containment is a critical piece of the equation, and so are fund-raising and a policy of well-thought-out expansion. If the bottom line drove every decision and no investments were made, he says, it would be a disaster.

Encouraged by his first year, Alpern says he has no doubt the school will reach its goals. From his perspective, the good days in the dean’s office outnumber the bad days by a wide margin. “I’d say the proportion is about 10 to 1, good days to bad,” he says.

Is he serious about that ratio? Well, yes, Alpern says, while acknowledging the extreme sunniness of the estimate. “You have to understand, I’m an optimist,” he adds. “You can’t ignore some of the bad news, but I try to focus on the good things.” YM

Michael Fitzsousa is the editor of Yale Medicine.