Understanding academic medical centers: Simone's Maxims.

INTRODUCTION Academic medical centers today represent a unique fusion of traditional academia, hospital functions, several levels of education, and, above all, patients. They are complex organizations trying to discharge an often conflicting melange of responsibilities. This complexity has grown in recent years with the increasingly rapid rate of change (1), stressing both faculty and leadership (2, 3). Lamenting the toll of change is not new (4). However, the qualitative difference in recent change is underscored by the shift in focus of two articles, 15 years apart, on academic governance by Petersdorf (5, 6), especially as they have affected deans and their dramatically shrinking tenures. Economic turmoil and its consequences are blamed most often for the angst in academic medical centers (7). And yet, some blame the faculty and leadership for not changing fast enough (8) or for choosing doomed strategic pathways in response to those pressures (9). In fact, a Forum on the Future of Academic Medicine in 1997, sponsored by the Association of American Medical Colleges, reached a consensus that novel management systems are crucial to future success but blamed the unwillingness of faculty to change as a major obstacle to progress (10). This turmoil can be perplexing to individuals working in such an environment, especially trainees and younger and midlevel faculty. They are the most vulnerable in the system and may not yet have sufficient experience to use as a reliable touchstone. Are there lessons or guidelines that can be learned and used as one proceeds through a career? Can one better understand academic institutions, their leaders, and processes? Are there some consistencies that broadly apply to help negotiate the increasingly stormy seas? Like many colleagues, the more my career has involved administrative and leadership responsibilities, the more I have become a student of academic medical centers and how they function. During my career, I have moved through the trainee and faculty ranks and been the responsible leader at the section and department levels. I have also had senior administrative responsibilities at major academic medical centers: St. Jude Children’s Research Hospital and the University of Tennessee; Stanford University Medical Center; Memorial SloanKettering Cancer Center; and the University of Utah. Throughout those positions, I have gained some wisdom and many battle scars. To make some sense of my experiences and what I learned from many others, I began years ago to establish personal rules of thumb, “maxims,” to discern some meaningful patterns in seemingly chaotic events and baffling human behavior. Thus, Simone’s Maxims gradually emerged to guide my own judgment. These maxims concern the behavior of academic medical institutions, their leaders, and their faculty from the individual’s point of view. They were accumulated and developed from years of personal experience and many mistakes, as well as occasional revelations, both personal and borrowed from others. Although these maxims are personal, each is supported by the experience of some colleagues. I am confident that my experience is not unique, and that at least some will resonate with others in academic medicine, each of whom will have personal variations. The maxims are offered mainly to those below the full professor level, because they are less experienced and also because we full professors tend to believe we know it all. They have grown and evolved over time, and they are likely to continue to do so; these are no tablets from Moses, to be sure. The maxims are contained in five categories: institutions, leadership, recruiting, job changes, and success.