 I'm delighted to welcome all of you to the 22nd lecture in honor of Dean Lowell Kageshaw, whose picture you see displayed on the screens. Dean Kageshaw had a distinguished career after medical school at Indiana University. He did internship in residency and his early faculty positions here at the University of Chicago. After leaving in the late 30s, Dean Kageshaw returned after World War II to become chairman of medicine in 1946 and then was appointed dean in 1947, a position he held here until 1960. During his 13 or 14 years as dean, he was recognized around the country as the dean of deans, sort of the leader of the American medical education movement. He helped move the double AMC from Evanston, Illinois to Washington to become a major organization for medical education. In 1956, he served as a special appointment for President Eisenhower to write a report on medical education, an important report which shaped medical education for the next 20 or 30 years. We're delighted that Dean Kageshaw's three children are able to be with us today, Dr. Richard Kageshaw, Carol Govan, and Diane Zink. Please stand up just for a moment. Thank you. And with no further ado, I'm going to ask Dr. Holly Humphrey if she would introduce today's speaker, Holly. Thank you, Mark. This is truly one of the highlights of the entire academic year for our Department of Medicine as we gather on an annual basis to celebrate Dr. Kageshaw's legacy. And I think it's only fitting that on the occasion when we celebrate the legacy of he who was the Dean of Deans, we have in our midst the Dean of Deans of American Medicine in 2011, Dr. Arthur Rubenstein. On April 1, 1981, 30 years ago, Dr. Arthur Rubenstein took over as chair of this Department of Medicine. That would begin a 16-year tenure overseeing and stewarding this department. Three months after he took over as chair of this Department of Medicine, on July 1, 1981, I became a third-year medical student at this very school. And so in the years that have followed, I've had a chance to watch and a privilege to work very closely with Dr. Arthur Rubenstein. I've had the chance to see him through the prism of a student, to work closely with him as a chief resident and as his program director, and as a faculty member at a university be loved by him over the years. And so how do I adequately summarize the 50-year career in academic medicine of Dr. Arthur Rubenstein? It's impossible. It's a career that has spanned three countries, beginning in South Africa, where he did his medical education and graduated from the University of Wittersrand in Johannesburg, then followed by a tenure in England, where he worked as a research assistant in Hammersmith Hospital in London. And then he came to the United States. And in this country, he has had an impact on three major institutions, where he has served ably. This institution, the University of Chicago, where he was a member of our faculty for 30 years, before leaving to become dean of the Mount Sinai School of Medicine in New York City, where he served for four years, and then most recently, a 10-year term as dean and executive vice president of the health system at the University of Pennsylvania School of Medicine. During this 50-year career, he has authored 379 papers, the very first paper published in the South African Cancer Bulletin was titled, Aspects of the Pathology of Chromosomes in Neoplastic Cells, being published in 1960. That paper was quickly followed by two publications in Nature and a career that went on to work with collaborators at this university on the fundamental descriptions and discoveries related to pro-insulin, C-peptide, and insulin. You may be interested that his most recent publication, number 379, is titled Mentoring Research Faculty in Academic Medicine. Along the way, in addition to these 379 publications, he has been honored multiple times. And I do not have the time to detail all of those honors, but let me highlight four. He is the recipient of the Banting Medal from the American Diabetes Association, the John Phillips Memorial Award from the American College of Physicians, the Robert H. Williams Distinguished Chair of Medicine Award from the Association of Professors of Medicine, and the Abraham Flexner Award for Distinguished Service to Medical Education, the highest award given by the Association of American Medical Colleges. This career has also included, beyond the publications and beyond the many awards and accolades, the fact that he has, in fact, inspired the careers of many, including those who have gone on to be scientists, clinician scientists, clinicians, individuals who have assumed leadership positions as section chiefs, department chairs, and deans, including our very own new dean, Dr. Kenneth Polanski, once a fellow of Dr. Arthur Rubenstein. He has also gone on to spur the careers of individuals not likely to assume a career in medicine, those who are underrepresented in medicine, including many women. In fact, you might be interested to know that in the 75-year history of the American Board of Internal Medicine, only three women have served as chair. First, Dr. Christine Castle. I was second, and most recently, Dr. Wendy Levinson. All three of those women have a direct lineage to the mentorship of Dr. Arthur Rubenstein. Sometimes, when we have the privilege of working with individuals who inspire us to the careers we come to love in this particular profession, we stand a little taller, we feel a bit better about the work that we do each day. But it is the rare individual who can make the tough decisions to be an active steward of precious resources, both money, faculty, student staff, and those who make up this complex of an academic medical center. Dr. Rubenstein has done that by keeping his enduring focus on the enduring values of this profession, including, at the center of it all, the patient in the clinic or in the hospital bed, whom we have the privilege of caring for. And along the way, he has stayed steadfastly close to those enduring values by the life he has led with great humility and inordinate distinction. He has not only mentored people, but he has mentored institutions, and ours is one that has been transformed. It is only fitting that Dr. Rubenstein deliver his talk today on academic medical centers, challenges, and opportunities. Arthur? Well, that was something to listen to. I thought I'd begin with two observations before. So one is, many people have thanked me for coming today. But if you ask me more often, then you make this kind of fuss in me. I'll come every time. When I go home, it's completely different. So don't hesitate. In fact, Holly, you might email that to my faculty. And secondly of all, I don't usually get anxious before I give a talk I've given, I don't know, 379, a lot of them. But I do feel a little anxious today, and I don't want to let you down. So give me some latitude. I'm going to try to tell you some of the things I've learned over the years. And if some of it might be relevant to you and have some impact, I'll be pleased. Let me first thank Mark Siegel and Harry Humphrey. You know, I have such close affinity to people here. Her introduction and, of course, Mark inviting me for this important lecture is very meaningful. And I want to thank the Kogyshel family. When I was chair here, I got to know them quite well. And they reminded me of their interactions with my wonderful wife of 48 years, Denise, who sends her love to all of you and to the Kogyshels. And she just couldn't be here because she had to have a knee put in recently. And otherwise, I think she would have come. I also want to thank the mentors who kind of created my academic possibilities here. And they really shaped my life in all kind of ways. Richard Landau, Joe Kersner, Al Tarliffe, Donald Steiner, and Life Sorensen. And I'm indebted to you forever. And then I want to mention, of course, the wonderful faculty who still hear many of them from our department of medicine. As Holly said, we set out in 1981 to create a great department of medicine as a team. And over the 16 years, I think we were quite successful, creating a wonderful milieu for teaching and education, research, and patient care. That really shaped my administrative ability, which I then transported to other places. But mostly, I also want to just say, you have just recruited here in October one of the great potential deans. But in six months, I'd say, he's already shown what he can do. And Executive Vice President for Health Affairs or Medical Affairs here. Of course, one of the greatest attributes a colleague can have is when the person he recruited from South Africa to join him, that was me, to join the endocrine division in the 70s. And then rapidly became better than me, but never really told me that. But I knew that. And then grew to run one of the great departments of medicine in this country at Wash U. And I always hoped he would be recruited back here, because I knew that the potential of the University of Chicago and its Academic Medical Center to really blossom and thrive needs a visionary leader, as all institutions do. And of course, when President Zimmer called me and said he was thinking about Kenneth, I had a number of things to say, which I won't relate to you. But when he appointed him, I congratulated him. And of course, the next 20 years here under his leadership are going to be spectacular. So Kenneth, I wish you luck. And I couldn't think of a better way. And I might have just thought of stopping the talk now, because so far, so good, right? So what can I tell you that you don't know? In a sense, I've been able to conduct an experiment. There's no randomized controls, which Dr. Meltzer will be disappointed in. But that would have been tough. On the other hand, when we created a great department of medicine together, there were some principles that we used that over and over again led to success. And so when I left here and went to Mount Sinai for a short time, but when I had the opportunity to really put them into practice as a dean at the University of Pennsylvania, I really thought about the possibility, which I'm going to describe to you, of how these principles may make or could make an institution more excellent, more efficient, and happier in terms of students and our staff and faculty and at a lower cost. And that's, in a sense, the experiment that I conducted with all kind of colleagues and a wonderful university for the past 10 years. And if there are any lessons in there that may be of interest to you, I'll be pleased. So here's the hypothesis in a simple way that a distributed leadership model and a team-based organization can create great value and excellence at a low cost or a lower cost for an institution. I'm going to try to put some of that in perspective for you. So I guess we can get going. So these are academic medical centers around the country. You can see there about 400 of them. Many are in urban institutions. They scatter throughout the country, most on the east, but not all of them. And a significant number here in the Midwest. And of those, 62 are distinguishable because they are very special by the quality of their research programs, research intensive, and high quality specialists. But in that setting, they also do education and patient care across the spectrum in a way that is important. Now, why are these so unique? Here's just some example in a quantitative sense. They are very expensive, cost a lot of money. And if they don't create value, as I'll describe, they can cause a lot of difficulty. And here you can see some examples. Penn, the academic medical center, is about half the university. Hopkins, about 64. University of Chicago is somewhat smaller, but the proportions are the same. And even at Duke, you can see the medical center there is a very major part of the university. That creates both opportunity and obligations. And of course, it's not surprising in that context that university presidents worry a lot about us. If we do well and we financially solvent, they usually tax the money and run the rest of the university on our money. Don't tell the president Zima that. And if we do badly, we put the university at risk. And that, of course, is a very dangerous thing. So we have a big responsibility because of this setup to function at the highest level in a very responsible way. On the other hand, the opportunity that we have in academic medical centers to do wonderful things is, in a sense, unparalleled. What other organization has the opportunity to do basic and translational science, clinical research, and cure and prevent disease in the context of training the greatest young people in the country? It's a unique opportunity and a responsibility that's most exciting and wonderful. And so, in a sense, we have an opportunity to do something very, very special. And it's in that context that we shouldn't give up that opportunity because of short-term problems or financial exigencies and miss the big, long-term opportunities that are so special. So when I came to the University of Pennsylvania, the finances, which even you can tell on this slide, were not in good shape. In the several years before I came in 2001, the Medical Center had lost $500 million, and the university was in chaos about it. There were opportunities to sell off the hospital to a profit organization. The faculty were anxious and disorganized and demoralized, and the president was extremely worried that this would have a very negative impact on the rest of the university for a long time. And so what I wanted to say is this gave me the opportunity. You might say, as my son did, dad, you'd be crazy to go to a place like that. And of course, there was some truth in that. But it also gave an opportunity to put in place the things that I mentioned to you that I'd learned here together with many colleagues running the Department of Medicine. And that was, could a distributed leadership approach and a team-based effort change the philosophy, the planning, and the finances of an institution that was great in many ways, but had fallen on hard times? And I viewed that as an interesting, difficult, but wonderful challenge. And so this put the setting in which I was worried about whether we could accomplish it. Many, many people have talked about the problem in academic medical centers that the leadership is distributed over departments, so-called silos, that the individuals had most interest in their own responsibilities, but in fact, did not really care in a real positive sense about how the whole institution might be. And in fact, that led to some departments thriving and others not, some institutes doing well and others not, and a belief that there was a variability across these institutions where the strong could thrive and the weak would then disappear, money was accumulated in parts that were not necessarily positive for the whole institution. And a variety of challenges, which as Gilmore said, was very, very difficult to organize in terms of a holistic approach to the institution. And so in fact, what I thought we might try to do there, together with a lot of very wonderful colleagues, and I'll go through that in some detail, to work over the last 10 years, this decade, and see because of the crisis which I found there, whether we could introduce this new model and what the impact would be. And what I'm gonna describe to you in some detail, but not of course nearly as much as all the data would show, is some of the way that can be done and then what the outcomes might be. And so here's the hypothesis, is it possible to manage an academic health center using a distributed model of leadership that preserves departmental authority, but also advances institutional goals? It seems simple, but many examples around the country over many years have shown that that was a very challenging thing to do. And if we could, could such an approach lead to enhance academic performance, efficient governance and improve financial management? This is particularly relevant because if you read the newspaper every day, you can see that it's almost inevitable there's gonna be less money in medical research, less money in healthcare, less money for academic medical centers in the next 10, 20 years. And so what we have to think about is how can we become more and more excellent at less cost? And so hence, this experiment is a forerun of what all of us are gonna have to deal with again, starting right now. So when I came, the government structure at the University of Pennsylvania overseeing the School of Medicine and the health system was extremely complex. The trustees and the president were up there, but then the organization of the oversight of the various components in the academic health center were very complex. And so the first thing I did was negotiated with the president, Dr. Judy Rodin and the Board of Trustees to try to simplify all this so that the reporting relations were clear, responsibility and obligations were transparent and the board oversight, which were very worried about the time because of the finances would be constructively helpful rather than negative. And so we did that and I won't go through all the details, but the model which you have here and which we have at Penn and lucky enough that a couple of places like Duke and UCLA and so on are really very important in my view because it's not the authority, but the ability to move things around, to integrate missions and to underpin them financially that this model gives you that's so important. So this is me answering to the president and the Board of Trustees. This board here is a subsection of the university board. This can be a number of ways. There's not just one model that's important. There are a variety of things with nuances that one can think about. And then the hospital here, the CEO answers to me theoretically. Of course one has to make that as a partnership and I recruited Ralph Muller, who was the CEO of the hospital here to join me. And then the practice plan and a variety of the subsections, all of which you want to eventually recruit great leaders and let them run their operations to the best of their ability under your guidance. So we began with a strategic plan. We had to do that because really speaking, no one knew what to do because of the financial crisis. The usual things in an academic strategic plan are here and I won't discuss them at all. Research, clinical care and education. There were two things that we stressed that were unusual. Because of the anxiety and worry of the faculty and students because of the existence of the institution being able to continue, we wanted to focus on making it a collegial, exciting and intellectually wonderful place to work. We always thought if the workforce, I hate that term, but students and faculty and staff really believed in the institution and thought that this was a great place to work. We would have less trouble retaining great people who were being picked off and of course being able to recruit people is the other side of the coin. And then we thought of this point that I mentioned to you that if we could have this distributed leadership model, could we create a milieu in the academic health centers which would be programmed for excellence at a lower cost. And so those are the two key pieces of the strategic plan. And then we hoped that if we were able to implement that, excellence in patient care and education and research would follow. So this is how we went about it. We decided that faculty, chairs and administrator leadership would need to adopt a holistic view of the institution. So when we recruited chairs or vice presidents or vice deans, we began by talking about what they could do for Penn Medicine, not what they could do for their particularly area of responsibility. And if we felt they could not contribute to the whole institution, didn't matter how excellent they were at their department or their area of jurisdiction, we decided we didn't want them to be in that position at Penn. And so we commented repeatedly on the importance of the senior leadership to have a collaborative approach where everyone would share in the institution's responsibility in addition to their own particular area. And of course, inherent to that, you have to give up some of your autonomy in favor of shared responsibility. And to do all this, we would want all the money and space and the usual things that are important to be transparent so that nobody would think if they were going to be good institutional stewardess that they were gonna give up some of their own practical things for other people. There had to be an institutional feeling of trust that one could do that. So here's the principles that we put in place then. We wanted the leadership alignment for coordinated decision-making. We wanted to clarify the roles of everybody in a very direct way for research and education and clinical missions. We wanted to measure everything we could as carefully and accurately as possible. You know, there is a theory in academia that you can't actually measure academic success. And there is of course some truth to that, but big parts of it you can measure. And as long as you don't look at the measurements as the be all and end all of everything, they can tell you to some extent how well or not well you're doing. We wanted to clarify the funds flow so that money would be taken off the table in terms of distrust or worry about each other. And so we wanted to make it as clear as possible. And then we put in a very controversial thing in place which actually turned out rather well. We all agreed when we came, all the chairs, all the vice deans, all the vice president in the hospital, that we would take one third of our salary right up front in the beginning and put it at risk. So it became part of an incentive plan. And then of that one third of our salary, half of it would be dependent on the institution's success and half our own individual area success. And then we put in a thing that was even more concerning but it turned out to be great actually. And that was if one or two key institutional goals that were very important were not met, we would lose the whole one third of the incentive part of our salary. And so of course one of them was the financial stability of the institution. We had various bottom lines and so forth. The other was stability of the best faculty recruiting of students and so on. So there were a number of things we put in there that were absolutely key indicators and we've changed them over the years together with the Board of Trustees. So these were the principles in which we set up the plan. And here are some of the ways that we actually put it into operation. So the executive vice president, these are people who span all the context of Penn Medicine. So these are leadership jobs that are not unique to one area or the other and they became critically important because they oversaw big parts of the operation. So myself of course, then a vice dean for professional services. This is the person who heads the practice plan, Peter Quinn at this time. And then a senior vice president who oversaw hospital and School of Medicine, a variety of important responsibilities there. And then a chief of staff and secretary to the board who worked both between the health system and the academic School of Medicine. And then these were ways that we implemented soon after I came to try to teach all of us how to do these things better. Now you know for many, many years people believe that academic leaders inherently know how to run things, how to become leaders, how to recruit, how to retain, how to manage finances, organize difficult interactions with faculty, heaven forbid, or students and all these things. But this is not nestly inherent in how we learn to do patient care or research. So what we decided early on is we needed all the leadership in the beginning to go through training courses, to try to learn how to do these things on the basis of business principles that had been effective in a variety of very important companies over years. And so we linked with the Wharton School and we did a whole lot of courses which are ongoing three or four times a year, 10 years later now. So we had a leadership program for chairs and senior administrators, a clinical leadership opportunity to think of how nurses and physicians and administrators would work, senior school medicine staff to think about how to adjudicate finances and move them around the institution. And then how to integrate better into the rest of the university in a university program. We have these several times a year with different groups of people in the institution. And I would say overall it's been enormously instructive in terms of teaching us a variety of principles of organizational leadership and implementation that have paid off over the years. So now I'll briefly tell you the way we've implemented over the 10 years. Of course, some of this took time and I wouldn't say that I did all this in the first few years or we did it. It took a long time and it's still of course a matter of evolution. So we have meetings every week or every two weeks of all the leadership of Penn Medicine, the hospital, the education and research leadership. And in there we discuss everything of importance to those individuals at that time. And the philosophy there is how can we be helpful when individual ones of us run into problems that we can't easily solve ourselves. So there's a lot of give and take there about how to do things better. Then we have a monthly meeting of the basic and clinical chairs. Where each of the chairs from clinical or basic present their work and others interact with them. Then we have a monthly meeting of all the institutes and centers with the department chairs. Where again in this case it's mainly administrative research underpinning or research productivity is discussed. And then the practice plan which spans all 18 clinical departments has a whole variety of faculty committees which oversee in great detail the practice plan. And then we did a number of things which were somewhat controversial but I would say overall they've worked out well. We centralized all the recruitment in the institution in a faculty run committee putting all the money that we had each year for recruitment under the ages of five senior chairs, three clinical and two basic signs and headed by the executive vice president for research dean, Glenn Galton in this case. And we then expected the department chairs or institute directors to put forward their candidates every year who were then evaluated for quality and excellence first by a university, a schoolwide committee. And if they pass that they were then put forward to this committee for financial money for money for recruitment. This allowed the whole institution to have a real stake in the recruitment of faculty. And of course during the recruitment process they didn't know just go to one department because many of the people involved in looking at their CVs or meeting with them during the recruitment process believed they could contribute in mentorship or space or interaction in research. So this has proved to be extremely positive. And then we led to implementation of a six year cycle for chairs, institute directors, vice deans and so forth and myself where every six years there would be a very thorough internal and external review. And if people didn't meet the level at which they should function then they would be asked to step down at that time. And then we also reviewed departments themselves every six years. So I guess the point I wanna make is we tried to centralize as much as possible but not under the administrative leadership under the faculty leadership in a way that everyone felt that they could contribute to making the place more excellent. And then of course the key issue that we wanted to implement was how did we move money around the institution with this model so that education and research which were always less money than the clinical operation if it's successful would be fairly and adequately resourced. And so we did a funds flow model which rewarded education and research from the clinical operation mainly the hospital system but some also tax on the practice plan. And so this gave everyone depending on what their particular mission was the opportunity to be successful in terms of financial reward if the institution did well. And of course we centralize the academic development fund that's recruiting money and we made a partnership between the practice plan the hospital and school management to fund this which is now somewhere around 40 odd million dollars a year and then we had these advisory committees which gave the funds after the chairs or institute directors would nominate candidates for funding. And then we integrated the annual budget between we would meet between the practice plan head hospital and school and do all the budgets for the departments together. And this is just how the funds flow works. I won't go through it in detail it's been published in academic medicine but essentially we take money and in academic medicine the money is nearly always in the hospital and we transferred it to teaching and education and clinical development in the departments but in doing it we did it with a transparent formula depending on the quality and expectations and performance of these areas in the department. And the details are not important what was important is every department chair or institute chair could see exactly how much everyone else got and when they were rewarded with this they knew why they had got either more or less funds than they might have otherwise. And this is how the academic development committee for recruiting work there is a request from chairs and then there's a pool of money then there's an advisory committee can see five department chairs and senior administrators and then they would make recommendations to me but I would never counteract the recommendations it's always worked out very well. And of course as people well know here and I think with Sharon O'Keefe's recruitment you're gonna be very comfortable with that. If you don't make money in the hospital system you have no money in an academic institution so despite all the issues about how unacademic that is delivering patient care at the highest quality of safety and efficiency and then making money in the hospital is key and you can see we had no money here we started to make some money in 03 and now we've done pretty well and a lot of that money then is transferred to the academic components of education and research and that's made all the difference over the last several years. Now this is gonna get more challenging in the future cause the country and Medicaid and Medicare is under a lot of stringency so for us the challenge is gonna be as this probably will go down how are we gonna run our institutions at the highest level of excellence with less money and that's a critical challenge that the best of us will do well and some of us will struggle with I'm talking broadly across academic medicine but those who have integrated systems like you have here with visionary leaders should rise to the top in this kind of very challenging atmosphere that gives me a lot of optimism for the future. Now let me just briefly then tell you what kind of outcomes we've had at the University of Pennsylvania with this kind of model. Now it is of course non-randomized as I said but in many ways I think as we have tried year after year to measure and assess how we're doing that we do believe that the most critical look at our model has said that it has a significant impact on what's been accomplished and I'll run through some of those metrics briefly for you. So this is run by Gail Morrison our senior vice dean for education who's Holly's equivalent and a wonderful leader there and I won't go through the details but you can see the theme that she's used in terms of our students is very similar to the philosophy that we've had for the whole institution so interdisciplinary research teams of the students, collaborative ways of working together, sharing accountability with each other, working with interdisciplinary teams including some nurses in some experiments here and coordination of care, patient-centered care. So much of the thing is different from how we used to do things and I think it's no different here but that philosophy to the brightest young students who are going to be our physicians of the future of course is a legacy that we should be very proud of. And you can see without the details going through the details that everything she has done which derives in many ways from these coordinated meetings we have has as its basis team approach, institutional vision and then how that's best for patient care and research. So right from the beginning the entry in entering medical students have two days orientation they're involved with the Wharton team right from the beginning. They stay in teams all the time so they get to know each other and collaborate together and they have some specific activities throughout their team. And you can see that even as part of the, before they go into the clinics which here in our place is right in the beginning as well they work as part of a team, they have team-based seminars, simulation is done as part of teams and so forth. And we do not give individual grades but share them as part of a team. So everyone is dependent on each other for success or failure. And of course we've put through the education faculty and the students with some of these programs that I think we can learn a lot from colleagues in other areas. We also made a decision early on which was really embedded in the University of Pennsylvania Medical School system but we accentuated and said that what we really wanna train is the leaders of academic medicine. Not to others couldn't be there but that the leadership was our goal. There are a lot of schools in this country that are beginning to train physicians in a whole variety of things for primary care or a variety of other things. And that's just not something that we are particularly good at or should focus on for a variety of reasons. So we've been very insistent on trying to train students to have the tools and the leadership capacity to change the way that healthcare and research is done in this country. So we have a whole lot of master's programs, law degrees, business degrees together with MD, a large MD PhD program. And then we've given one year certificates to students who do four years in one year and not qualified for these in terms of global health and so forth. And that's been very effective I think in terms of giving them the knowledge and tools and the social ability to work in a complex environment and contribute importantly to the country. And you can see the 160 students in our medical school class, half of them do something in addition to the MD degree. So these are the certificates I talked to you about, the one year thing, the combined degree, we have 22 PhD students per year MD PhD and 18 master. So there's 40 here and about 40 there. So about 80 of 160 do something in addition to the MD. And now outcomes which are early on have shown that many of these students go on to do all kind of interesting things in research in the government, in leadership opportunities, in intrapreneurship of business and so forth. And most rewarding, and I would say if I wanted to take one slide and point out my legacy, this is the medical school graduation questionnaire when we ask the students, indicate whether you agree or disagree with the statement, I'm satisfied and so on. And here the pen numbers, 95% of the students say they agree or strongly agree that they were satisfied with their medical education. The number around the country in these two categories is about 86 and in terms of strongly degree, we're way ahead. So that first thing in our strategic plan that we began with nine years ago, where we wanted it to be a happy and collegial and interactive place, at least seems by these outcome measures to be true. So in research quickly, we try to take research away from being focused in departments. And this required a lot of effort in terms of space allocation and financial allocation. But under Glenn Galton's leadership, we developed a variety of key things in our strategic plan. And of course, these will be involved of multiple departments, institutes and centers. And we put all the money and space into groups of people working in this way. And I think it's paid off. This is our research portfolio. These are the funds from the stimulus funds. And we've been very successful at that. And our space utilization per square foot is high. And we got a lot of money from the stimulus fund. So that's one way of looking at it financially, but perhaps again, the most exciting thing is, we started to track right back in 02, the 10 most competitive journals and a whole variety of other things like citation indexes and H values and so forth. And then we try to encourage the faculty if they did really meaningful work to try to publish in the most competitive journals, JAMA, New England Journal, CEL, JCI and so forth. And you, sorry. And you can see this has gone up. This is in six months. We hope this year it will be very significantly higher. And of course, there's just one way to judge these things. We hope in the end that these indicate a long-term real important contribution to people's health. And then in clinical work, we did the same team approach of work closely with Ralph Muller and others and we have a triumvir to have a physician leader and nurse leader and a project manager for quality. And these are unit-based teams on every floor of our hospital, every unit in the hospital, ICUs, medicine floor, surgical floors. We have a team in the operating room and so forth. And they are equal in terms of their role. Not one of them is dominant. In fact, sometimes it rotates. And we try to use these unit-based leadership teams to collaborate with outcomes in mind and see if they can deliver that kind of outcome. And here's some of the early successes of this. This is bloodstream infections when we put in the team. We believe that they are pretty low levels. This is a variety of things, bloodstream infections, urinary tract infections, ventilator, associated pneumonia. All of them have come down now. And we think a lot of it is this collaborative team-based approach where the responsibilities lie with a group of people, each of which is responsible in a sense for the whole unit. And this is observed over a expected mortality and one would be what you would expect. It's less than that. And then we've tried to look at whether with all this pressure over the last 10 years, how the faculty are doing in terms of their belief in loyalty and satisfaction from the institution. And again, in a variety of questionnaires done objectively, this one by the AMC as well, more than 90, well, about 90% of the faculty are very satisfied. This is at the highest level. There are a variety of, these are the number of questions that relate to this. You can see they're not really satisfied with how much we pay them. So if you have some money to spare, this would really help push this up. But on really important things, collaboration, mentoring and feedback, more than 90% said they were very satisfied. Climate, culture and collegiality a lot and so forth. So we do have some work to do obviously on some. This was perhaps a little disappointing and so forth. But in general, and the clinical operation, of course, we've pressed them very hard. So that's really understandable. On the other hand, I see many opportunities here for Penn Medicine to improve and be great with less money but great collaboration and a real belief in the institution. Now this also translate, of course, into the biggest problem that academic medical centers have and that is retention of great faculty, recruitment of great students to stay on and then the recruitment of great students and faculty to join. And of course, they're not really worried in general to begin with about money and space and this, but they do very much respond to this when they visit the institution and talk to other faculty and students and house staff and so on. So I do believe there's a big upside opportunity that later translates into efficiency and excellence that is underpinned by these kind of things. So this is a little more detail that I told you, more than 90% are pleased about feedback, mentors, collaboration. Workers appreciated and so on. It's just the kind of questions that went into those numbers. So you're very lucky here in a sense because when I came to Penn, our facilities were really outdated because we had lost a lot of opportunity in the 90s. Whereas here at the University of Chicago, you have a new hospital coming on board and the most beautiful research labs and lots of new space for education and so on, which you should feel really proud and good about. I have been able together with a lot of colleagues and support from the university president and board of trustees built two important buildings which in a sense are gonna be great for the future. This is our outpatient building modeled on the de-camp here, endowed by Mr. Perlman and which has been a great success for patients and their families feeling good about coming to Penn. And physicians and house staff and students love working there. The electronic medical record is in there, radiology, it's based not on departments but on cancer care, cardiovascular care and so on. The same theme that I began with right in the beginning and although it's bumps along the way, I think overall it's quite successful. And then probably the thing I'm most proud of, we did eventually secure enough money to build a research building and so we started to look at where to do it and the only space available at Penn was like a block away and of course I was a great believer as life and I did right in the beginning of trying to put everything together so people would mix and vision and mission would be intertwined rather than separated. And so we were sitting around at this meeting, I told you about of the leadership every week and I said it's really gonna be bad to put this research building a block away because people won't walk up and down to the clinical operation or the hospital and so on. And so one of the senior administrators said, well why don't you just put it right on top of the outpatient building? And I said that was ridiculous, which it was but we did it. And here it is and this building will open in May and it's going to be beautiful. Not so much because the labs are different but here are interactive spaces where physicians and clinicians and students and researchers will have lunch and seminars and small group teaching and so forth and they only have to walk here and here even faculty will do that. So we're very excited about that and mainly because I think the promise of translational research which is one of our important missions can be done better in that kind of organization. So here's the summary of my talk. I think academic medical centers are complex entities with multiple forces and all of us deal with that but of course the upside if one can analyze it is so beautiful and as with any organization the success of AMC can be predicated upon excellence and commitment. Mainly of the people, the resources by themselves are not enough and our experience suggests that a distributive model of leadership and integrated can allow departments to thrive while emphasizing a team-based approach. So I want to thank you. It's a real delight and pleasure for me to come here and I'm just thrilled by the opportunity to be part of your game. Thank you. So we have time for a few questions Arthur. Thank you very much for a wonderful talk and overview. I think we on campus, we're not allowed to build Ireland, Rockefeller, Chapel. So we have to think about other options but you did point one out. So there are microphones. If people have questions, please reduce those and there's one David. There's just a randomization though, if I'm not wrong. Not a randomization. Arthur, it's wonderful to have you back. One of the things I was really taking your talk was the importance of team-based productivity and you mentioned counting toward people financially as both the group and the individual but one of the areas where productivity is also measured is promotion. So could you talk a little bit about the promotion process and the way your team-based measures with productivity and influence that? Yeah, it's a key point. And a lot of what I say, you have to take with a pinch of salt. I embellished it a little bit. If you talk to the faculty, they may give you a different story. So I'm just, so I would say, starting with Zuhunni's leadership at the NIH where he put out his roadmap, he made it clear and I think gets too little credit for his leadership there about how important team-based science is for the modern, for some of the big modern questions that we have to answer and I heard some of it today in the presentations at Excellent Scientist here. So we have pushed hard from the School of Medicine to try to be sure that individuals' contribution to multi-authored approaches or studies can be recognized without them being first- or last-authored or uniquely focused. Now, I wouldn't say it's that simple because these are always controversial issues, but in the promotion process, we try to define what role, particularly now we're talking about research-oriented faculty, contribute to research studies if they're not individual studies. And we've been quite successful with our Committee on Appointments and Promotions. Now, when it goes, all of our promotions go to the university for final approval. And all the deans, 12 deans sit around to discuss these issues. And I would say we still have a lot of debate with the schools of, well, let's just say other schools, about this point, because tenure in the School of Arts and Sciences or let's say the law school is very individualistically based. So it's a process of evolution and education, but I would say in general, we have lost very, very few faculty who've contributed uniquely to part of a team and made some important contributions. Of course, how we get outside letters to acknowledge that and respond to that also depends on how I write to the reviewers and point out particular things that the individual has recruited. So I would say it's a very important complex thing. We somewhere along in acknowledging it well without us being there all the way. Is there a place for a separate genius preserved at the University of Pennsylvania? And I guess you can't say no that there's no place, but I wonder is there a risk of such an individual being punished by the way this system has been organized? Yeah, it's a really important question. Are we kind of dampening down individuality by this approach? We have 1,400 faculty. My guess is the geniuses, they are doing great. You know, this approach doesn't involve every single person and creative department chairs and so on will foster their careers. And if I had a complaint, they'll tell me to bug off or something like that. So I would say I don't think it's a problem, but you know, I don't have a control thing. On the other hand, we are very, very careful about looking at who's left the institution every year. And we sit for some hours and really criticize each other if somebody good has left for not a good enough reason. And I would say there must be very few of these in the last several years that I'm really worried about. So I think it's okay. That's, but probably time will tell. Is your organization of teams really agenda-faculty-driven? I would interpret a little differently to that. I think the agenda is driven by the leadership. The faculty are busy teaching and seeing patients and research. And in a sense, it's not their job. I mean, we're there to listen to them. I think what I was trying to say is once we agree upon an agenda, then the agenda has to be promulgated, communicated and driven by the faculty leadership. But mostly the agenda is driven by the leadership, the dean, the CEO of the hospital practice plan, few key chairs and so on. On the other hand, if it's just their agenda and no one else embraces it, nothing happens. So I think that's our job and then we need to communicate, get them on board, ask for their criticism advice and then agree as a large group that this is in the institution's best interest. And then it depends, there's some very important issues and then there are a lot of unimportant issues and how one distributes that so as not to waste people's time is a work in evolution. But it's a dynamic process. But I think we do have a big responsibility to drive the institutional agenda. So Arthur, many thanks again. Wonderful lecture. Thank you.