The Evolution of the Medical School Deanship: From Patriarch to CEO to System Dean

Abstract

Medical school deanship in the US has evolved during the past 200 years as the complexity of the US health care system has evolved. With the introduction of Medicare and Medicaid and the growth of the National Institutes of Health, the 19th-century and first half of the 20th-century role of the medical school dean as guild master transformed into that of resource allocator as faculty practice plans grew in scope and grew as an important source of medical school and university revenue. By 2000, the role of the medical school dean had transformed into that of CEO, with the dean having control over school mission and strategy, faculty practice plans, education, research dollars, and philanthropy. An alternative path to the Dean/CEO model has developed-the System Dean, who functions as a team player within a broader health system that determines the mission for the medical school and the related clinical enterprise. In this paper, the authors discuss the evolution of the medical school dean with respect to scope of authority and role within the health care system.

What a medical school chair wants from the dean

“…Medical schools had far fewer students, faculty did little research, and any affiliated hospitals were small in size. 2 Deans did not function as organizational managers, but rather as visible and visionary leaders and quintessential academicians. 3 Such deans ruled authoritatively and anecdotally, since they personally embodied the academic medicine enterprise.…”

“… 3 , 6 This also prompted the integration of medical schools within larger universities and health science centers. 2 , 3 Second, the development of faculty practice plans as an engine for financial margins for medical school expansion created a new role for the dean as an chief executive officer (CEO) of a health care system. 7 , 8 This pressure has continuously expanded to this day, such that financial success often overshadows other outcomes as a metric of success for deans.…”

“… 9 , 12 These three major national changes – the creation and expansion of the NIH, the assembling of the Centers for Medicare & Medicaid Services, and the related expansion of faculty clinical practice plans, markedly altered the requirements for effective leadership by medical school deans. 2 , 13 – 16 …”

“… 7 , 15 – 20 As clinical revenue becomes even more important in sustaining the research and educational missions, medical school deans have turned toward enhancing this vertical integration of faculty care giver with hospital and health insurance plans as a mechanism to promote efficiencies and to increase revenue for the medical school. 2 , 15 , 16 , 19 In this new era, deans currently need to merge skills in human resources, financial management, and federal and state regulations with more traditional expertise in education, research, and clinical care. 2 , 3 , 9 , 14 , 21 , 22 The current dean may play such varied roles as leading the affiliated hospital, managing the practice plan, negotiating with insurers, leading accreditation self-studies, or managing NIH center grant renewals.…”

“… 2 , 15 , 16 , 19 In this new era, deans currently need to merge skills in human resources, financial management, and federal and state regulations with more traditional expertise in education, research, and clinical care. 2 , 3 , 9 , 14 , 21 , 22 The current dean may play such varied roles as leading the affiliated hospital, managing the practice plan, negotiating with insurers, leading accreditation self-studies, or managing NIH center grant renewals. 10 , 14 , 21 Since these diverse tasks often require expertise beyond one person, this means the dean has had to delegate specific authority to associate deans and chairs with defined expertise within the required specialties.…”