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Point–Counterpoint: The Traditional Departmental Model Is the Right Structure for Academic Health Centers in the 21st Century

Kastor, John A. MD

doi: 10.1097/ACM.0b013e31824d5932

Dr. Kastor is professor of medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; e-mail:

Editor’s Note: This essay presents arguments for the purpose of revealing key issues about a topic, and does not necessarily represent the views of the author. Commentaries by M. Karpf and R. Lofgren, and J. Young and D. Cosgrove, appear on pages 555-556 and 552-554.

The Cleveland Clinic’s institute system for structuring departments and divisions may offer advantages,1 but applying the model at other academic health centers (AHCs) will be challenging. In this essay, I discuss characteristics inherent in the Cleveland Clinic system that illustrate why the model is difficult to apply elsewhere.

Cleveland Clinic CEO Delos (“Toby”) Cosgrove,2 who was instrumental in developing and applying the institute system, reported hearing from CEOs at other AHCs that they liked what they heard about the system but doubted they could apply it at their institutions. What makes the Cleveland Clinic different from other AHCs in this regard? Establishing an institute system requires a leader, the dean at most AHCs, who can convince chairs to accept an organizational overhaul. If many resisted, the dean would have to consider imposing the change. How many deans have such authority and would be willing to risk their jobs by imposing unpopular changes to establish an institute system? The CEO at the Cleveland Clinic, however, has greater authority than most deans have. Although Cosgrove had to convince skeptical colleagues to accept the change, they knew that he had the power, supported by his board of directors, to force the conversion to the institute system if necessary.

The group practice is the hub of the Cleveland Clinic and has been since the organization’s founding in 1921. Physicians and surgeons consider themselves members of a group practice that happens to own hospitals and clinics. Despite recently building a medical school, the Cleveland Clinic remains primarily a clinical operation, albeit a superb one, where research and education take complementary roles. This unique environment helps to explain why the institute system, which is primarily an administrative structure to provide more efficient and effective care of patients, developed at the Cleveland Clinic and not at a more conventional AHC.

The institute system also changes the traditional administrative structure within the AHC. Instead of reporting to a department chair, the chief of a specialty division reports to the chair of his or her institute, who may not be a member of the division chief’s specialty. Many chairs and division chiefs will resist transferring their traditional authority over clinical operations. Division chiefs in other AHCs may not be readily willing to share power with institute chairs who are not members of the same specialty or to report to a physician or surgeon from another department. Even at the Cleveland Clinic, the change was not universally accepted, particularly at the beginning. Instead of improving administrative organization, the institute system can be seen as converting smaller silos (departments and divisions) into larger ones (institutes) while not resolving organizational and personnel problems associated with these systems.

Where to assign certain specialties can present a problem. Bariatric surgery, for example, is in the Endocrinology, Diabetes, and Metabolism Institute at the Cleveland Clinic rather than the Digestive Disease Institute, its more logical home. The reason given is that many obese patients have diabetes. Infectious Diseases, also needing a home, is in the Medicine Institute, in the absence of a more specific place for it. The Medicine Institute is unlike typical departments of medicine, a difference that contributed to the decision of the Residency Review Committee of the Accreditation Council for Graduate Medical Education to certify the medical residency at the Cleveland Clinic for a limited period of three years soon after the new structure was implemented.3

The novelty of the new system has interfered with some external recruiting, particularly into positions of leadership. This could present a serious problem at traditionally structured schools of medicine where most candidates for department chairs and division leadership are familiar with the conventional system. “I would not have come if institutes were there when I was being recruited,” said one department chair who did not wish to be identified. As with other fundamental reorganizations of AHCs, such as hospital mergers, the process of planning and implementing an institute system requires time and effort from the doctors and staff that would otherwise be directed to their usual responsibilities.4

Although several institute chairs and financial administrators at the Cleveland Clinic are confident that the system will save money, supporting data are limited so far, thereby removing, at least for now, an important reason for switching from the traditional model to the institute system.

Despite its virtues, application of the institute system to most AHCs will range from difficult to impossible.

Acknowledgments: The author thanks the Cleveland Clinic physicians and administrators whom he interviewed.

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1. Kastor JA. The Cleveland Clinic institute system is the right structure for academic health centers in the 21st century. Acad Med. 2012;87:558
2. Cosgrove DM. President, CEO, and Rich Family Chief Executive Chair, Cleveland Clinic. Personal communication with J.A. Kastor. November 22, 2010
3. Young JB. Professor of medicine and executive dean, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and George and Linda Kaufman Chair, Cleveland Clinic. Personal communication with J.A. Kastor. September 30, 2011
4. Kastor JA Mergers of Teaching Hospitals in Boston, New York and Northern California. Ann Arbor, Mich
© 2012 Association of American Medical Colleges