Reflections on the Pattullo Lecture: an Ethics Perspective

Reflections on the Pattullo lecture 27

Richard Culbertson, PhD, MHA, MDiv

In his 2018 Pattullo Lecture, Dr. Gary Filerman invokes his fellow University of Minnesota student and 2016 Nobel Laureate Bob Dylan, noting that “The Times, They are a-Changin” (1964). As society and healthcare have evolved considerably from 1964, so too has Mr. Dylan’s work. After all, he precipitated a musical revolution when he famously forsook acoustic for electric instru- ments in 1965. Perhaps it is best summed up in his 1999 Oscar-winning release, “Things have Changed.” Through the lens of Mr. Dylan, let us elaborate on several of the challenges posed by Dr. Filerman in his Pattullo lecture. Just as Mr. Dylan has been able to keep his music relevant in a rapidly diversifying musical universe through his “Never Ending Tour,” so too has Dr. Filerman in his call for “climate change” in the discipline he pioneered and shaped, that of Health Administration Education.

Gotta Serve Sombody (Dylan, 1979) A starting point to consideration of “climate change” in Health Administra- tion Education is to look at the idea of vocation as developed by his esteemed Georgetown colleague Edmund Pellegrino, MD. At the root of the concept of vocation is the Latin word vocatio, a call or a summons to enter a lifelong career grounded in service. The term has obvious religious overtones dat- ing to the early Church and individuals voluntarily entering into an order.

Please address correspondence to: Richard Culbertson, PhD, MHA, M.Div, School of Public Health, Louisiana State University Health Science Center, 2020 Gravier, New Orleans, LA 70112, Phone: (504) 568-5700; Email: [email protected]

Acknowledgement: Supported in part by U54 GM104940 from the National Institute of Gen- eral Medical Sciences of the National Institutes of Health, which funds the Louisiana Clinical and Translational Science Center. The content is solely the responsibility of the author and does not necessarily represent the official view of the National Institutes of Health. 28 The Journal of Health Administration Education Winter 2019

In this construct, a person then professes allegiance to certain fundamental principles of the entity to which she or he has been called. Max Weber (1946) called attention to vocation as the basis of a life-long career in his ground breaking 1918 lectures “Politics as a Vocation” and “Science as a Vocation.” Pellegrino referred to this as “the voluntary self-imposition of higher than ordinary standards” (Rapport, 2001). In his extensive writings on the subject of education, Pellegrino advocates for greater attention to the presently unfashionable idea of virtue ethics. Pel- legrino views virtue ethics as complimentary to the principles-based approach that has dominated ethical theory of professions in recent years (Darr, 2019). Indeed, the famous Belmont Report of 1979 is based upon a principles approach in establishing ethical principles and guidelines for the protection of human subjects of research (Department of Health, Education, and Welfare, 1979) In his summary of essential virtues of the physician, Pellegrino includes: Fidelity to Trust, Benevolence, Intellectual honesty, Courage, Compassion, and Truthfulness (Pellegrino, 2002). It is his insight that these virtues are essential to the healing process as reflected in the physician-patient relationship, but are also “crucial as well to the fulfillment of the responsibilities of physicians to society, in public health and organized medicine” (Pellegrino, 2002). Moving from the profession of medicine to that of health management, one can find numerous parallels between Filerman’s call for “climate change” and a reaffirmation of professional and organizational values. These values have been eclipsed by others in a more commercialized world of healthcare. Pellegrino asserts that the virtuous physician could not “see herself as an entrepreneur, an investor, or as owner of a healthcare facility like a hospital operated for profit. She would not claim proprietary rights over her knowl- edge” (Pellegrino, 2002). His assessment brings to mind the observation at- tributed to Uwe Reinhardt that when a physician is referred to as a provider or a patient as a consumer, an angel dies. It has been suggested by Andrew Hoffman that “business schools reform their vision to promote values of business serving society in order for students to see business as a true calling rather than simply a career” (Hoffman, 2018). Although drift to a more commercial model for healthcare is looked upon as an unfortunate development, Hoffman argues that it is within business and the market that lasting solutions to societal problems will be found. In this view, it is no accident that the coalition of Amazon, Berkshire- Hathaway, and J. P. Morgan-Chase is seen as the best chance for radical restructuring of the health system rather than through legislated reform. In light of the success of Mr. Bezos in an unthinkable restructuring of the sup- Reflections on the Pattullo lecture 29 ply chain, one might suspend judgment even though past efforts at reform have failed in the main. The hiring of Atual Gawande, MD as CEO of the yet unnamed venture is another reason for guarded optimism (Abelson & Hsu, 2018). No less a transcendent intellectual leader in the world of business than Peter Drucker wrote that “the business enterprise…exists for the sake of the contribution which it makes to the welfare of society as a whole” (Drucker, 1980). In this regard, Drucker joins Filerman as critical of the view attrib- uted to Milton Friedman and Michael Jensen. In his lecture, Filerman takes direct aim at Friedman’s influence on society on accountability for enhancing shareholder wealth above all as an ethically challenged view of the role of organizations and their leaders in society.

The Disease of Conceit (Dylan, 1989) The case illustrations developed by Dr. Filerman in the Pattullo Lecture both involve a CEO of an organization who loses a job as a result of negative Board action. In both instances, the Board is seen as dismissive of exemplary recom- mendations by the administrators who place the attainment of a social good over the attainment of short- or long-term financial gain. One significant force is the evolution of governance in the United States and its role in the crisis of leadership that Filerman argues requires climate change. Drucker famously described the American hospital as a “dual headed monster” with split roles and responsibilities between management and the medical staff (Drucker, 1980). The Board was seen as the oversight mechanism responsible for assuring accountability on the part of both structures. In turn, a division of labor between the two was enforced formally in bylaws of the hospital and informally in its culture. This division was referred to as the “gauze curtain” and physicians were deliberately excluded from positions on the board of the organization (Yaggy & Hodgson, 1985). This convention was abandoned over time with the inclusion initially of the elected leader of the medical staff on the Board and later other physicians as well. For example, in the 1998 restructuring of Aurora HealthCare of Wisconsin, four of fifteen seats on the system Board were reserved for physicians (Culbertson & Martin, 2006). There have been beneficial aspects to the removal of old walls of governance in constructively expanding the professional scope of the health executive. Quality of care was historically viewed as the province of the medical staff, with quality review and improvement largely delegated to the medical staff. Freidson (1970) observed that peer review was a standard expectation of professional autonomy, as only fellow physicians were deemed competent 30 The Journal of Health Administration Education Winter 2019 to evaluate the work of another physician. Bosk (2003) noted the limitations in sustaining public trust in the peer review process when limited to professional peers. The Institute of Medicine’s report “To Err is Human” highlighted the incidence of medical errors with the famous assertion that between 44,000 and 98,000 persons died annually as a consequence of medical errors (Kohn, Corrigan & Donaldson, 2000). Quality of care committees at the Board level, once an oddity, became a standard expectation of good governance. The professional obligation and accountability of the executive to assure quality of the health outcomes of the organization as well as the expansion of Board oversight have been widely regarded as game-changing and beneficial to the improvement of quality and the establishment of a culture that analyzes and undertakes initiatives to enhance quality. It has also resulted in the dramatic expansion of professionals devoted to the quality mission (Daley et al., 2018).

Money Doesn’t Talk, It Swears (Dylan, 1965) What of the former exclusive province of the Board and management: the arena of finance? “No margin, no mission,” the maxim inspired by Peter Drucker and articulated by Sister Irene Krauss, has certainly maintained its compelling power in governance circles (Newport, 1991). It is suggested that Boards may be focused inordinately on the bottom line at the expense of other mission critical elements. It is also equally plausible that they are often led in this direction by their executive leadership. During Dr. Filerman’s illustrious career a marked change in the compensation profile of executives educated in health management has taken place. Whereas the highest reported CEO annual salary of a non-profit hospital executive in 1987 was $750,000, The Wall Street Journal‘s Andrea Fuller (2017) reported 17 non-profit hospital system CEOs who earned in excess of $5 million in 2014. This phenomenon is not by any means confined to the non-profit arena. Ellison reports in Becker’s Hospital Review (2018) that the CEO of HCA Health- care made 312 times more than the median employee in 2017. In a related university-based area of endeavor, Division I athletics, the salary paid to three-time national championship-winning coach Woody Hayes at Ohio State seems a pittance by current standards. Hayes’ salary was indexed to that of a full professor of English by his choice, and topped out at $43,000 in 1978 (Lombardo, 2005). By contrast, Urban Meyer, his Ohio State succes- sor several times removed, earned $7.6 in 2018 for his comparable success (Berkowitz, et al., 2018). Reflections on the Pattullo lecture 31

It is argued that a failure in governance has led to the current situation of extreme compensation disparities. The Wall Street Journal carried a story entitled “If the CEO is overpaid, Blame the Compensation Committee” (Pozen & Kothari, 2017) in which the authors argue that compensation committees rely on faulty performance metrics. These metrics, such as choice of improper peer group for comparative purposes, result in excessive compensation packages (Pozen & Kothari, 2017b). Pay packages do provide a convenient basis to accord role model status to executives who are then recognized as role models for students of health management. The glorification of the “C-Suite” and its occupants seem to furnish an externally verifiable measure of contribution to the profession that eludes measurement in the classic approach of virtue ethics as advocated by Pellegrino. Without the means of comparison on non-financial metrics, it is difficult to envision the “climate change” in restoring professional virtues that Dr. Filerman recommends occurring in real time.

I Accept Chaos, I’m Not Sure Whether It Accepts Me (Dylan, 2008) Charles Bosk (2003) describes the learning and development of a surgical resident as above all a “moral education.” This is initially surprising, as we think of surgery as a discipline demanding great precision and technical skill. It is Bosk’s insight that moral or normative errors are more likely to lead to the dismissal of a surgeon or surgical resident from the collegium of surgeons than are technical mistakes (provided they are addressed and not repeated). As Gawande (2002) observes, even the most adroit surgeon will nick the bile duct during performance of a cholecystectomy once in every 200 cases on average. Medical schools have moved in the direction of recognizing the impor- tance of more than biological or physical science-based preparation for the practice of medicine. This shift is demonstrated by the 2015 revision of the MCAT examination to assess an applicant’s proficiency in the social sciences and humanities (Association of American Medical Colleges, 2018). The challenge of restoring the sense of a moral as well as technical education is presented by Dr. Filerman as not simply an ideal, but rather a necessity based upon the changing environment of healthcare. He foresees retrenchment from the current golden age of healthcare prosperity that has led to exemplary financial results for those organizations and their leaders that have survived industry consolidation. This will be a difficult shrinking if it comes to pass, and not merely for C-Suite occupants as healthcare is now a major source of middle-class jobs in the United States. As an illustration, the American Association of Profes- sional Coders (2019) reports over 180,000 persons employed in medical coding 32 The Journal of Health Administration Education Winter 2019 nationally. The average salary earned by these individuals is $52,411 per year across a broad range of healthcare organizations. This occupational group was unrecognized prior to 1990 and has emerged as a significant group that even provides students for graduate study in health administration. Nonaka and Takeuchi (2011) have advanced the idea of practical wisdom as a desired attribute of contemporary leaders. This notion parallels Filerman’s call for the development of a standard of leadership that emulates role models and the positive influence they provide to faculty and student learners. They assert that “business now demands a different kind of leader – one who will make decisions knowing that the outcomes must be good for society as well as the company. Leaders must keep a higher purpose in mind” and the CEO must be, among other things, “a teacher with good values and strong principles from whom others want to learn” (Nonaka & Takeuchi 2011). Returning to the departure point of this essay in citing vocation as the fundamental building block of a profession, Toyota Motors CEO Eiji Toyoda stated, “To do what you believe is right. To do what you believe is good. Doing the right things, when required, is a calling from on high” (Nonaka & Takeuchi, 2011). It is the obligation to reinvigorate this balance that is the test for faculty of health administration faculty now and in the future.

Coda: Forever Young (Dylan, 1973) Gary Filerman has sustained his status of moral leadership and critique over five decades. In so doing, he has remained vibrant and insightful even as the healthcare arena he helped to shape has undergone dramatic change. A thought from old Bob sums up this author’s wish for Dr. Filerman on the occasion of his Pattullo lecture and the spirit invoked by his remarks:

May your hands always be busy, May your feet always be swift, May you have a strong foundation When the winds of change shift May you stay forever young

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