Geisel School Of Medicine at Dartmouth Board of Advisors Winter Meeting
February 7, 2020 DUANE A. COMPTON, Ph.D. Dean Professor of Biochemistry and Cell Biology
January 30, 2020
Dear Geisel Board of Advisors,
Happy New Year! I am looking forward to the conference call next week.
Our agenda has two main items for discussion. One is to discuss our ongoing planning efforts for reaccreditation by the LCME (Liaison Committee on Medical Education for the AAMC). The school has a standing committee that is charged with ensuring continuous attention to all of the LCME accreditation standards. However, our current accreditation is due for renewal and that process requires extensive self- study documentation followed by in-depth external assessment and review. The self-study document is due in January 2021 with the site visit scheduled for April 2021. Thus, a major focus of our efforts during the next year will be the data collection and writing of the self-study document.
Second, we will review the financial performance in the current fiscal year and discuss the recently submitted budget for the next fiscal year. Overall, our financial performance continues to track very closely to our long- range projections for the school, although there are several specific activities that have substantial impact on our budget that are important for us to discuss.
I look forward to our discussion next week.
Sincerely,
Duane A. Compton
ONE ROPE FERRY ROAD • HANOVER, NEW HAMPSHIRE 03755-1404 • TELEPHONE: (603) 650-1200 • FAX: (603) 650-1202
1 GEISEL SCHOOL OF MEDICINE FY20 PROJECTED OPERATION RESULTS
MANAGEMENT DISCUSSION & ANALYSIS (Updated January 2020)
I. EXECUTIVE SUMMARY
Having completed two full quarters of the fiscal year, management of the Geisel School of Medicine is projecting a fiscal year end operating deficit of ($7.3M), against a budgeted operating loss for the period of ($10.2M), an improvement of $2.8M or 28%. The improvement in overall operating performance against budget is focused primarily within the research enterprise and is driven by two revenue events:
(1) The anticipated receipt of a gift to support the Serious Health Illness Incubator, a joint program between the school and Dartmouth-Hitchcock (D-H) that will support interdisciplinary team projects formed to address improving the care of serious illnesses, over the next three fiscal years at $1M per year, and
(2) The one-time conversion of a sponsored project from the Moore Foundation into a gift of $1.7M.
Additionally, vacancy savings are anticipated across both faculty and staff lines as the school has been actively managing and prioritizing the filling of vacant positions across all missions of the school, amounting to $0.8M. Programmatic highlights are discussed below.
II. UNDERGRADUATE MEDICAL EDUCATION
The program in Undergraduate Medical Education (UME) is currently projected to perform slightly below budget by $0.3M, or 2% for the fiscal year. A reduction in tuition revenue due a higher than budgeted number of student splits and research years ($0.5M) is the main driver of this change. Total UME expenses of $18.1M are down slightly ($0.1M) compared to budget.
III. GRADUATE AND OTHER PROFESSIONAL EDUCATION
All Geisel-based PhD programs met enrollment targets in FY20. Combined enrollment for the master’s level (MPH) programs at TDI is up compared to budget (Residential: 65 actual vs. 66 budget; Online: 76 actual vs. 68 budget), which resulted in an anticipated surplus in tuition revenues of $0.3M, or 4%. Personnel expense is expected to be down compared to budget by $0.5M largely due to a reduction in administrative support for the MPH program as part of the TDI FY19 reorganization activities.
Enrollment for the master’s in health data science degree in the Quantitative Biomedical Sciences (QBS) program was down significantly compared budget (30 budgeted vs. 13 enrolled) with a resulting reduction in tuition revenue of ($0.7M). Work is currently underway to execute on strategies to bolster enrollment for this program in the upcoming fiscal year, including working with a third-party firm to enhance digital marketing towards potential applicants.
IV. RESEARCH PROGRAMS
Research-related activities are anticipated to perform better than budgeted by $2.9M, or 19%. The improvement in overall operating performance is based on the two previously mentioned revenue events:
2 (1) The anticipated receipt of a gift to support the Serious Health Illness Incubator, a joint program between the school and D-H that will support interdisciplinary team projects formed to address improving the care of serious illnesses over the next three fiscal years at $1M per year, and
(2) The one time conversion of a sponsored project from the Moore Foundation into a gift of $1.7M.
Additionally, at the time the FY20 budget was established, it was contemplated that the Office of Clinical Research (OCR) would transition from the Norris Cotton Cancer Center (NCCC) to D-H prior to the start of the fiscal year. Due to the timing of the renewal of the NCCC core grant, submitted in January 2019, it was decided to defer this transition to October 2019, resulting in offsetting revenue of $0.5M from D-H and expense of ($0.5M) for this jointly-supported program. Finally, the faculty recruitment plan contemplated in the FY20 budget has slowed due to the pace of active searches to fill faculty line positions, resulting in an anticipated savings of approximately ~$1.3M.
V. ADVANCEMENT ACTIVITIES
The Joint Development Office, which provides philanthropic support services for Geisel and D-H based programs, is expected to have a slower than budgeted rate of spend on operating expenses during the period as they continue to ramp-up operations under their recently formed leadership team and in alignment with budget expectations. Across Geisel, current-use gift revenues are once again anticipated to exceed expectations in FY20 by $2.7M.
VI. OTHER ACTIVITIES
There are two activities that currently reside in this mission: the High Value Healthcare Collaborative (HVHC) and ongoing work related to joint research activities with clinical departments at D-H. In both cases these activities should breakeven on the school’s operating statement, with HVHC membership funds drawn down from the balance sheet to offset expenses incurred by HVHC and payment from D-H for expenses incurred on the school’s ledger in the period. The projected improvement compared to budget of $0.2M is due to clinical department activity that did not have an offsetting payment in the budget, which has been resolved in the revised projection.
VII. PLANT OVERHEAD AND ADMINISTRATION
Plant Overhead revenue is projected to be down slightly compared to budget by ($0.2M) due to the elimination of an internal rent charge to TDI as part of the reorganization of that program in FY19. Similarly, debt service is also projected to increase due to an internal accounting change where the debt service TDI had been directly charged (previously captured in the admin cost pools) is now recorded in plant operations at ($0.3M). Additional savings are anticipated as the school continues to exit leased space and occupy school owned space, freeing up $0.2M. Administrative cost pools are anticipated to perform better than budget due to the previously mentioned changes in internal accounting and the realized savings in personnel expense of $0.5M, both of which are associated with the TDI reorganization in FY19.
VIII. LOOKING FORWARD TO FY21
Management of the Geisel School of Medicine recently submitted its FY21 budget for approval by the College Trustees projecting a fiscal year operating result of ($6.0M). Compared to the current FY20 projection, this would be an improvement of $1.3M or 18%. This improvement is largely driven by the anticipated receipt of $4M from the Geisel bequest distribution in FY21. These proceeds will be largely offset by an expected decline in sponsored research activity across the school in FY21 that was associated with the non-renewal/replacement of several large multi-year
3 research projects ending in the current (FY20) fiscal year. Where we expect to see some erosion in the funded portfolios for some departments (TDI – AHRQ, CDC & Microsystems Academy; Microbiology & Immunology – COBRE & Superfund), we are also anticipating significant growth in other units, including two of our newer departments (Biomedical Data Science, $1.5M – new COBRE, and Epidemiology, $2.1M – ECHO program) compared to FY20 projection. Overall, the FY21 operating budget, absent the Geisel bequest distribution of $4M, aligns with prior year long range projections. It also includes $5M in new program development support for continued faculty recruitments (10 planned) and increased investment in our core education programs (Medical Education, MPH and graduate education).
4 Geisel School of Medicine Board of Advisors February 2020
Strategic Update
Geisel School of Medicine 2020
Medical Education Research Dartmouth-Hitchcock • LCME reaccreditation Partnership update • Tenure-track Faculty • COBRE grant submitted recruitment process Center of Neurocircuitry • LCME reaccreditation & Neuromodulation strategic plan • Joint Development • Launch of enhanced Office updates mental health services Healthy Students – Healthy Physicians
• Leadership recruitment
• Department of Medical Education faculty recruitment
6 LCME Reaccreditation Planning Dashboard
7 LCME Reaccreditation Planning Dashboard
Subcommittees • Leads should be completing drafts of their portions of the DCI • Can expect ISA table data by February 10 • Now until March 1: Complete first pass responses to DCI sections • March 1 – June 1: Meet with subcommittee stakeholders, refine, & polish sections • June: Administrative review of DCI; Consultant formal review of responses • July 1 First Draft of DCI complete
8 LCME Reaccreditation Planning Student Survey Data
• ISA Team has gathered the necessary 70-80% response rate per class • Putting data in LCME required format and starting analysis • Will send data tables by February 10
9 LCME Reaccreditation Planning Consultants Assessment Phase DCI Preparation and Submission Survey Visit • Review and provide observations on • Advise about the resolution of • Mock Survey Visit (4-6 weeks relevant institutional information risks and draft materials as prior to Survey visit) (e.g. bylaws, committee charters, requested • Assist in managing Green room policies, procedures, handbooks, • Advise writing teams regarding (prep-room) for LCME survey meeting minutes) best practices in completing the visit • Provide advice on initiating the DCI and providing other support • Assist in managing De-briefs DCI, Self-Study materials during Survey Visit • Provide initial feedback on the ISA • Comment on DCI draft • Assist in preparing • Facilitate development of a Gap • Comment on draft Self-Study faculty/staff/students for Survey Analysis of needs related to the Executive Summary visit and interviews LCME review and associated workplan using an advisory process
• Contract Manager assigned last week (meeting today) • Consultants are scheduled to visit and meet with everyone February 10th. • Intent for this visit: Get to know Geisel leaders working on DCI; discuss specific challenges; • Output for visit: Action plans to address issues.
10 LCME Reaccreditation Planning
Standards 1. Mission, Planning, Organization, and Integrity 2. Leadership and Administration 3. Academic and Learning Environments 4. Faculty Preparation, Productivity, Participation, and Policies 5. Educational Resources and Infrastructure 6. Competencies, Curricular Objectives, and Curricular Design 7. Curricular Content 8. Curricular Management, Evaluation, and Enhancement 9. Teaching, Supervision, Assessment, and Student and Patient Safety 10. Medical Student Selection, Assignment, and Progress 11. Medical Student Academic Support, Career Advising, and Educational Records 12. Medical Student Health Services, Personal Counseling, and Financial Aid Services
1.1 Strategic Planning and Continuous Quality Improvement A medical school engages in ongoing strategic planning and continuous quality improvement processes that establish its short and long-term programmatic goals, result in the achievement of measurable outcomes that are used to improve educational program quality, and ensure effective monitoring of the medical education program’s compliance with accreditation standards.
11 Enhanced Student Mental Health Support
Healthy Students, Healthy Physicians
Current State Pilot Phase (AY 2019 - 2021) Full Program (AY 2021 - )
SCREENING No standardized screening Standardized screening (ISP) Standardized screening (ISP)
Dick’s House – 9.8 FTE counselors, 1.2 FTE Contracted community provider: 0.5 FTE Geisel/Dick’s House: 1.0 FTE counselor for 425 MD STAFFING psychiatrists for 6,500 students counselors for 425 MD and MD/PhD students and MD/PhD students 0.2 FTE psychiatrist: assessment and medica on 0.2 FTE psychiatrist: assessment and medica on management, only with full funding management Neuropsychiatric assessment & tes ng
Face-to-face only Modali es: Face-to-face, video, phone, text; Modali es: Face-to-face, video, phone, text; ACCESS individual, small group individual, small group In-take process: 3 steps to counselor (days to In-take process: 1 step to counselor (contact made In-take process: 1 step to counselor (contact made weeks) within 24 hours) withn 24 hours) Single physical site Two physical sites Two physical sites Limited hours and scheduling, anchored to the Full calendar year and customized hours Full calendar year and customized hours undergrad academic calendar Limited con nuity (mostly short-term care) Con nuity through four years Con nuity through four years Students n referred to community providers, No cost to students No cost to students with more scheduling challenges and co-pays
Mental Health First Aid training for students, sta Mental Health First Aid training for students, sta STANDARDIZED TRAINING and faculty and faculty
WELLNESS & RESILIENCY Mindfulness and medita on Cogni ve Behavioral Therapy for medical students Imposter Syndrome awareness Visi ng lecturers/workshop leaders (i.e. Brene Brown on empathy, vulnerability, and shame)
DATA AND MEASUREMENT AAMC annual surveys; ad hoc surveys by Geisel AAMC annual surveys; standardized Geisel surveys AAMC annual surveys; standardized Geisel surveys Swigart Ethics Fellowship project focused on Full implementa on of Swigart project process, outcomes, and qualita ve analysis recommenda ons and na onal benchmarking
September 2019 12 Active Leadership Recruitments
• Director, Dartmouth Institute for Health Policy & Clinical Practice
• D-H Chief Research Officer and Geisel Associate Dean for Clinical Research
• Associate Dean, Diversity & Inclusion
• Senior Associate Dean for Medical Education
• Associate Dean, Student Affairs
• Associate Dean, Evaluation & Assessment
13 Tenure-track Faculty Recruitment Update
Currently open searches • Biochemistry & Cell Biology – COBRE junior • Biochemistry & Cell Biology – Cancer Biology and Therapy (joint with NCCC) • Molecular & Systems Biology – Junior faculty position • Biomedical Data Science – Bioinformatics and Computational Oncology • Microbiology & Immunology – Junior faculty position • TDI – Population Sciences (joint with NCCC) • Medical Education – Neuroscience • Medical Education – Physiology • Medical Education – Pharmacology
14 Development Update
Notable New Gifts and Commitments to Geisel: MD Scholarship Peter Millett MED ’95 MD Scholarship Doug Williamson D ’85 MED ’93 MD/MBA Scholarship Peter Linden and Faith Golding Healthcare Delivery Incubator Dick Levy Center Global Health Equity Anonymous Others to be announced soon….. 15 Important Dates
March 20 Match Day
May 7-8 Geisel Board of Advisors meeting (Hanover, NH)
June 6 Geisel MD Class Day/Commencement ceremony
June 13 Geisel/TDI MPH Class Day
June 14 Dartmouth Commencement
January 2021 LCME Survey Package submission
April 25-28, 2021 LCME Site Visit
16 Geisel School of Medicine
Board of Advisors – Finance Update February 7, 2020
Geisel Comparative Financial Schedule
($ In Millions) FY20 Budget vs. FY21 Budget vs. FY18 FY19 FY20 FY20 FY21 FY20 Projection FY20 Projection REVENUE: Actual Actual Budget Projection Budget Fav/(Unfav) Fav/(Unfav) Tuition, All Fees, Room and Board $ 42.4 $ 46.9 $ 49.0 $ 47.9 $ 50.2 $ (1.1) (2.4%) $ 2.3 4.8% Gifts 3.5 7.8 4.4 7.1 10.5 2.7 37.8% 3.4 48.0% Endowment Distribution 26.0 27.2 29.0 29.2 30.6 0.1 0.5% 1.4 5.0% Other Investment Income 0.1 0.0 0.1 0.1 0.0 - - (0.0) (41.6%) Research Revenue 115.7 99.0 93.3 92.1 86.3 (1.2) (1.3%) (5.8) (6.3%) Medical Services and Support Revenue 11.7 13.4 11.0 11.2 12.6 0.2 2.2% 1.4 12.2% All Other Revenue 6.4 11.9 6.4 6.3 6.2 (0.1) (2.0%) (0.1) (1.2%) Total Revenue $ 205.8 - $ 206.3 - $ 193.2 - $ 193.8 $ 196.5 $ (0.6) (0.3%) $ 2.6 1.4% Faculty/Instructional Salaries 15.0$ 15.3$ 15.1$ 14.4$ 16.5$ 0.7$ 4.9% $ (2.1) (14.6%) Staff and Student Salaries 26.1 24.8 23.6 24.1 26.0 (0.5) (1.9%) (1.9) (7.7%) Fringe Benefit Expense 13.1 13.5 13.1 12.7 14.7 0.4 3.2% (2.0) (15.4%) Sponsored Compensation & Fringes 37.7 37.9 39.8 38.2 35.1 1.6 4.1% 3.2 8.3% Total Compensation Expense 92.0$ 91.5$ 91.6$ 89.4$ 92.1$ 2.2$ 2.5% $ (2.8) (3.1%) Financial Aid - Graduate 21.6$ 22.6$ 23.3$ 23.1$ 24.4$ 0.1$ 0.5% $ (1.3) (5.6%) Operations and Maintenance 13.1 14.4 14.9 14.8 14.0 0.1 0.7% 0.8 5.3% Debt Service 8.0 8.3 8.3 8.3 8.3 (0.0) (0.1%) (0.0) (0.0%) Professional Fees and Purchased Services 14.3 14.2 12.0 12.3 12.9 (0.4) (3.0%) (0.6) (4.7%) Net Internal Expense 10.2 11.2 10.4 10.0 11.6 0.3 3.4% (1.5) (15.3%) All Other Expense 11.4 13.5 16.0 16.1 14.5 (0.2) (1.1%) 1.6 10.2% Sponsored Non-Compensation Expense 48.1 33.9 27.0 27.0 24.6 (0.0) (0.0%) 2.4 9.1% Total Non-Compensation Expense 126.7$ 118.0$ 111.8$ 111.8$ 110.3$ $ (0.0) (0.0%) 1.5$ 1.3% Total Expense 218.6$ 209.5$ 203.4$ 201.2$ 202.5$ 2.2$ 1.1% $ (1.3) (0.6%) Operating Surplus/(Deficit) BEFORE HVHC $ (12.8) $ (3.2) $ (10.2) $ (7.3) $ (6.0) 2.9$ 38.9% 1.3$ 18.0% HVHC Internal Adjustment (4.1) - - - -
Operating Surplus/(Deficit) AFTER HVHC $ (16.9) $ (3.2) $ (10.2) $ (7.3) $ (6.0) 2.9$ 38.9% 1.3$ 18.0%
18 FY20 Budget Core Mission View
Graduate Masters Professional Other Inst. Advance- Plant Admin Cost MD Program Programs Programs Education Research Activity ment Other Overhead Pools Grand Total
Tuition and Fees $ 24,938,239 $ 14,947,516 $ 9,144,295 $ - $ - $ - $ - $ - $ - $ - $ 49,030,050
Gift & Endowment Revenue 5,681,504 187,096 59,692 500,000 3,784,949 42,689 12,661,041 3,983,469 1,266,101 5,282,540 33,449,080
Sponsored Research Revenue 181,275 - - - 91,044,254 - - - - - 91,225,528
Clinic and Hospital Revenue 150,692 - - - 2,529,134 296,834 4,000,377 1,631,544 750,000 1,600,254 10,958,835
Other Internal Revenue 33,922 140,000 414,500 - 5,600,511 - - - 3,037,660 2,197,181 11,423,774
Other Operating Revenue 41,085 - - 262,000 2,059,989 28,000 77,000 3,302,491 496,862 192,375 6,459,802 Total Revenues $ 31,026,717 $ 15,274,612 $ 9,618,487 $ 762,000 $ 105,018,837 $ 367,523 $ 16,738,418 $ 8,917,504 $ 5,550,623 $ 9,272,350 $ 202,547,070
Faculty Salaries $ 2,094,984 $ 164,218 $ 995,271 $ 19,298 $ 19,677,532 $ - $ - $ 1,013,345 $ - $ 4,448,631 $ 28,413,279
Staff/Student Salaries 2,804,063 151,131 1,578,169 143,568 20,013,156 991,494 3,961,266 1,659,863 597,976 7,703,665 39,604,351
Fringe Benefits 1,542,687 110,372 864,533 57,003 12,580,017 336,768 1,386,324 866,939 209,292 4,189,076 22,143,010 Subtotal: Personnel Expenses $ 6,441,734 $ 425,721 $ 3,437,974 $ 219,869 $ 52,270,704 $ 1,328,261 $ 5,347,590 $ 3,540,147 $ 807,268 $ 16,341,372 $ 90,160,641
Scholarship and Stipends $ 5,117,301 $ 15,445,074 $ 1,418,396 $ 30,000 $ 2,942,770 $ - $ - $ 343,496 $ - $ 12,002 $ 25,309,039
Occupancy and Maintenance 369,660 - - - 1,717,285 - 437,000 - 12,614,428 - 15,138,373
Debt Service ------7,919,835 350,668 8,270,503
Professional Fees and Purchased Services 5,298,251 121,980 959,840 40,000 16,323,232 41,750 1,253,350 1,219,496 712,460 721,168 26,691,527
Internal Expense 187,632 157,062 414,556 30,000 3,708,620 21,604 124,775 636,878 6,198,192 12,962,709 24,442,028
All Other Expense 813,436 189,004 303,900 22,400 12,607,645 1,806,418 765,875 3,341,936 130,264 2,744,335 22,725,213 Subtotal: Non-Personnel Expense $ 11,786,280 $ 15,913,120 $ 3,096,692 $ 122,400 $ 37,299,552 $ 1,869,772 $ 2,581,000 $ 5,541,806 $ 27,575,179 $ 16,790,882 $ 122,576,682
Total Expenses $ 18,228,014 $ 16,338,842 $ 6,534,666 $ 342,269 $ 89,570,256 $ 3,198,033 $ 7,928,590 $ 9,081,953 $ 28,382,446 $ 33,132,254 $ 212,737,323
Contribution Margin $ 12,798,703 $ (1,064,230) $ 3,083,821 $ 419,731 $ 15,448,581 $ (2,830,511) $ 8,809,828 $ (164,449) $ (22,831,823) $ (23,859,904) $ (10,190,253)
19 FY20 Projection Core Mission View (Updated January 2020)
Graduate Masters Professional Other Inst. Advance- Plant Admin Cost MD Program Programs Programs Education Research Activity ment Other Overhead Pools Grand Total
Tuition and Fees $ 24,399,779 $ 14,724,968 $ 8,758,953 $ - $ - $ - $ - $ - $ - $ - $ 47,883,700 Gift & Endowment Revenue 5,888,558 250,172 59,702 500,000 6,259,613 42,696 12,646,424 3,982,619 1,273,508 5,376,509 36,279,801 Sponsored Research Revenue 318,920 - - - 91,796,929 - - 27,300 - - 92,143,149 Clinic and Hospital Revenue - 325 - - 3,384,667 297,321 3,556,997 1,612,395 750,000 1,600,254 11,201,958 Other Internal Revenue 11,290 761,729 414,500 - 6,002,727 170,000 - 2,763 2,847,199 640,519 10,850,727 Other Operating Revenue 41,085 - - 262,000 2,663,023 16,550 77,000 2,620,539 462,820 192,665 6,335,682 Total Revenues $ 30,659,632 $ 15,737,194 $ 9,233,155 $ 762,000 $ 110,106,959 $ 526,567 $ 16,280,421 $ 8,245,615 $ 5,333,527 $ 7,809,947 $ 204,695,016
Faculty Salaries $ 1,995,743 $ 109,577 $ 1,007,273 $ 40,256 $ 19,163,790 $ - $ - $ 984,717 $ - $ 4,333,934 $ 27,635,289 Staff/Student Salaries 2,605,674 168,136 1,168,679 131,321 21,608,358 815,424 3,932,064 1,277,759 561,896 7,860,738 40,130,050 Fringe Benefits 1,435,193 97,199 686,607 57,496 12,748,793 277,252 1,293,033 761,971 194,842 4,064,616 21,617,003 Subtotal: Personnel Expenses $ 6,036,610 $ 374,912 $ 2,862,559 $ 229,073 $ 53,520,941 $ 1,092,676 $ 5,225,097 $ 3,024,446 $ 756,739 $ 16,259,289 $ 89,382,341
Scholarship and Stipends $ 4,993,304 $ 15,295,633 $ 1,424,512 $ 30,000 $ 3,204,519 $ - $ - $ 155,884 $ - $ 21,186 $ 25,125,038 Occupancy and Maintenance 369,660 - - - 1,758,524 - 461,837 204,849 12,421,867 - 15,216,736 Debt Service ------8,274,677 - 8,274,677 Professional Fees and Purchased Services 5,324,510 109,834 1,067,068 72,850 16,992,862 108,665 1,253,350 1,451,507 542,453 929,725 27,852,823 Internal Expense 558,098 818,238 515,952 56,587 4,769,026 20,939 124,775 415,272 6,375,680 10,660,872 24,315,439 All Other Expense 839,373 227,658 219,781 31,272 11,497,214 1,820,643 765,875 2,993,657 174,780 3,286,895 21,857,149 Subtotal: Non-Personnel Expense $ 12,084,944 $ 16,451,363 $ 3,227,313 $ 190,709 $ 38,222,145 $ 1,950,247 $ 2,605,837 $ 5,221,169 $ 27,789,457 $ 14,898,678 $ 122,641,862
Total Expenses $ 18,121,554 $ 16,826,274 $ 6,089,873 $ 419,782 $ 91,743,085 $ 3,042,923 $ 7,830,934 $ 8,245,615 $ 28,546,196 $ 31,157,966 $ 212,024,203
Contribution Margin $ 12,538,078 $ (1,089,080) $ 3,143,282 $ 342,218 $ 18,363,873 $ (2,516,356) $ 8,449,487 $ 0 $ (23,212,668) $ (23,348,020) $ (7,329,186)
Total Margin Percentage 41% -7% 34% 45% 17% -478% 52% 0% -435% -299% -4%
Budgeted Surplus/(Deficit) - FY19 $ 12,798,703 $ (1,064,230) $ 3,083,821 $ 419,731 $ 15,448,581 $ (2,830,511) $ 8,809,828 $ (164,449) $ (22,831,823) $ (23,859,904) $ (10,190,253) Variance: Projection to Budget $ (260,625) $ (24,851) $ 59,461 $ (77,513) $ 2,915,292 $ 314,154 $ (360,341) $ 164,449 $ (380,845) $ 511,884 $ 2,861,067 -2% -2% 2% -18% 19% 11% -4% 100% -2% 2% 28%
20 FY21 Budget Core Mission View (Submitted January 2020 for Trustee Approval)
Graduate Masters Professional Other Inst. Advance- Plant Admin Cost MD Program Programs Programs Education Research Activity ment Other Overhead Pools Grand Total
Tuition and Fees $ 25,421,165 $ 15,319,941 $ 9,461,073 $ - $ - $ - $ - $ - $ - $ - $ 50,202,179 Gift & Endowment Revenue 6,143,850 194,639 62,098 500,000 4,685,043 44,410 18,340,096 4,137,044 1,317,475 5,715,164 41,139,819 Sponsored Research Revenue 352,460 - - - 85,970,015 - - - - - 86,322,475 Clinic and Hospital Revenue - - - - 2,961,879 361,085 5,211,512 1,386,243 750,000 1,899,871 12,570,590 Other Internal Revenue 2,683 668,664 471,750 - 5,131,424 170,000 - - 2,955,059 438,809 9,838,389 Other Operating Revenue 38,804 - - 732,200 1,755,903 30,000 65,000 2,761,074 844,449 1,601 6,229,031 Total Revenues $ 31,958,962 $ 16,183,244 $ 9,994,921 $ 1,232,200 $ 100,504,264 $ 605,495 $ 23,616,607 $ 8,284,361 $ 5,866,983 $ 8,055,445 $ 206,302,483
Faculty Salaries $ 2,478,363 $ 154,324 $ 1,433,641 $ 44,797 $ 18,837,663 $ - $ - $ 879,890 $ - $ 4,699,477 $ 28,528,155 Staff/Student Salaries 2,787,960 165,658 1,198,176 101,809 20,711,692 983,253 4,933,563 1,249,990 614,293 7,826,411 40,572,803 Fringe Benefits 1,689,185 115,193 819,001 42,464 12,845,187 340,496 1,770,557 762,403 221,145 4,438,905 23,044,537 Subtotal: Personnel Expenses $ 6,955,508 $ 435,175 $ 3,450,818 $ 189,070 $ 52,394,542 $ 1,323,749 $ 6,704,120 $ 2,892,283 $ 835,438 $ 16,964,793 $ 92,145,495
Scholarship and Stipends $ 5,575,371 $ 15,709,311 $ 1,677,080 $ - $ 3,409,088 $ - $ - $ 36,000 $ - $ 71,388 $ 26,478,238 Occupancy and Maintenance 380,856 - - - 487,124 - 487,517 210,421 12,708,657 - 14,274,574 Debt Service ------8,274,684 - 8,274,684 Professional Fees and Purchased Services 4,953,498 86,840 1,142,418 385,000 15,209,653 120,900 1,325,353 2,076,310 700,710 645,306 26,645,988 Internal Expense 570,425 870,810 485,083 30,000 4,264,714 21,500 94,150 525,251 6,153,779 11,146,719 24,162,431 All Other Expense 839,205 178,906 315,117 38,000 10,989,032 2,021,574 1,350,012 2,544,096 132,517 1,927,835 20,336,294 Subtotal: Non-Personnel Expense $ 12,319,355 $ 16,845,866 $ 3,619,698 $ 453,000 $ 34,359,611 $ 2,163,974 $ 3,257,032 $ 5,392,078 $ 27,970,347 $ 13,791,248 $ 120,172,209
Total Expenses $ 19,274,863 $ 17,281,042 $ 7,070,516 $ 642,070 $ 86,754,152 $ 3,487,723 $ 9,961,151 $ 8,284,361 $ 28,805,786 $ 30,756,041 $ 212,317,704
Contribution Margin $ 12,684,099 $ (1,097,798) $ 2,924,405 $ 590,130 $ 13,750,112 $ (2,882,228) $ 13,655,456 $ 0 $ (22,938,802) $ (22,700,596) $ (6,015,221)
Total Margin Percentage 40% -7% 29% 48% 14% -476% 58% 0% -391% -282% -3%
Budgeted Surplus/(Deficit) - FY20 Projection $ 12,538,078 $ (1,089,080) $ 3,143,282 $ 342,218 $ 18,363,873 $ (2,516,356) $ 8,449,487 $ 0 $ (23,212,668) $ (23,348,020) $ (7,329,186) Variance: FY20 Projection to FY21 Budget $ 146,021 $ (8,717) $ (218,877) $ 247,913 $ (4,613,761) $ (365,871) $ 5,205,969 $ (0) $ 273,866 $ 647,424 $ 1,313,965 1% -1% -7% 72% -25% -15% 62% -53% 1% 3% 18%
21 Geisel Media Highlights: November 2019 – January 2020
New Rules for End-of-Life Planning and Palliative Care in NJ – NJ Spotlight 30Jan2020 — Cites a 2018 Dartmouth Atlas of Healthcare finding that patients nearing death in New Jersey undergo the nation’s most aggressive medical treatments, often at odds with the individual’s personal desires and high financial costs.
Coronavirus: China Has Quarantined 50 Million People. Experts Worry That Might Backfire – Los Angeles Times 28Jan2020 — Quotes Elizabeth Talbot, professor of medicine, in an article about the quarantine measures being taken in China to curb the spread of coronavirus. Chinese authorities have indefinitely barred 50 million people from traveling and advised them to stay home to contain the rapidly spreading virus. “We would almost certainly not do any quarantine on the scope that China is doing now,” Talbot said of the United States’ methods for handling disease outbreaks. “We have a different cultural acceptance of restriction of our rights, and quarantine always bumps up against that.”
‘Small’ Tactics to Counter Big Pharma’s Influence on Medication Overload – STAT 28Jan2020 — Highlights the “Drug Facts” box—a standardized, single-page format for conveying drug effectiveness and risk of harm—developed by researchers Steven Woloshin, professor of medicine, community and family medicine, and of The Dartmouth Institute for Health Policy and Clinical Practice, and the late Geisel professor Lisa Schwartz.
Drugs Cost More When Manufacturers Sell Directly to Physicians, Study Says – Becker’s Hospital Review 27Jan2020 — Features a study conducted by researchers at Dartmouth that found that drugmakers promoting their drugs directly to physicians affect prescribing quality and can raise drug prices, but the practice is more commonplace in smaller health systems with fewer physicians.
FDA Approves Ubrogepant for Acute Treatment of Migraine What the Data Show – Neurology Today 23Jan2020 — Quotes Stewart Tepper, professor of neurology, in an article about how a new oral agent, ubrogepant, was approved by the U.S. Food and Drug Administration for treatment of acute migraine. “The advantage of this drug and of its cousin (rimegepant) is the side effects are really minimal,” said Tepper.
Lessons from My First Patient – Boston Globe 19Jan2020 — An article by Sathvik Namburar, Geisel ’22, on his experience during anatomy dissections in which he thought often about his patient’s life.
22 Researchers find VISTA molecule silences immune system against cancer – Drug Target Review 17Jan2020 — An article on a new study showing that the VISTA molecule stops the immune system from responding to self-antigens quotes Randolph Noelle, professor of microbiology and immunology. “We have learned that keeping your immune system quiet is a challenging and very active process,” Noelle said.
This Immune Checkpoint Could Be a New Target Against Cancer, Autoimmune Diseases – Fierce Biotech 16Jan2020 — Quotes Randolph Noelle, professor of microbiology and immunology, in an article about a study he conducted that found an immune checkpoint that could also serve as a therapeutic target for cancer and autoimmune diseases.
U.S. Prices for Healthcare Services Far Outpace Peer Nations – Forbes 15Jan2020 — Briefly cites data from the Dartmouth Atlas Project that shows there is a persistent unexplained variance in hospital costs intra-regionally.
Can We Design Our Way to Better Health? Some Vermonters Think So – Seven Days 15Jan2020 — Quotes James Rustad, assistant professor of psychiatry, in an article about user- experience designer Katie McCurdy and her startup Pictal Health, which helps people suffering from chronic illness create visual depictions of their symptoms to share with their doctor. Rustad says he’s interested in pursuing long-term research on the effects of design work such as McCurdy’s. He treated 10 veterans who had worked with McCurdy to map their health problems. “I think the patients found the process of working with her quite therapeutic,” Rustad said. “I thought she was really able to capture the breadth and depth of their life experience.”
Despite Decades of Initiatives, Rural Physicians Grow Scarcer – Managed Care 14Jan2020 — An article about the declining number of rural physicians, which cites a study lead by Lucy Skinner, Geisel ’22, that projected that there will be 9.4 doctors for every 10,000 residents of rural areas in contrast to 29.6 for every 10,000 residents of non-rural areas.
The Best Skin Cancer-Fighting Foods to Add to Your Plate – Shape 14Jan2020 — Cites a study conducted by researchers at the Geisel School of Medicine that found that people who drank two cups or more of tea daily were significantly less likely to get squamous cell carcinomas than non-tea drinkers.
The Downside of Strong Growth in Health Care Jobs: Higher Costs – STAT News 14Jan2020 — Quotes Jonathan Skinner, the James O. Freedman Presidential Professor in Economics and professor of The Dartmouth Institute for Health Policy & Clinical Practice, and Carrie Colla, associate professor of The Dartmouth Institute for Health Policy & Clinical Practice, in an article about how job growth in the health care sector is leading to higher costs. “It is unlikely that health care cost growth will moderate without a corresponding moderation in the growth of health care employment,” said Skinner and Colla. (The quote comes from Skinner and Colla’s new book, titled The Trillion Dollar Revolution.)
23 More Education Needed on Breast Density and Screening Choices – Drugs.com 06Jan2020 — Features a study co-authored by Karen Schifferdecker, director of the Center for Program Design and Evaluation and assistant professor at The Dartmouth Institute for Health Policy and Clinical Practice (TDI) that explored women’s knowledge of breast density and its correlation with cancer risk.
Do ‘Baby-Friendly’ Hospitals Work for All Moms? – The New York Times: Parenting 06Jan2020 — Quotes Alison Volpe Holmes, associate professor of pediatrics, medical education, and of The Dartmouth Institute for Health Policy and Clinical Practice, in an article about the effectiveness of the Baby-Friendly Hospital Initiative, which encourages hospitals and birthing centers to promote breastfeeding in response to plunging breastfeeding rates worldwide.
Thanks, a Lot – AAMC 03Jan2020 — Quotes Catherine Pipas, professor of medical education, community and family medicine, and The Dartmouth Institute for Health Policy and Clinical Practice, in an article about how students and doctors can learn to practice gratitude to ward off burnout and rekindle their love of medicine. Pipas encourages medical students and physicians to practice gratitude by building quiet time into their daily routines, regularly calling out people at meetings for things they did well, forming coffee groups with colleagues to share appreciations, and looking for opportunities to practice kindness to others. “We need to have the time, the tools, and the permission to use these,” says Pipas.
Trans Policies Highlight Rift Over Gender – The Laconia Daily Sun 02Jan2020 — Quotes Jack Turco, professor of medicine, in an article about the current debate in New Hampshire school districts surrounding policies to prevent discrimination and promote inclusion of transgender students.
At the Hospitals for Dec. 29, 2019 – Valley News 28Dec2019 — Jocelyn Chertoff, professor and chair of radiology, was named the 2019 Outstanding Educator of the Year by the Radiological Society of North America. The annual award recognizes those who have demonstrated a commitment to the field of radiology, are pioneers in their specialty and have made significant contributions to radiological education over the past 15 years.
Study by Geisel Group Details Process Enzyme Plays in Cancer – Valley News 22Dec2019 — Quotes William Kinlaw, active emeritus professor of medicine, and Leslie Lupien, Guarini ’19, in a feature story about research they co-authored that examined how an enzyme called Lipoprotein Lipase, or LPL, was present when cancer cells consumed fats from the bloodstream.
24 Dartmouth-Hitchcock Neurologist Honored – The Barre Montpelier Times Argus 21Dec2019 — Barbara Jobst, the Louis and Ruth Frank Professor in Neuroscience, has been named the 2019 recipient of the J. Kiffin Penry Award from the American Epilepsy Society.
Over the Counter: Opioids Aren’t the Only Option for Chronic Pain – Wicked Local Bolton 17Dec2019 — Cites a study conducted by researchers at the Geisel School of Medicine showing potential benefits of low-dose naltrexone—a non-addictive option to treat chronic pain.
What We Don’t Know About I.V.F. – The New York Times Parenting 17Dec2019 — Quotes Judy Stern, professor of obstetrics and gynecology and of pathology and laboratory medicine, in an article about the lack of knowledge surrounding the long-term effects for the women who undergo I.V.F. and similar procedures to promote pregnancy. “By the time you go years out from the procedure, the procedures have changed, dramatically,” says Stern.
Vaping’s Dangers Loom Large Amid More Than 50 U.S. Deaths This Year – Science News 16Dec2019 — Quotes Susanne Tanski, associate professor of pediatrics, about the dangers of vaping as teen use of e-cigarettes continues to rise.
Breast Cancer Cells Use Unexpected Mechanism to Suck Up Fats – Genetic Engineering & Biotechnology News 16Dec2019 — Quotes William Kinlaw, active emeritus professor of medicine, in an article about a study he co-authored with additional researchers from Dartmouth College and the Dartmouth-Hitchcock Norris Cotton Cancer Center that examined how fat might influence breast cancer cells.
Baking a Process into Writing Your First Draft of a Scientific Piece – Medium 15Dec2019 — An opinion piece by Anna Adachi-Mejia, associate professor of pediatrics, community and family medicine, and of the Dartmouth Institute for Health Policy and Clinical Practice, in which she shares advice on how to write a scientific article.
Rapid Fire Q&A with R. Brooks Robey, MD, FAPS – The Physiologist 12Dec2019 — The November issue of The Physiologist features a Q&A with R. Brooks Robey, MD, FAPS, associate professor of medicine at Geisel and associate chief of staff for research at the White River Junction VA Medical Center.
DHE Re-Emerges as ‘Magic’ Migraine Treatment – Healio 11Dec2019 — Quotes Stewart Tepper, professor of neurology, about how acute migraine treatments containing dihydroergotamine, or DHE, could soon return to the mainstream, providing a less cumbersome treatment option for some of the 39 million Americans with migraine.
25 Study: Medical Students from Rural Backgrounds Declining – Valley News 09Dec2019 — A feature story about a study led by Scott Shipman, assistant professor of pediatrics, community and family medicine, and The Dartmouth Institute for Health Policy and Clinical Practice, that found a decline in numbers of medical students from rural backgrounds as the overall number of medical students has been on the rise.
Study: Fewer Medical Students Are Coming from Rural Areas, Tied to Rural Workforce Shortages – NHPR 04Dec2019 — Quotes Scott Shipman, assistant professor of pediatrics, community and family medicine, and The Dartmouth Institute for Health Policy and Clinical Practice, in a feature story about a study he led that found that the number of medical students coming from rural areas has fallen by almost 30% since 2002.
Taking Multiple Fracture-Associated Drugs Significantly Increases Fracture Risk – Doc Wire 29Nov2019 — Quotes Rebecca Emeny, a postdoctoral fellow at The Dartmouth Institute for Health Policy and Clinical Practice, about a study she led that identified drugs that increase fracture risk in the elderly.
‘There’s Something Terribly Wrong’: Americans Are Dying Young at Alarming Rates – The Washington Post 26Nov2019 — Quotes Ellen Meara, professor of The Dartmouth Institute for Health Policy and Clinical Practice, in an article about a study published Tuesday that looked at the past six decades of mortality data, and found that death rates from suicide, drug overdoses, liver disease, and dozens of other causes have been rising over the past decade for young and middle-aged adults, driving down overall life expectancy in the United States for three consecutive years. “There’s something more fundamental about how people are feeling at some level—whether it’s economic, whether it’s stress, whether it’s deterioration of family,” said Meara. “People are feeling worse about themselves and their futures, and that’s leading them to do things that are self-destructive and not promoting health.”
It’s Not Just Poor White People Driving a Decline in Life Expectancy – The New York Times 26Nov2019 — Quotes Ellen Meara, professor of The Dartmouth Institute for Health Policy and Clinical Practice, about a new analysis of more than a half-century of federal mortality data published in JAMA that found that the increased death rates among people in midlife extended to all racial and ethnic groups, and to suburbs and cities. The states with the greatest relative increases in death rates among young and middle-aged adults were New Hampshire, Maine, Vermont, West Virginia, and Ohio. “The fact that it’s so expansive and involves so many causes of death—it’s saying that there’s something broader going on in our country,” says Meara. “This no longer limited to middle-aged whites.”
What Are the Connections Between Stress and Migraine? (Audio) – RTE 25Nov2019 — As a guest on RTE Radio, Stewart Tepper, professor of neurology, discusses migraine causes and treatments. (Stewart’s comments are included in the second clip embedded in the article.)
26 Canadian Doctor: Beware of the Pitfalls in a Medicare for All Plan – CNN 25Nov2019 — An opinion piece by Adam Kassam ’14, in which he discusses whether a Medicare for All plan is the best way to achieve universal health coverage.
Health-Care Staffing: Feast or Famine – Business NH Magazine 21Nov2019 — Quotes William Torrey, professor of psychiatry and of The Dartmouth Institute for Health Policy and Clinical Practice, in an article about healthcare staffing shortages. “There’s a national shortage of psychiatrists,” says Torrey. “Studies show that most counties in the country don’t have enough psychiatrists.”
How These Neurologists and Neuroethicists Navigate the Difficult Ethical Questions – Neurology Today 21Nov2019 — Cites the contributions of James Bernat, emeritus professor of neurology, to the development of the field of neuroethics.
The Customer is Sometimes Right: Direct-to-Consumer Ads in Rheumatology – Healio 19Nov2019 — Quotes Steven Woloshin, professor of medicine, community and family medicine, and The Dartmouth Institute for Health Policy and Clinical Practice, in an article about direct-to-consumer (DTC) advertising, and how it has become a significant part of the health care system in the United States. “It is easy to predict the future of DTC advertising,” says Woloshin. “It is going to get bigger and bigger.”
Oral CGRP Drug for Acute Migraine Bests Placebo – MedPage Today 19Nov2019 — Quotes Stewart Tepper, professor of neurology, in an article about a study on an oral gepant drug for migraine treatment. Tepper was not involved in the study.
How to Talk to Your Doctor About a Serious Condition – The Hill 18Nov2019 — Cites a study conducted by researchers at The Dartmouth Institute for Health Policy and Clinical Practice that found that the majority of patients with advanced lung and colorectal cancer didn’t understand that chemotherapy was unlikely to cure their cancer.
How Drug Promotion Rules Impact Physician Prescribing Practices? – International Business Times 17Nov2019 — Quotes Steven Woloshin, professor of medicine, community and family medicine, and of The Dartmouth Institute for Health Policy and Clinical Practice, about a study he led along with fellow researchers from Dartmouth and Harvard Medical School that shows that the way pharmaceutical companies are permitted to share information about their drugs can influence physician prescribing practices.
Are There Benefits to Chlorophyll Supplements? – The New York Times 15Nov2019 — Quotes Timothy Gardner, associate professor of medicine, in an article that examines whether or not there are benefits to chlorophyll supplements.
27 The Face of Cancer Care and Research – NH Magazine 15Nov2019 — A brief profile of Steven Leach, the Preston T. and Virginia R. Kelsey Professor and director of the Norris Cotton Cancer Center, who built a national reputation as a specialist in pancreatic cancer research and treatment at Johns Hopkins University and Memorial Sloan Kettering Cancer Center, two of the nation’s 51 NCI designated Comprehensive Cancer Centers.
Drugs That Increase Fracture Risk in Elderly Identified in JAMA Study – Specialty Medical Dialogues 14Nov2019 — Quotes Rebecca Emeny, a postdoctoral fellow at The Dartmouth Institute for Health Policy and Clinical Practice, about a study she led that identified drugs that increase fracture risk in the elderly. (Similar coverage in McKnight’s Long-Term Care News.)
Patients Just as Satisfied When Surgeons Give Fewer Opioids for Pain – Reuters 12Nov2019 — Quotes Richard Barth, professor of surgery, about a study that found that patient satisfaction scores didn’t suffer for surgeons who cut their prescribing of opioids for pain by more than 50%. “Our previous research looked at how much opioid was being prescribed and how many patients actually used it,” says Barth, who is the study’s senior author.
With Cyanobacteria Blooms Into Fall, Is Vermont Doing Enough to Protect Public Health? – VT Digger 10Nov2019 — Cites research by Elijah Stommel, professor of neurology, in an article about how Vermont still doesn’t have recreational or drinking water standards for cyanotoxins.
The Mystery of a 1918 Veteran and the Flu Pandemic – Snopes via The Conversation 10Nov2019 — A pick-up of a 2017 opinion piece by Ruth Craig, emeritus professor of pharmacology and toxicology, about the 100-year anniversary of the 1918 flu pandemic, which killed roughly 40 million people and was unusual in that it killed many healthy 20- to 40-year- olds, including millions of World War I soldiers.
Déjà Vu All Over Again: Health-Care Spending Back on the Rise – The Hill 10Nov2019 — An opinion piece by Carrie Colla, associate professor of the Dartmouth Institute for Health Policy and Clinical Practice, and Jonathan Skinner, the James O. Freedman Presidential Professor in Economics, professor of community and family medicine, and of the Dartmouth Institute for Health Policy and Clinical Practice, in which they reflect on what the Affordable Care Act (ACA) has accomplished so far—and what it hasn’t. “The ACA laid the foundation for fundamental health-care reform and expanded coverage to many previously uninsured. Now it is time to continue reform in a way that makes health care more sustainable not just for a few brief years, but for the long-term,” said Colla and Skinner.
28 Machine Learning Identifies Esophageal Cancer Better Than Current Methods – HealthData Management 07Nov2019 — Quotes Saeed Hassanpour, assistant professor of biomedical data science and epidemiology, about how he and colleagues from Dartmouth have developed a deep learning model to accurately identify cancerous esophagus tissue on microscopy images instead of the high-cost, time-consuming manual annotation process used by pathologists. “Our new approach outperformed the current state-of-the-art approach that requires these detailed annotations for its training,” says Hassanpour. “The result is significant because our method is based solely on tissue-level annotations, unlike existing methods that are based on manually annotated regions.”
5 Reasons for Completing Medical School in 5 Years – U.S. News & World Report 05Nov2019 — An opinion piece by Cassie Kosarek ’20, in which she shares five reasons that many students choose to take a fifth year to complete in medical school.
Study: New Immigrants Less Likely to Use Prescription Opioids – Valley News 04Nov2019 — A feature story about a study led by Brian Sites, professor of anesthesiology and of orthopaedics, that found that new immigrants to the U.S. are less likely to use prescription opioids than native-born Americans.
At the Hospitals: Nov. 3, 2019 – Valley News 02Nov2019 — Ellen Meara, professor of The Dartmouth Institute for Health Policy and Clinical Practice, has been elected to the National Academy of Medicine. Meara’s appointment was announced in late October at the academy’s annual meeting in Washington, D.C. “I am incredibly honored to be recognized by the profession in this way and am eager to support (the National Academy of Medicine)’s mission of offering independent advice to improve health for all,” Meara said.
No Link Between Colonic Polyps at Younger Age and CRC – MedPage Today 01Nov2019 — Quotes Joseph Anderson, associate professor of medicine, and Lynn Butterly, associate professor of medicine, in an article about a new study that found that colonic polyps detected in younger patients did not increase the likelihood of finding advanced adenomas, including colorectal cancer, at follow-up colonoscopy.
The Rising Power of Peers—and What That Means for Leaders – Forbes 01Nov2019 — Quotes Karen Fortuna, assistant professor of psychiatry, in an article about how employees trust their coworkers more than their leaders with their mental health issues. “Peer support has consistently been found to reduce mental health distress and promote quality of life,” says Fortuna.
Bacteria Need Genetic ‘Passcode’ to Survive the Gut – Technology Insider 01Nov2019 — Continued coverage of research co-authored by Benjamin Ross, assistant professor of microbiology and immunology, that found that efforts to improve microbiome health–including next-generation probiotics–may need to be individualized.
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