The search for a new president at the Johns Hopkins University -- which passed its January deadline yesterday without completion -- has been complicated by the troubling financial issues facing academic medical research centers across the country, Hopkins officials said.
In years to come, major medical centers such as Hopkins will see a drop in revenue for treating patients from the government and private insurers, an issue that will demand considerable attention from the university's next president.
Formally, Johns Hopkins Hospital and the university are separate institutions, with the medical school under the university's wing. But the new university president will lead a new, powerful committee of medical school and hospital officials that has broad oversight over major policies.
Federal officials are predicting significant reductions in payments to hospitals for Medicare and Medicaid patients. And health maintenance organizations are shepherding clients away from more expensive academic hospitals to community hospitals, diverting money from research and education. In response, the Johns Hopkins Hospital and Health System has courted a new patient clientele based heavily on family practice.
But that strategy has created a clash between the hospital and the medical school, where many medical professors believe the culture that produced some of the world's greatest research is being debased. Some at Hopkins say that unresolved divide encouraged the recent resignation of two top medical school officials and has made it more difficult to find a new president by Hopkins' self- imposed deadline.
In recent weeks, some senior medical professors, including several department chairmen, have met privately with hospital trustees to lobby for major change in the management structure in the medical complex. So much attention has been focused on the status of Hopkins Hospital and Health System President James A. Block that the chairman of the hospital trustees, George L. Bunting Jr., issued this statement to hospital employees yesterday:
"It has been brought to my attention that inaccurate rumors are circulating regarding Dr. James Block's position at Hopkins. There has been no change in his status as president and CEO of the Johns Hopkins Health Systems Corporation and the Johns Hopkins Hospital."
The chairman of the university's board of trustees rejected the notion that conflict between administrators at the medical center had affected the presidential search. But Morris W. Offit acknowledged that changes in the medical center's administrative structure over the past year have led to what he termed understandable, but overblown worries.
The 19-member search committee has been engaged in talks with a handful of potential candidates in recent weeks, said Mr. Offit, who is leading the search. There is no short list, however, 13 months after the announcement of former President William C. Richardson's resignation. Acting President Daniel Nathans, a Nobel prize-winning molecular biologist, has ruled himself out as a candidate.
"The search could conclude in the next few weeks, it could conclude in the next few months," Mr. Offit said. "We'll have a president in place very shortly, and that will help to stabilize any person's uncertainty to the future."
The tensions at Hopkins are at heart driven by the new economic realities of medicine, Hopkins officials said. To make Hopkins more marketable to HMOs, Dr. Block, president of the hospital, has led a drive to bring the practices of primary-care physicians who are not faculty members under the Hopkins umbrella.
The move has angered senior professors, who believe that push could strip Hopkins of the pioneering patient care and research that earned it world renown.
"There is great concern that until [officials] get the medical center situation taken care of, they won't be able to attract anybody good" as president, said a doctor knowledgeable about Hopkins management. "Otherwise, that person will spend all his time on the East Baltimore campus.
"Hopkins exists because of a self-fulfilling mystique that it's excellent, and therefore it attracts excellent people," the doctor said. "[Hopkins] always will be very good. The question is whether it will be great. The esprit de corps is at risk of being fractured."
A recent pair of departures in the medical school surprised some at Hopkins. Medical Dean Michael E. Johns announced that he would leave this summer to become medical chancellor at Emory University in Atlanta. In mid-January, Executive Vice Dean David Blake, Dr. Johns' chief deputy, said he would become senior vice president of the Association of American Medical Colleges in Washington.
Neither Dr. Johns nor Dr. Blake cited the changed structure as their reason for departing, and few interviewed say that is the primary cause for their leaving. But both officials found the situation less appealing in recent months, say physicians knowledgeable about their departures.
Dr. Johns and Dr. Block declined to comment for this article.
Hopkins was rebuffed in its approach last year to John V. Lombardi, the president of the University of Florida at Gainesville, who flirted publicly with coming to Baltimore before deciding in December that he would stay in Florida.
That rejection was accentuated by uncertainty about the future roles of top leaders of Hopkins Hospital and the medical school, several Hopkins officials said.
"If people start working with one another, settle down in their roles, this may all change," said Dr. Robert Heyssel, former president of Hopkins Hospital.
"Is there anxiety, and unease, about this governance structure? Yes," said a senior Hopkins administrator. "One doesn't like to be there in the middle of it." But "in California, New York, it's the same everywhere."
After clashes broke into the open last summer, the university president was placed at the head of a powerful committee of top hospital and medical school leaders called John Hopkins Medicine. Dr. Nathans said the new relationship between the Hopkins health system and the medical school was still evolving. "I can't say that things have moved as rapidly as I've anticipated, but I think they're moving," he said.
The panel meets regularly to iron out issues involving management, marketing, legal affairs and strategic planning. Dr. Nathans has spent most of his time on those issues since assuming the role of president and he said the new president will have to devote much time there.
"It has to be somebody who's willing to do that kind of work in East Baltimore," Dr. Nathans said of the new president. "It may well discourage certain people from being willing to take that position. But I don't think it's skewing the search as much as people think."
Dr. Nathans argues that the leadership of the medical school is less important than the work of the researchers and physicians they oversee.
Mr. Offit said people should not worry about the future -- or the present -- of Hopkins. "I understand their concerns, and I respect their concerns. People get a little unsettled by transitions because it's the unknown and the uncertainty," he said. "Very few people understand what's involved in a whole search process. I have learned one thing in my six years as chairman -- and that's to respect the process."