Paternal Style Leaves Mortal Wounds

s a clinical service chief in an academically affiliated, tertiary care medical center, I see some troubling omissions in Federal Hospital's case. Kenneth Madsen fails to articulate the hospital's missions and goals. The medical staff is referred to as "high-powered," and the polite indifference to Madsen's interim role as the acting director leads me to believe those staffers do not feel his vision for the hospital is consistent with theirs. Nor do they believe he can be a credible advocate for them. Specifically, only clinical leaders can make decisions about what constitutes appropriate state-of-the-art care at a leading academic medical center.

A clear mission statement is important for employees at all levels of the organization. A hospital's mission resembles that of a church or a university more closely than a factory's. Ideally, all employees should feel they are contributing to a mission that is sacred: caring for the sick, teaching the next generation of health care practitioners, or finding more effective therapies for illnesses that are poorly understood. At the National Institutes of Health, I was part of an organization whose employees at many levels (including members of the building management service, security, food services, etc.) embraced the mission and felt they had a role.

Federal Hospital is in trouble if, in the absence of its director, it cannot prepare competently for an external review of its strategic planning. The dilemma highlights the dangers associated with managing a complex organization by benevolent paternalism. Although Ackerbein enjoyed prestige and credibility, his autocratic management style proved to be a profound disservice to his institution. The void created by his illness would have been obviated by the creation of a management team.

It is hard to imagine Federal Hospital's vision and mission could reflect the imagination and creativity of only one person. In a complex medical center, developing a realistic operating budget, identifying opportunities to cut costs and realize savings, and deciding which administrative and clinical services can be exported, shared or purchased rely heavily on input from a management team. I would guess Ackerbein not only left the medical center dysfunctional upon his absence, but also stifled the managerial growth of his senior administrative and clinical staffs when he was present. I have to believe that opportunities to improve efficiencies and to pursue new areas of interest were lost because of Ackerbein's secretive and controlling management style.

Also, shielding the hospital from cutbacks and consolidation should have been data-driven-by evidence that eliminating a certain service would hurt clinical care, residency training programs or research-not dependent on the charismatic style of its director.

I recognize that the final selection of a deputy should be reserved for the director. But it is hard to imagine that a suitable candidate could not be found for such a prestigious position in a year's time. I wonder if Ackerbein elected not to rely on a search committee of leaders from the administrative and clinical sides of the house.

I found myself becoming angry with Ackerbein for not having created mechanisms for the hospital to do more than simply operate on a day-to-day basis in his absence. The growth and development of the organization should not depend solely on his presence.

I have met with clinical service chiefs from various state and federal hospitals who have expressed similar concerns about their own facilities. Many are excluded from senior management, even though they are the only ones with sufficient grasp of the clinical content of the hospital's workload. They feel that fiscal austerity and evaluation of health care are driven more by concerns about cost than about good medical care. In fact, for many there has been cynicism and impotent rage. They wonder with all the insistence on quality, whether anything has really improved.

Dr. Stephen I. Deutsch is trained in both adult and child psychiatry and has a Ph.D. in biochemical pharmacology. He has been chief of the Psychiatry Service at the Veterans Affairs Medical Center in Washington since January 1987.