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For the Record

Leading edge

By Stephen P. Spielberg, M.D., Ph.D.

May you live in interesting times!" Usually referred to as a curse, that phrase could also be cast, I believe, as a call to leadership. Looking back through history, I doubt that those living at any given time would not consider their own era challenging or "interesting." Indeed, if there were no challenges, no obstacles to overcome, there likely would be little innovation, creativity, or progress in human society. Today, we face huge challenges in medicine and health care, but I would argue that our ability to face these "interesting" times has never been greater.

Dedication: In November, we held a wonderful event at DMS—the dedication of a portrait of the late Dr. Marsh Tenney, as painted by Dr. Robert Gosselin. Marsh came to DMS in truly "interesting" times. In the mid-1950s, DMS had reached a critical juncture. The national licensing board for medical schools had placed the School on probation. DMS was at serious risk of closing after over 150 years of continuous operation. Marsh arrived as chair of physiology and associate dean and subsequently became dean. With an abiding faith in scientific research as the foundation of medicine, he attracted outstanding new faculty, including Bob Gosselin. With crucial support from the Board of Trustees, he breathed new life into the institution.

Marsh is credited as the "refounder" of DMS, and that title is no overstatement. Within a year, probation had been lifted, dozens of new faculty hired, and new buildings built. Recalling those times at the portrait dedication, Drs. Heinz Valtin, Roger Smith, and Bob Gosselin (all pioneers in the refounding with Marsh) emphasized the vision; implementation skills; collegiality; and interactions among the Dartmouth College Board of Trustees, the DMS faculty, the Hitchcock Clinic, and Mary Hitchcock Memorial Hospital that laid the groundwork for what DMS is today. They talked with pride of the roles they and their colleagues had played as scientists, physicians, mentors, and teachers; many of our current faculty studied with these giants. This event made it clear how each generation contributes to the next. Our debt to the leaders of the past is enormous; our responsibility to the future leaders of DMS and of medicine is one we must not shirk.

Impact: Fifty years have passed since the refounding, and once again we face many challenges—most significantly, constraints in the funding for academic medicine. Yet if we look around at our School—at the remarkable growth in our facilities, at the breadth of DHMC's impact in the region, at the nearly 100-fold growth in the faculty since Marsh Tenney arrived, at the phenomenal increase in our knowledge of human biology—we can't fail to have confidence in our ability to meet the challenges. Yes, National Institutes of Health (NIH) grants and Medicare and Medicaid reimbursements are being squeezed. We are advocating, at the state and national levels, for appropriate support for our missions of education, research, and patient care.

And at the same time, we are working internally to assure our continued success in the face of these external pressures. In the research realm, for example, we are taking steps to maximize the rate at which DMS grant proposals are funded—adding internal peer review within departments and formal mentoring of new investigators by senior faculty who are experienced in grant-writing and -reviewing. We are also mindful of the fact that the NIH is allocating a bigger percentage of its budget to large, collaborative research projects, so we will be responding to requests for applications for these translational research projects. Up to 60 such grants will be funded over time, defining those institutions that will lead the medical investigative effort in the years to come. The planning process for this application is thus key to our success.

Constraints: Financial constraints in the clinical realm are very real as well. As reimbursements fall, the pressure on clinicians' time mounts, putting the institution's other missions, including clinical teaching, in jeopardy. Our response to these challenges needs to be collaboration among all components of DHMC—the School, the Hospital, and the Clinic. We need good "metrics" with which to measure the efficiency of both our clinical and our teaching activities. We must regularly remind ourselves that efficient and excellent patient care, and efficient and excellent teaching, are not mutually exclusive but complementary activities. We also must explore and implement innovative, creative ways of better providing care for our patients and teaching for our students and residents. We have outstanding faculty and we need to support, foster, recognize, reward, and celebrate their efforts at innovation.

Finally, as we focus on stewarding present resources and meeting daily challenges, we must not forget the importance of investing for the future. Fifty years ago, struggling to maintain the very existence of the Medical School, Marsh Tenney and his colleagues aggressively raised funds for and built new facilities for the future—labs and classrooms and libraries in which our faculty and students still, today, work and study. It might have seemed more expedient if those refounders had not thought so big, had focused on the most immediate problems. But if they had, it is quite clear in retrospect that DMS would likely not have survived into the 21st century.

So today, while assuring our financial and programmatic strength in the present, we need to invest in our future—responsibly balancing current needs with new initiatives. I believe we are fortunate to live in "interesting" times, to have the opportunity to work together to serve our students, our patients, and society.

"For the Record" offers timely commentary from the dean of Dartmouth Medical School. Spielberg, a pediatrician and a pharmacologist, is in his third year as DMS's dean.

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