At the Center of Health

Snyderman: repositioning the medical center Photo: Chris Hildreth

Ralph Snyderman steps down this summer after fifteen years as chancellor for health affairs and president and CEO of the Duke University Health System. After completing his medical internship and residency at Duke and, later, serving on the medical-school faculty, Snyderman left Duke in 1987 to work in the biotechnology industry as a senior vice president at Genentech Inc. He returned as chancellor in 1989.

In the coming year, Snyderman will take a sabbatical at the University of California, San Francisco. After that, he will return to Duke to teach, conduct medical research, see patients in rheumatology, and serve as executive director of Duke's new Institute for Prospective Care.

When you returned to Duke as chancellor, what were your early goals?

My first priority was to strengthen the School of Medicine. Duke, in 1989, was recognized as an outstanding school of medicine. I would say, however, that if one did a fair comparison to the groups that we wanted to compare ourselves to at that time--Harvard, Hopkins, Washington University, UCSF, Yale, Cornell, Columbia--while we had a very good reputation, clearly, we didn't have the strength in fundamental basic research that they did.

Also, it was apparent to me, particularly having worked in the biotech industry, that recombinant DNA technology, which was revolutionizing our understanding of human biology and health care, was an area of research that had totally passed Duke by.

We truly needed to strengthen the core of our faculty in research, number one. And, number two, we needed to focus on never again allowing a major new field or an emerging field of research to pass us by.

What I didn't realize at the time, but I think in retrospect was very important, was focusing the institution to always be in a leadership position. Never play catch up. Try to anticipate the emerging fields. If there's anything that captures the intention of the leadership direction I've tried to emulate, it is that we ought to be thinking about where the fields are going and have Duke be in a leadership position.

Where do you see those opportunities now?

I think they're very clear, and I've tried to articulate them over the last four or five years. Even though medicine has been recognized as a profession probably for 5,000 years in one form or another, science did not begin having an impact on medicine until the early part of the twentieth century, at which time there was virtually an explosion of the number of fields of science, from anatomy to biochemistry to physics to immunology and microbiology. Medicine in the early 1900s incorporated these into understanding what physicians ought to do. This gave medicine the capability of being better and better in diagnosing disease and trying to treat it. And that's almost where we still are right now.

But I think there is an opportunity to have another transformation similar to a century ago in which the power of science and technology and know-how can anticipate problems before they occur.

The opportunity going forward is to implement personalized medicine. By doing that, every individual would have access to a personalized health plan that was specific for them at that time in their life, their genetic background, their environmental exposures, so that they would be able to plan for health the way we plan now for finances, for retirement, for vacation, for everything.

Who would ever think of running a company without a five-year strategic plan? Why don't we do that for our health? That is the major opportunity for Duke--to be in the vanguard for developing personalized health care and what I've been calling prospective medicine. I really believe that five years from now--certainly within ten years--the standard way of health care will be prospective.

Doesn't this extend the reach of medicine far beyond the hospital or the doctor's office, to take into account everything we're exposed to, the conditions under which we live, even a patient's motivation to stay healthy?

You have to start somewhere. One of the most fundamental and profound changes is that prospective medicine shifts the balance of responsibility to a large degree from the physician's being responsible for your health to giving you knowledge and a plan and saying you're responsible for your health.

How will the genomics revolution affect health care and your vision of prospective health care?

The genomics revolution will provide a lot of opportunities to improve health. The one that we have seized upon, because we think it's important and under-appreciated, is the ability to predict risk. We're already learning that by using genomic strategies one can predict the outcome of certain diseases.

For example, some of our researchers here at Duke have done extensive genomic analysis of breast-cancer tissue. And what they could show is that, depending on the level of expression of certain genes, one could determine how aggressive the tumor is. The pharmaceutical and the biotech industry have already understood this--at least, the smart ones have--to say that we should be designing our therapy to the specific molecular nature of the disease. So, if an individual develops a particular disease in which we have tissue and could characterize their problem, it is likely that the therapy can be designed specifically for them.

As important as that is, it's almost trivial compared to the power of genomics to predict whether, for example, a child is likely to develop insulin-dependent diabetes--Type I diabetes. If it looks like it's actually developing, we may have tools to shut it off before it happens. Think of how powerful that is. It's almost like a Star Wars kind of thing. Are we really going to be able to do that? Absolutely.

Duke has become known for its leadership in integrative medicine. Is integrative medicine the same thing as prospective medicine?

Prospective health care is a concept of trying to anticipate events before they occur, as opposed to simply treating disease. Along with that concept is personalized health planning, so that people would be provided an understanding of their health risks, and their health plan would enable very early diagnosis of something that is about to occur, so that it could be treated at the earliest possible time. It is also a form of health care that puts the major responsibility on the individual.

By integrative medicine, we're saying that the health-care system would allow individuals to avail themselves of all the conventional strategies that we have, many of them being pills or therapeutic procedures. But, in addition to that, it would allow individuals in the appropriate setting to get the full benefit of what are now called complementary and alternative therapies.

Let's say an individual has severe chronic low-back pain. Conventional medicine would do the workup with all the diagnostic imaging and determine whether back surgery was necessary, or the usual kinds of physical therapy, pain medication, anti-inflammatory medication. However, I think it would be generous to say that this was effective in the treatment of more than 30 to 40 percent of people.

What do you do with the rest? Unfortunately, a lot of them were having back surgery, even though it didn't help, or were being given big doses of medicines that would either not work or cause all kinds of side effects. What we're saying is that out of that residual, let's say, 70 percent of people, how many would benefit from acupuncture? How many of them would benefit from stress reduction with mindful meditation? How many would benefit from tai chi or yoga? Integrative medicine becomes a strategy to enhance prospective medicine.

During your time as chancellor, the medical center dealt with two widely publicized crises--the shutdown of human subject research by the federal government in 1999 and the death in 2003 of JÈsica Santill·n after the transplant of an organ that did not match her blood type. What did you learn from those experiences?

One of the things I've learned is that in an institution as big and complex as this, with 12,000 people, with 1.5-million patient interactions per year, even if you control at the 99.99 percent level, every once in a while something's going to pop up that you haven't anticipated, and it's going to be an unusual event. It doesn't characterize everything else.

These two different events--both of them have a certain commonality and that is the importance of prospectively, using that word again, trying to have the appropriate systems and controls so that individuals are more fully aware of the consequences of their behavior.

The OPRR [Office for Protection from Research Risks] shutdown of clinical research was absolutely unanticipated by me or the senior leadership. We always felt that we were complying, but, with the avalanche of regulations and changing regulations, to have systems--major systems that are expensive and complicated--for compliance was something new. Now, we have a compliance office, and we have all kinds of procedures, not only in clinical research, but also in billing, collection, everything we do. So, that's one of the things we learned--complexity.

Another thing it taught me is that when something bad happens, you have to focus on it, totally. Come clean, understand it, and fix it. Look whoever it is in the eye and say, "I was wrong. Not only am I going to fix it, but I'm going to fix it and become a model of what we ought to be." That's what we did with OPRR. That led to opening things back up within four days, and we did become, to some degree, a model institution for protection of individuals in clinical trials.

The second event was more painful because it involved a human life. It involved a family. It was a tragedy. It was a mistake. All of those things were true. It was horrific. On the other hand, the perception that I had, which I will always have, is that the hand that we were dealt was--no matter how you looked at it--a losing hand in terms of how it could be perceived by the press and the public.

What did we learn from that? Well, we again learned oversight of practice and having redundant systems and the fact that we really did need to have a much greater safety net around many of the things that we did. It led to a momentous energy in thinking about systems that were required for patient safety, as well as a culture that needed to be established here--that patient safety is embedded in every physician's head. It was not articulated that way. And so, we had to change the culture here at Duke.

Have your ideas about health care and your experiences as chancellor strengthened the links between medicine and other parts of the university?

Absolutely. I have spent a lot of time with [Divinity School Dean] Greg Jones and the Care at the End of Life Institute, and we're doing a number of things together, including work in genomics. We felt that the empowerment of genomics to help people's health will be limited to some degree by technology, but that the greater limiting factors will be ethics, law, policy. One of the reasons we proposed and founded IGSP [the Institute for Genome Sciences and Policy] was the understanding that some of the most important medical advances require the acceptance and the understanding of so many human problems other than what we're trying to do in preventing or treating disease.

Now that you will have more time to see patients, will you practice medicine differently than you did earlier in your career?

The biggest mistake I've made in the practice of medicine is to think that my primary job was coming up with the diagnosis, the therapeutic plan, and then handing it to the patient. What I didn't realize is that my responsibility went beyond my telling them what to do to developing a partnership so that they would be convinced that this was really what they needed to do. For most things we treat, the real work is done by the patient. It's an illusion to think that the real work is done by a pill or by a procedure. That could do an awful lot, but ultimately, the responsibility falls to the individual to do what needs to be done.

--interviewed by Sara Engram
Engram, former deputy editorial page editor for The Baltimore Sun, has covered public-health and medical issues for many years. She is the author of Mortal Matters: When A Loved One Dies.