Editorial

RiChaRD h. DaFFneR, mD, FaCR

The Purge

During my tour of duty in the Air Force, I saw an older Master Sergeant in the ED for symptoms of sinusitis. I noted that he was wearing Command Pilot wings on his uniform. I had always thought that military pilots were all officers. And so, after discharging my patient, I asked my top sergeant why an enlisted man had pilot’s wings. He told me, in a matter-of-fact way that my patient had been “RIFfed”—part of a ReductionIn-Force (RIF). RIF is a mechanism of terminating military personnel who have poor performance (efficiency) reports. In the case of my patient, he had been in the Air Force for 17 years and needed three more years of service to retire and be eligible to collect a pension. He was allowed to continue as an enlisted man (at a pay grade below that of his previous rank of Major).

In academia, there is an adage that “you’ll move three times before you find a home.” Presumably, with each move you will advance one more academic rank. The positive side of that premise is that with each move the individuals will encounter different philosophies and methods of dealing with clinical situations and broaden their experiences. Still, today, a few people are fortunate enough to stay permanently in their first job.

I’m frequently asked how I came to settle in Pittsburgh, interestingly, my third position post residency. I explained that several years ago in a previous editorial1. What started the events that led me here was a departmental purge, a harsher version of a RIF. The word “purge” often conjures up images of the removal of real or perceived political rivals by dictator Joseph Stalin in the former Soviet Union. More simply, a purge is defined as getting rid of someone or something unwanted. In Stalin’s regime a purge was fatal. Stalin was reputed to have said, “I have no problems. No man, no problem.”

The roots of the purge that resulted in my relocation to Pittsburgh began in the early 1970s. The late Dr. William Anylan was Dean of the medical school as well as Chancellor for Health Affairs of Duke University. Bill was a man of vision who built the Duke Health system to the powerhouse it is today. In 1972, he gave an interview to The New Physician in which he was asked what he envisioned health care would look like at the turn of the century. Bill must have had the world’s largest crystal ball because he accurately predicted what the state of health care would be in 30 years: reduced reimbursements, the closing of smaller hospitals and/ or mergers with large facilities, community hospitals providing mostly primary care and referral of patients with complex medical or surgical issues to larger tertiary care academic centers, such as Duke. Today, we see how Dr. Anylan’s predictions have come true here in Pittsburgh with the ascendency of the UPMC, Allegheny Health Network, Heritage Valley, and Excela systems, and the demise of St. Francis, Southside, Suburban General and many other smaller hospitals. (UPMC is the largest employer in the Pittsburgh region today).

Duke was one of the first academic medical facilities to offer their clinical faculty a private practice benefit through the founding of the Private Diagnostic Clinic (PDC) in 1931 as an independent, for-profit group practice affiliated with Duke Hospital and Duke University. The University created this arrangement, in part, to help recruit more faculty by permitting them to engage in private practice and subsequently supplement their incomes. The PDC was self-governed and not subject to university direction. Under their by-laws, a small percent of the earnings of each department was kept by the PDC for management (including billing) and the balance was paid to the clinicians in each department, as each chairperson

saw fit. In addition, each department chairperson was obligated to make an annual contribution to the medical school (“Dean’s Tax”). The Department of Diagnostic Radiology, during my residency was very profitable, and the chairman, a true mensch (a person of integrity and honor) was generous in distributing benefits to his staff. He was under pressure, however, from Dr. Anlyan to increase his department’s contributions to the medical school, and he told the dean that he would do so only when the chairmen of Surgery and Medicine increased their contributions. And for that, he was “urged” to retire in 1976.

Under Dr. Anylan’s guidance, Duke began a program of retrenchment – cutting of expenses – in the late 1970’s to prepare the medical center for the changes he foresaw coming in health care. All department chairs were told to reduce costs and streamline their operations. Chairpersons in academia wield tremendous power without ,in most cases, fear of legal interference. Faculty who are unhappy with the chair’s decisions know that their only real alternative is to leave for what they hope will be greener pastures. Tenure, a system whereby the institution and the individual faculty member make a lifetime commitment to each other, is not a safeguard from removal. Tenured faculty may be dismissed for “cause,” such as failure to perform their assigned duties or some act of moral turpitude. Without “cause,” tenured faculty can be “encouraged” to leave. (As an example, one tenured full professor, whom my chairman wanted to leave, returned from vacation to find his reserved parking space was gone. In addition, his office was occupied by three transcriptionists and his new office was in a converted janitor’s closet. He took the hint and left shortly thereafter.) The new chairman of radiology decided the best way to accomplish Dr. Anylan’s goals was two-fold. First, he decided to “encourage” senior faculty, who had the highest salaries, to leave. While most organizations and academic departments have a pyramid-shaped hierarchy, his philosophy was to have an inverted “T”, with most of the faculty at the entry (Instructor and Assistant Professor) levels, and the upright arm of the inverted “T” occupied by a few of the chairman’s loyalists. John, my mentor and a tenured full Professor, was one of many faculty members pressured to depart. I, too, as an Associate Professor was on the chairman’s “hit list” and was aware that my Duke days were numbered. And thus, the purge began, with most of the senior faculty leaving. Their places were taken by younger hires fresh out of residencies or fellowships, who were told not to plan on making their time at Duke a permanent stop. They were told to work hard, publish some scientific papers, and move on to a promotion elsewhere. In this way, the lowest paying positions were rolled over, with the result that the chairman was able to contribute several million dollars of clinical money back to the institution.

The second method used was to reduce the number of faculty perks. Faculty travel and payment of society dues were restricted to attendance at two national society meetings. Coincidentally, these societies were ones in which the chairman was active. These actions alone convinced many senior faculty members to leave. Ironically, most opted for private practice, because of the bad taste left in their mouths from their academic experiences.

I was young and naïve in those days and believed that I was doing all the right things to guarantee a long career at Duke. Academic promotions are based on three things: service, teaching, and research. I was doing a significant amount of clinical work, was recognized by the residents and medical students for my teaching, all the while building a solid CV through my publications and presentations at national and international society meetings. As a result, I thought I was secure. My epiphany came when the chairman informed me, at the conclusion of my sixth year that I was eligible for tenure. At that time, Duke had changed the tenure eligibility rules for clinical faculty from seven to eleven years of service. However, those individuals who had been working under the old system were “grandfathered” to be eligible at seven years. What I did not know was that under those old rules, if there were no negative incidents during the individual’s first seven years of employment, that tenure would be automatic. The chairman encouraged me to formally apply for tenure. Six weeks later he came and “apologized” for having misled me, telling me that tenure was being denied to most applicants, and if I did not want to be forced to leave after my seventh year, I would have to withdraw my tenure application. I agreed, and he told me to write him a letter stating my intentions. And with that, he cheated me out of

From Page 11 tenure. It was then that I realized my days at Duke were numbered and that I would become one of the victims of the purge.

Most chairpersons are honest and forthright. They do not hesitate to communicate their wishes to their faculty. I would have appreciated if the chairman, who always told people that they could speak frankly, had told me (and the others) that I had no future at Duke and should be looking to move on. I would not have been happy, but I would have respected the man for his honesty. Instead, not wanting to be thought of negatively, his modus operandi was to put the individuals whom he wanted to leave in no-win situations. For example, he told me he wanted me to work with the ENT surgeons and the oral surgeons to utilize head and neck CT scanning for their patients and then to write several papers on the subject. He then told the CT people not to notify me when they had a head and/or neck case. Thus, I would not be able to comply with his request, grounds for dismissal.

Fortunately, as I have previously written1, I was recruited to come to Pittsburgh and, like the line in the Godfather movies, I was made an “offer I couldn’t refuse.” I have been happy ever since, in a 31-year career that married the very best features of academia and private practice. As a final footnote, on my exit interview, I asked the chairman why he pushed me out. For once he was honest with me. He said, “Don’t you realize I can hire three people for the same money I’m paying you?”

“Will they do the job as well?” I replied.

“That’s not the point,” he said.

And that was my second epiphany. Those at the top, (no matter the discipline) play on a different field, with different rules, and different priorities than those of us below them. Hard work and following all the rules are no guarantee of a successful career if the chairperson wants you out. I, however, was fortunate to be able to make lemonade when I was given a big lemon.

Reference

1. Daffner RH. Taking the tide. ACMS

Bulletin 2019 (Oct) 324-325.

Dr.Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine

The opinion expressed in this column is that of the writer and does not necessarily reflect the opinion of the Editorial Board, the Bulletin, or the Allegheny County Medical Society.

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