A wise person once said, “Goodbyes only hurt because what came before was so special.” Oh, and it has been so special. (Dr. Who – The Power of the Doctor - October 2022)
Looking back on 15 years serving as the dean of the University of Hawai‘i (UH) John A. Burns School of Medicine (JABSOM), I am drawn to many special moments. More importantly, those years were filled with many special people.
I have been blessed with the opportunity to serve the people of Hawai‘i, assist our great medical school, and help contribute to the proud history of Hawai‘i. Like most transplants to Hawai‘i some of my colleagues questioned whether I would have the fortitude to stay in this role for more than a few years. Indeed, I was initially recruited to help the school obtain full accreditation after a failed dean search, and achieving full accreditation was not expected by many at the time.
Several of the dean candidates before me questioned how UH could have a cancer center separate from the medical school. This situation remains a challenge adversely impacting both the cancer center and the medical school. Others were struck by the absence of a university hospital and the fledgling and flailing faculty practice affiliated with the medical school. A well-coordinated approach to training health professionals was not present at the time.
Many promises previously had been made by UH leaders regarding the viability of the new campus at Kaka‘ako and the role of the medical school in the university and the state. Similar promises were being made about the cancer center which was in the process of moving to Kaka‘ako. Neither program was popular with the general faculty at Manoa, given there were other long-standing challenges with facilities, program support, and operations across UH Manoa.
Given all these challenges, the JABSOM department chairs and administrative leadership team had their hands full. We were fortunate to have a talented media lead (Tina Shelton), a committed development officer (Jeffrie Jones), a phenomenal grants development administrator (Tammy Ho), a wise admissions director (Satoru Izutsu) – (who I quickly assigned as senior associate dean and later as the vice dean), and a strong office of medical education led by (Richard Kasuya) who subsequently became an associate dean for medical education.
We quickly recruited additional skilled talent from within the JABSOM ranks and a few from afar. Among the early recruits were Nancy Foster (who returned home from Colorado to serve as Chief Financial Officer and to lead our operations and finance team) and Roy Magnusson (who followed me from Oregon and filled many roles for the medical school and practice plan).
We faced challenges on several fronts during those early days.
At that time, the faculty practice plan was poorly managed and Pat Blanchette stepped away from her founding chair of geriatric medicine role to help implement sweeping fiscal, operational, and cultural change. She also helped us formalize an academic affiliation agreement between UH and the practice plan. Dr. Blanchette went on to play major roles with the cancer center and in the JABSOM dean’s office. At that time, Roy Magnusson took over the practice plan which was contributing about $7M annually in extramural support for faculty and staff in the medical school.
The school successfully defended its primary accreditation 9 months after my arrival and received a well-deserved maximum of 8 years of reaccreditation. The administrative and educational team continued to function at a high-level and received a second 8 years of reaccreditation in 2017.
At the legislature, on the Manoa campus, and with the public, the school began to better explain its many contributions to the public’s health, the many ongoing efforts to address the physician shortage across Hawai‘i, its vital role in the provision of graduate medical education following medical school graduation (ie, JABSOM’s many residency and fellowship programs), and its growing contributions to research innovations and the Hawai‘i state economy. This growing awareness demonstrated that JABSOM was truly making good on the promises of past deans and university leaders through hard work, efficient operations, and strong science. The medical school quickly established itself as a national leader in National Institutes of Health (NIH) grant acquisition for public, community-based medical schools.
The medical school’s reputation grew, especially for its contributions to primary care education and its connection with the community. JABSOM earned top quartile rankings in the US News & World Report Rankings, despite our faculty and student numbers putting JABSOM in the lower quartile of all US medical schools by employee numbers. Although students from Hawai‘i had always excelled, student quality became more visible nationally, thus allowing our students access to the best residency/fellowship training programs in the country. Further, despite ongoing redistribution of state-directed medical school resources elsewhere in Manoa by campus leadership, the medical school found a way to grow opportunities for medical students. The class size has grown from 62 entering students (where it had been for more than a decade prior to my arrival) to 77 students entering each year. Programs to increase education on neighbor islands have supported this effort.
A key factor in the JABSOM success story has been philanthropic efforts led by hard-working development officers. Our development team has always been small, and we have lost several team members to retirement and/or more financially promising opportunities elsewhere. Yet, these ambassadors of the goodwill done every day by JABSOM faculty, staff, learners, and leaders have done phenomenal work on behalf of JABSOM. They helped develop a successful internal giving campaign engaging our own faculty, staff, and leadership to invest in the school. They helped advance a major scholarship program that has helped put JABSOM in the top echelon of US medical schools for the proportion of students graduating without educational debt, despite JABSOM students having one of the lowest family median income levels nationally. These development officers have helped grow JABSOM’s foundation market value from $23M in 2008 to $72.6M in 2022.
Graduate medical education at the medical school has always been a partnership with the major health systems on Hawai‘i, and the Hawai‘i Residency Programs, Inc. was created to allow support for services across multiple health systems under the sponsorship of the medical school. Two years after my arrival, we were stunned by self-inflicted wounds during the reaccreditation of our residency and fellowship programs. The challenge of a short accreditation cycle (ie, a status one step before probation might be assigned and which can discourage resident applicants from coming to or staying in Hawai‘i) could only be addressed by the medical school assuming a greater role in the coordination and oversight of the graduate medical education programs.
Fortunately, Naleen Andrade (former department chair of psychiatry) agreed to help us rebuild our relationship with the health systems and the Hawai‘i Residency Programs, Inc. With her help and that of the members of the UH Office of General Counsel, formal agreements delineating mutual responsibilities were developed and the medical school increasingly assumed a role guaranteeing a higher quality of training for medical school graduates in Hawai‘i. This effort - subsequently led by Lee Buenconsejo-Lum as the associate dean for academic affairs and designated institutional official for graduate medical education - has continued to flourish with return of full accreditation status to 18 different training programs.
As was alluded above regarding the challenges of working side-by-side with the cancer center which has a separate UH governance structure, despite significant mission overlap, the medical school has continually sought ways to support and assist the frequently changing cancer center leadership. The medical school assisted with the formation of the Hawai‘i Cancer Consortium and the medical school provides access to its vivarium facilities for the cancer center faculty members, thus saving many millions of dollars for UH, among other supportive activities. For 18 months beginning in Fall 2014, I oversaw both the UH Cancer Center and JABSOM while a new cancer center director was sought. Operational synergies, cross-unit faculty development activities, and aligned strategic initiatives were implemented, a few of these remain at this time. Fortunately, UH leadership has begun to develop plans for better coordination of these highly complementary UH Manoa units. Some degree of a unified structural governance between the medical school and cancer center would immensely benefit the people of Hawai‘i, but such action is the task of UH leadership.
Growth of the Kaka‘ako campus into the state’s Health & Well-Being campus (as envisioned by former Governor Benjamin Cayetano) has been slow, but in addition to support of the construction of the UH Cancer Center building on the property overseen by JABSOM, there have been other investments by JABSOM to strengthen and coordinate the Manoa-based health sciences. For example, after a fire on the Manoa campus, JABSOM relocated the teaching clinic for the Department of Communication Sciences and Disorders (speech pathology) to a modern space in the 677 Ala Moana building in Kaka‘ako. The JABSOM Department of Native Hawaiian Health also has grown in the adjacent 677 Ala Moana building – creating an opportunity for housing a new NIH-sponsored clinical translational research grant (PIKO) with strong community partnerships. Due to deterioration of clinic space at Leahi Hospital, the teaching and HIV/AIDS research clinic (ie, Clint Spencer Clinic) was moved into a translational research clinic on the JABSOM campus.
With a growing understanding of the significance of the physician workforce shortage in Hawai‘i, medical leadership with many contributions from Kelley Withy (Hawai‘i and Pacific Area Health Education Center director) identified multiple factors contributing to this shortage, as well as methodologies for quantifying and tracking the physician demand over time. The school leadership worked with legislators, donors, and federal agencies to develop the most successful health services federal-matching-loan repayment program in the country; a provider tax credit for those primary care clinicians volunteering to train future health care professionals in their practice; support for neighbor island travel and training for learners; a job recruitment program for physicians wishing to return or move to Hawai‘i; and other initiatives to grow our physician workforce and strengthen our communities.
In 2022 the legislature and Governor David Ige provided key financial support to help expand neighbor island growth of physician training both at the medical school level and during residency and fellowship training. Opportunities for greater participation in clinical training at sites overseen by the Veterans Administration Pacific Islands Health Care System is an important component of this effort. The state support complements efforts that JABSOM has undertaken through philanthropy (eg, working with the Chan Zuckerberg Initiative) to recruit, train, and retain JABSOM learners on neighbor islands. This effort is being done in part to address the disproportionate shortage of physicians on neighbor islands and in part as a component of JABSOM’s efforts to address health disparities in Hawai‘i, especially among Native Hawaiians and Pacific Islanders.
JABSOM was one of the first UH Manoa academic units to advance opportunities for Native Hawaiians. Although my predecessors launched a number of these initiatives, it took the work of many others including community donors to grow these programs. JABSOM programs, supported in large part through philanthropy, provide multiple pathways for Native Hawaiians and underrepresented minority groups in medicine to prepare for health profession education in Hawai‘i, including stipends and scholarships to support our ‘Imi Ho‘ola post-baccalaureate students preparing for medical school and during their medical school education. The JABSOM Kaka‘ako campus embraces Native Hawaiian culture and includes a healing garden with local traditional healing plants and an ahu dedicated to four Native Hawaiian elders of our medical school (Kekuni Blaisdell, Benjamin Young, Marjorie Mau, and Naleen Andrade). Dr. Blaisdell was the school’s first chair of the Department of Internal Medicine. Dr. Young served as the first associate dean for admissions and founded the school’s post-baccalaureate pathway program. Dr. Mau served as the school’s founding chair of the Department of Native Hawaiian Health and is an internationally recognized health disparities scholar. Dr. Andrade served as the school’s chair of the Department of Psychiatry, graduate medical education leader and innovator, former President of the American Board of Psychiatry and Neurology, and has held a multitude of leadership posts for the Queen’s Health System.
Although still working with many community partners to grow our Native Hawaiian presence and leadership, JABSOM via its many traditions and programs has been a leader in honoring the profession’s Native Hawaiian heritage and commitment to the peoples of Hawai‘i and the Pacific. The school has embraced the state’s multiethnic and multicultural essence. Many of our research efforts have highlighted an interprofessional and cross-cultural effort to reduce those health disparities found in Hawai‘i. With the help of Noreen Mokuau (dean emeritus of the Thompson School of Social Work and Public Health), our research teams acquired major grants from the NIH allowing us to focus on understanding and solving health challenges for the people of Hawai‘i and developing the next generation of scientists.
Many other medical school scientists warrant recognition for their work in cancer, aging, multicultural behavioral health, cardiovascular disease, human development, diabetes, and infectious diseases (including vaccine development). They contributed greatly to our success by generating a robust research engine in the medical school. This success was guided in part by Mariana Gerschenson who has worked tirelessly to mentor junior investigators, basic science department chairs and others. While maintaining her own successful research career she has championed collaborative research, graduate health science educational programs, and the acquisition of resources for health science research at JABSOM and UH Manoa. It is unfortunate that many in the community and within UH leadership have narrowly focused on the educational mission of the medical school and overlooked that with very modest state support for research, JABSOM has been a major contributor to the research reputation and extramural funding success of UH Manoa. Indeed, there remain individuals at UH Manoa who fail to see the great synergy proven possible when a medical school successfully melds education, research, and community service.
Perhaps one of the more interesting paths which JABSOM has traveled has been related to its development of a robust clinical learning environment for medical students, residents, fellows, and other health science learners. With the support of the University Health Partners of Hawai‘i (the JABSOM developed faculty practice plan for UH health sciences) and through partnerships with multiple health systems in Hawai‘i, clinical learning programs have matured and received national recognition.
Following phenomenal work by Patricia Blanchette and Roy Magnusson to grow the practice plan, Larry Shapiro (former dean of the Washington University School of Medicine – St. Louis, Missouri) agreed to lead the practice plan through a challenging transition period during which the practice plan and two major health system partners (Hawai‘i Pacific Health and the Queen’s Health Systems) would each embed components of the JABSOM practice plan historically connected to those health systems. The leadership of the academic departments will continue to receive practice support for faculty, assist with health system oversight of a growing academic faculty, and along with leadership of JABSOM, be active in the strategic planning and integration of clinical operations and clinical education in those health systems. Along the way, the practice plan has supported the UH Cancer Center and nursing school in their own clinical endeavors.
Of course, these are just some highlights of my experience working as dean of JABSOM with so many wonderful individuals from JABSOM and our larger community ‘ohana. In closing, I am reminded of the words of another wise person who reflected on the importance of finding work that fills one’s soul, rather than one’s wallet.
“No amount of money can take the place of not having to work for a living.” (Hedges – 1970)
Figure 1.
Jerris Hedges MD, MS, MMM