Centennial Oral Histories:
Ralph Snyderman, MD

Ann Pelham  0:20  

I’m here today with Dr. Ralph Snyderman, who is a leader across many decades at Duke, particularly and entirely in the health area and medical education. And we’re going to spend some time — it’s very easy to get distracted by all the parts of your life — but we’re going to try to focus on Duke. And we’ll start with when you became the chancellor of the Duke University Health System in 1989. And in fact, at that time, it wasn’t quite the Health System. Is that right?

Ralph Snyderman  0:51  

Sure. And you said [to] focus on Duke. That’s easy for me to do, because I’ve been at Duke for at least two-thirds of my entire life. So when I was appointed chancellor in 1989 it was a total surprise to me. When I got a call saying, literally, “Ralph, we need you to come back to your institution.” [It was] very, very touching to me. I had no experience whatsoever in major academic administration. I had been on the faculty at Duke as a physician-scientist for 15 years, so I knew the institution very well. Even before that, I had my clinical training at Duke — my internship and my residence. So I’ve been at Duke for a long time. I left Duke in 1987 to go out west to San Francisco — it was always a dream of mine — to be at Genentech, a leading biotechnology company. And I never thought I’d be coming back to Duke. Until I got that fateful call. So when I came back to Duke, my thoughts and my ambitions were really very ill-formed. I thought it was a tremendous honor because I truly loved Duke, and I still do. My main goal was to make this a highly impactful, important institution that was known to be ranked amongst the best of the very best. I didn’t have much more detail than that. And when I came in I really needed to learn the job. My initial focus was in strengthening the areas that I knew best – research, science, a very important part of what we did at that time at the medical center. My initial focus was on building the faculty [and] bringing in outstanding scientists, which we were able to do. Bring in outstanding chairs, many members of the National Academy of Sciences. That took initially about two years, to at least learn that much about the job. Then I really understood the job a lot better. And the job was being responsible for the entire institution — the School of Medicine, the School of Nursing, allied health professions, the hospital, the practice, the whole thing.

AP  03:33

Quite a big job. 

RS  03:35

It was a very big job, because the responsibility of the chancellor was to make sure the entire institution ran, and ran as well as it could. And after I had been here a couple of years — the initial two years, I really felt as though I needed to learn the business. I mean, that’s a whole different story, but I had to learn every part of everything that I was responsible for, including how the hospital ran and the various interstices of many different things. But after about two years, I made a startling discovery, which was kind of frightening. The entire capability of the medical center, the hospital, the clinical faculty, basic science faculty, [and the] schools depended on revenue from the clinical enterprise. In other words, our clinical faculty — the members of the clinical departments — saw patients through the Private Diagnostic Clinic. And they admitted their patients to Duke Hospital. Those activities created revenue. That revenue flowed back to pay for most other things. Research pays for part of itself, but to be able to make everything balanced, the clinical revenues were critically important. 

About two [or] three years after I came to Duke, the phenomenon of managed care started sweeping the country. Before that our specialists — and we had the best specialists, I think, amongst the best in the world — physicians would refer their patients to the specialists, and everything ran beautifully. It made a lot of sense. But as soon as the insurance companies started taking over where patients would go, as a reasonable cost-saving measure, they started restricting the flow to private practice. Don’t want to get into all the details but the model that we had, which was a clinical faculty that was entirely specialty practice, could not sustain itself. It could not survive in and of itself when the referring doctors, by necessity, had to refer somewhere else. So it was almost an epiphany to me over a short period of time. [I thought] “Oh, my God. This whole beautiful enterprise, all these beautiful Gothic buildings, you know, people, toing and froing, is dependent on a model which no longer is financially viable.” So that dominated after the first two or three years. That dominated a big portion of what came. It became obvious that we needed to change the structure, and ultimately it led to the concept of the creation of the Duke University Health System. We needed to create a clinical enterprise that not only practiced specialty medicine, but reached out way into the communities that we served, and provided full service of healthcare.

AP  6:54  

And how does the Duke Clinical Research Institute fit into that new scheme?

RS  7:01  

That’s very, very important. Because if you look at the overall function of the Medical Center, it has three core missions – education — very, very clear. [There is the] School of Medicine, School of Nursing, [the] Physician Assistant [Program], [the] Physical Therapy [Program], and on and on. A tremendous educational mission, very, very important. Residency programs. Clinical care, I just mentioned that. It is our responsibility to deliver the best [and] most innovative clinical care. The third piece is research. And research is absolutely vital. The idea of having the capability of discovering new things that may have an impact on medicine. But the idea of the [Duke] Clinical Research Institute in many ways differentiated and still differentiates Duke from any other medical center in the country or the world. And that is [because] the responsibility of most medical centers has been considered to be discovery research. Breakthroughs in understanding things. My feeling having grown up at Duke and being trained clinically and the excellence of our clinical practice is that we were positioned better than almost anybody to translate basic discoveries into practical applications. What they call translational research. And we had some very strong translational research. So the idea was that we would institutionalize our clinical research, which occurred in many different little parts of the Medical Center, and create this whole new model of an academic clinical research organization. And that concept, with the leadership of [Robert] Rob Califf — who is currently the commissioner of the FDA, he and I go a long [back] way together — his leadership, and the idea that we actually worked on together, and the support of the Medical Center, enabled the Duke Clinical Research Institute, the DCRI, to be the largest, by far, academic clinical research organization in the world.

AP  9:20  

It’s an impressive accomplishment. I’m just going to put the dates here now. You came in 1989 back to Duke. DCRI — I say that because the sign is at the top of a big building now in downtown Durham — the Duke Clinical Research Institute was 1996. The Duke University Health System was established in 1998. Have I got all those right? You were a busy person for those years.

RS  9:51  

Being Chancellor for Health Affairs I used to say [that] most people have jobs, and that’s a good thing. There are professions. And being a chancellor or things like that is different – it’s a way of life. It really was a way of life. And I embraced it. I loved it. I loved it. It was a tremendous honor and a tremendous privilege. But you’re right. I mean, it was not exactly 24/7, but you’re on call all the time.

AP  10:25  

What challenges were there when you were moving Duke from a hospital system and a medical school to an integrated operation?

RS  10:36  

I think the main challenges in any type of leadership. Most people think that a great leader has great ideas and develops great pathways for things to happen. The truth of the matter is that’s necessary, but that’s just table stakes. Once you have an idea of what is the right thing to do — you have to have a pretty good idea and listen to a lot of people to develop the idea what is the right thing to do — but then the next 80% [to] 90% is getting everybody else to go along with it. So to move from where we were when I came here in 1989, which was a series of highly independent faculty. I mean, every faculty [member], more or less, has to make their own way, whether it’s through clinical practice or research. So individual faculty members, divisions, departments, schools, each of them function to a degree of independence – high degree of independence. And here comes me saying, “This model needs to have some substantial modifications. We need to organize — in addition to what everybody is doing, all the different people, departments, divisions, etc. — we need to have an overarching capability of doing things as Duke University Medical Center and Health System. We need to have an overarching structure that creates things that otherwise could not be created, that benefits the capability of the institution and doesn’t deny the important independent functions of everybody else.” That is a big challenge. Number one – thinking about how we actually do it. In everything I do, there are 20,000 people that were involved in it. To convince people that they had to give up something to get something else. To convince a very strong department chair [like the] Department of Medicine, Department of Surgery [that] we need to take away some of the things that you used to own and make it a corporate entity, and in return, you’re going to be getting to be part of this great corporate entity. You’ll get it back. That degree of trust is very, very hard. You have to earn it. You have to earn it. So the biggest struggle, once we figured out what we needed to do, [was] to get people to understand and buy in. And by buying in, they made the entity far better than anybody could ever imagine.

AP  13:30  

You mentioned Rob Califf. I know that the call that you got out in California to come back to Duke was from [Robert] Bob Lefkowitz, who was later a Nobel Prize winner. Are there some other individuals who sort of got it – the message that you were delivering – who helped you lead the change of Duke into an enterprise-wide operation?

RS  13:54  

There were many. Let me just stop with Bob Lefkowitz, just for one moment. He’s my closest friend. We met when I first came here. He came in 1973. We started running together. And we’ve calculated that the two of us, pretty much one-on-one, ran over 50,000 miles together. So we became very good friends. When I was at Genentech [I was] very, very happy. I loved it there. I was really, you know, getting engaged and involved and I enjoyed San Francisco. He called me up. I mean, I was coming back from a meeting in beautiful Lake Tahoe. What could be better? And I get a message. “Call this number at Duke.” And as Bob Lefkowitz says, he’s the one who told me, “Duke needs you. You need to come back. This is where you need to go.” But at any rate, [William] Bill Anlyan was my predecessor. When you have a successor, the predecessor and successor don’t always really work together well. There [are] issues of trust, and changing things, and all that kind of stuff. Bill Anlyan was one of the dearest, most sincere individuals. My relationship to him was like family. I loved him, I trusted him, and he was a very valued partner and an advisor. You know, he helped me navigate things. [Phillip Jackson] “Jack” Baugh, who was chairman of the Board, probably in 1991 [or] 1992 [or] 1993, he helped me survive times that were very difficult, when very powerful people within the Medical Center didn’t want this new kid on the block to come back and mess things up. So Jack Baugh was very, very important. 

[William] Bill Donelan, I guess you could say he was chief financial officer. Very, very helpful. From the very beginning he helped me navigate Duke. What I say with real honesty, the people who made this happen were probably about 16,000 people who worked for Duke. I mean, really, it was an amazing joint enterprise. The clinical chairs were very important. Rob Califf was very important. Vicki Saito, who was my head of communications. I was a kid who grew up in Brooklyn, and I had never done anything like this before. Even though I had been polished a little bit by being at Duke, coming back as chancellor I needed people to kind of keep me straight and engaged and communicating. Vicki was very important. Cindy Mitchell, who worked with me probably the last 10 years that I was chancellor, also. [I was] very heavily dependent on her telling me where to go, where to be, managing my calendar. But I really want to say with all sincerity, all the department chairs, many of the leadership of the clinical faculty, [Nannerl] Keohane, who was my boss, the president of Duke University. There has to be some degree of tension between the president of the University and the head of the Health System. I’ll give you a little inside story. You’re on the board. When we were creating the Health System, and we were starting to buy hospitals and it was a big risk, taking a lot of money. And to their credit, the Board of Trustees supported this, John Koskinen, Randy Tobias, they supported this, and Nan Keohane supported it. But I remember one board meeting when we were talking about buying a hospital, and people were getting a little nervous. One of the members of the board pointed to Nan Keohane and said, “If that hospital goes under, you’re the one that’s responsible.” And he points to Nan Keohane. I’m thinking, “Oh my god, that has got to be [laughs], what is she feeling right now?” So there were a lot of people that made this happen. 

AP  18:15

It wasn’t just a walk in the park. 

RS  18:17

It was not a walk in the park. But it was a great adventure.

AP  18:21  

We’ve talked some about the research at Duke, and the accomplishments. The AIDS research, the COVID research that’s come out of the [Duke] Human Vaccine Institute. There are many, many examples. But you also took your interest in Duke [and] in medical education in another direction. And that was the partnership in Singapore, that I think got started under your watch. Is that right?

RS  18:50  

It is correct. And one of the things I always had in mind, and I remember discussing this with Nan one time. She [asked] “What [is] one word that describes you, and what you [are] looking for, and what you [are] doing in the Medical Center. I said, “Impact.” I hadn’t really thought about it, but I said, “Impact.” Whatever we [did], I wanted to make a real big difference. And having Duke be a force nationally — a force for good, for improvement of health — was our very, very high priority. But giving us an international bent [and] focus, I thought was a tremendous opportunity. Because what we had created conceptually was very important. There was an initiative at Singapore to find some partner in the United States to create a medical school in Singapore. They had 10 institutions that they were going to look at. Quite frankly, Cornell was the one. It was theirs to lose. Because the dean, or the individual who was leading it on the healthcare side, came from Cornell. The deputy prime minister of the Singapore government was part of the team. He ultimately became president — Tony Tan. And so they interviewed Duke. And at that interview, I met Tony Tan. And I told him, “It’s so interesting, you mentioned about the DCRI and all the things that we did that you might consider entrepreneurial. It’s not the normal thing that an academic institution does.” And Tony really liked that. So when all was said and done, they said, “Duke, you know, do you want to do it?” And I visited a number of times. Another person [who was] very helpful [was] Bob Taber, Head of Technology Transfer. He was very instrumental in doing the deal with Singapore. So it came about by the search of Singapore to find a partner. They wanted the best in class, but they also wanted an innovative institution. And Tony Tan, who [as] I said, ultimately became president and he was president for many years. He and I struck up a friendship, and I came back many times. And it was a wonderful thing,

AP  21:30  

Well, and it is today. It still operates, and I think it is serving both institutions, Duke and the hospitals and medical schools they’re affiliated [with] in Singapore.

RS  21:42  

Absolutely. I think they’ve been very innovative in terms of modes of education. I still visit there from time to time. And to a credit to our faculty, [Patrick] Pat Casey, [K.] Ranga [Rama] Krishnan, [and R. Sanders] Sandy Williams, they came up with beautiful models of education that are actually coming back and enhancing education here.

AP  22:12  

And in many ways, my understanding, and you can correct me, is that the opportunity to test new ideas in Singapore came back to Duke, and it enhanced Duke’s willingness, in many ways, to try something new. Have them listen to the lecture first, maybe even on video — that was probably later — and then go into the lab having been informed and have the conversations around the lab work [and] not just be a passive absorber of a lecture.

RS  22:47  

You’re absolutely correct. And the other point that you made is very, very important. Because what Singapore is offering is – in a sense – a test bed, in one of the probably most innovative countries in the world, that would enable us to do things there with more agility, and sometimes much easier than we could ever do here. And the point that you made, I’d like to emphasize, because it’s really true. When we started thinking about personalized healthcare – a whole new concept of an approach to health and an approach to medicine. One of the people at Singapore — because they weren’t going to give us a whole bunch of money — who was familiar with what I was doing, familiar with the work that I was interested in, he said, “Ralph, you will be able to do this in Singapore much more quickly than you could do it in the United States.” And he was correct.

AP  23:50  

Well, you mentioned personalized health care, and I know that’s a theme that runs through your own approach and philosophy about medicine. Can you talk about what that means and where you have seen it evolve over the past two or three decades?

RS  24:06  

Sure. Thank you for asking that. It really is something that is near and dear to my heart and [that I am] still actively involved in. Probably about 1998 we had just created the Health System, and we were doing very, very well. We actually had something akin to 2 million patient visits, if you look at all the outstretched areas of the Health System. And every year — well, you remember the Board — every year I would make a report to the Board, and probably whoever my counterpart is [is] making reports of the Board. And as you might imagine, you want them to really like what you’re doing. So you’re totally honest, but you embellish it as much as you can. And I would do that every year. I loved it. The Board loved it. 

One year, as I was looking more — not only [at] the basic research or the education, [but] the actual clinical care — and I was looking at the 2 million patient visits that we saw at Duke. And we were one of the best clinical entities in the world. Almost all of them were individuals that had a disease, a chronic disease, and they had something go wrong. They would come to Duke, we would fix it, and they would go back [to their life] and they’d still have the chronic disease. That was about the time that the human genome was being sequenced. So for the first time in the history of humankind, we were going to have some outline of the map of genetics, which is very important in susceptibility. And I was thinking, “Isn’t it a shame that the medicine is practiced to try to fix things that were already broken?” I mean, that’s important. But as we start looking with genetics, and we start thinking of the evolution of one’s life and the evolution of disease, shouldn’t medicine be looking at the dynamics of trying to get involved in a patient’s life journey and provide them care for where they are in their life journey, rather than wait until they get sick and then take care of them? And with that came the idea that we need to take medicine and flip it around. That rather than looking at medicine as disease once it has already occurred, try to understand the dynamics of the person’s health and be able to predict what are the risks that they’re facing. And that healthcare ought to be reducing the risk. It’s a totally different way of practicing medicine.

AP  26:47  

And at the same time, you’ve also got more knowledge if that disease does come about, exactly what sort of disease they have. I have an in-law with a particular type of cancer, but they were able to say, “Well, this is, this isn’t a 10, and it’s not a five, but it’s somewhere in there.” And in some other kinds of situations, “That’s a three. We don’t have to worry about that.” How do those two threads, those two changes come together?

RS  27:22  

Beautiful. I love it. It’s a great question. So you know, the concept of thinking in terms of mitigating risk and being able to give each individual what they need came out of this concept that is now called personalized medicine [or] personalized health care. And then you’re talking about if an individual has a problem, how do you give them precisely what they need? So if you talk about cancer, [it] is a beautiful example. It used to be, and it still is, for many kinds of cancer, that if you have a cancer you get a general diagnosis of what that cancer is, and the degree of severity, and whether it’s spread [or] metastasized or not. And the therapy is radiation therapy or chemotherapy, but basically everybody gets almost the same thing based on the nature — the general nature — of their disease. What has revolutionized cancer is to define each individual’s tumor. What is driving that tumor? What is driving the cells to be a cancer cell? And if we could identify specifically what that driver is, and if we have a medicine that works on inhibiting that driver, that is what we call targeted therapy. And that has been one of the great advances of personalized medicine, and that’s why it’s called precision medicine. Finding out specifically the driver of the disease for that individual, and having a drug or a therapy that goes directly to that.

AP  29:13  

So let me just think about these different words. Prospective healthcare, personalized healthcare, and precision healthcare. At the end of the day, is it all coming together and is that the benefit?

RS  29:28  

You know, it’s been a bit of a fruit salad for names. It’s been difficult for me. When we first came up with this idea, the question is “What do we call it?” Because it’s revolutionary. I liked the word prospective at that time because it was still so early. Because rather than being retrospective —

AP  29:52

Once you’re sick already.

RS  29:53

Once you’re sick, it’s retrospective. We were going to flip it around, so initially we called it prospective health care. Nobody seemed to like that too much. So it went from that to personalized health care, and it’s still called that. But then a lot of people said, justifiably, “Now wait a minute, what this really is, is what you pointed out, trying to find the precise diagnostic, the precise therapeutic, and let’s call it precision medicine.” So I call it personalized precision medicine myself.

AP  30:27  

You’re putting together where the person is with where the disease is. So it is both directions in some ways. Well, we’ve looked back, and we got to the place where you had spent 15 years as the chancellor and helped create the Duke University Health System. You retired from that. You stepped down from that job. Could you talk a little bit about what happened next, just to make sure we’ve got the full story?

RS  31:03  

Well, you know, I stepped down. It was an intense job.

AP  31:08  

15 years. I think you’re the longest-serving. Was Dr. [William] Anlyan —

RS  31:14  

Dr. Anlyan was [in the position] longer than me.

AP  31:18

But it was a bit of a smaller operation. 

RS  31:21

It was a different operation. But I give him all the credit. Dean [Wilburt] Davidson, let’s see he was from 1930. No, he was probably longer. He came in —

AP  31:29

But that was a different era, in many ways.

RS  31:33

A different era. I’ll just interject one thing. I was thinking about this as I was thinking of having this interview. I came here to Duke as an intern. [crosstalk] I came on the faculty of 1972. I came as an intern — I hate to even admit it publicly — in 1965. I was this young little pup from Brooklyn, New York, coming here as an intern. The reason I bring it up right now is that I remember seeing, at least several times, Dean Davidson. Do you believe that? He used to come to medical grand rounds with his white coat and had a pipe. I don’t think the pipe was lit. I’m sure it wasn’t lit. But I was thinking, “How many people here at Duke ever saw Dean Davidson?” That’s scary, I mean for me.

AP  32:19  

A connection of eras, I think.

RS  32:20  

It really was. That was a transition of the eras. But when I stepped down I took a mini sabbatical at UCSF. As I said, I love San Francisco. I live down there. And we created a company that did some aspects of personalized medicine. And ultimately it was purchased by McKesson. But I have been involved continuously in trying to further the field of personalized precision medicine. I’ve done it helping out part-time in venture companies [and] investing in personalized medicine companies. And I found it to be an awful lot of fun. I’m on some public boards that deal with personalized medicine, including a very, very big genomics board. But I continue to have a small operation, a small center called the [Duke] Center for Personalized Health Care. And what we do, I just absolutely love it. We have a lot of undergraduates and medical students who work with us, and we do actually develop clinical working models to deliver personalized health care. And we’ve come up with a model of care that we really think [is] very, very good for caring for individuals with multiple chronic diseases. Because the current healthcare system, even though it’s changed a lot, still focuses on point interventions for chronic disease.

AP  33:59  

So you want to come home with them. 

RS  34:01  

You have to do that. You absolutely have to do that. You have to have a way that supports the individual over time and enables them to be far better involved in their own care. So we’ve come up with that model. [It] really was developed at Duke. We started a small little company that was spun out of Duke, and I am on the board of that company. But I continue to be very actively involved in what I truly love [which] is things related to health care and things related to Duke. 

AP  34:38  

Well it sounds like that center gives you a connection also to education [and] to the students. And I know that’s something that you also feel strongly about. You’ve got a Snyderman — is it a fellow that comes – there are a couple every year? Can you talk about that?

RS  34:56  

There is. It’s such a wonderful thing. A member of the board, Julie Esrey — she comes back from time to time — she was a really fantastic member of the board. And her husband, [William] Bill Esrey, who was the CEO of Sprint. We got to be very, very good friends. So they made a contribution for this fellowship. And the other individual is Joe Moore, who took care of Bill Esrey, so it’s the Snyderman/Moore [Healthcare Scholar]. I’m not even sure — a scholar [or] fellow. And we have either one, or next year we’ll have two. And I just love it. I mean, there is nothing more empowering and challenging, in a very good way, to have the best and the brightest undergraduate or medical students work with you. I mean, they’re so good, they’re so earnest, and they’re so early in their career. And to be able to develop a very special relationship being a mentor. And I still don’t know exactly what that means, because it’s an extension of being a friend, being an individual who wants to help. And it’s an interactive kind of thing. It gives me great joy, and I think it’s really quite productive. We’ve published a lot of papers together. 

AP  36:26  

I know one element of this is to give even an undergraduate a chance to do some research, is that right?

RS  36:31  

Yes. Duke is such an amazingly good place in terms of their own curriculum, they have the undergraduate school curriculum. Then they have focus groups. I’ve participated in that in personalized healthcare. And then there are student initiatives called house courses. And I don’t know for how many years, for at least the last 10 years, there have been students who wanted to do a house course on 21st century medicine or healthcare. So I’ve been the mentor. Each semester I will give usually two presentations, but the students do most of them. Very, very frequently students from that course, from that house course, will come and work in the Center. And I have one right now that’s just graduating. She’s spectacular, and she’s now going for a graduate degree at Duke. 

AP  37:32  

So do they end up always in medicine, or just in different aspects of health?

RS  37:37  

Different. This is a very interesting thing that I found, is that when undergraduates decide that they want a career in healthcare, usually it’s medicine. That’s the freshman mindset. And as we do the house course we have every year — and the freshmen are almost always [saying], “I want to be a physician” — by the time they graduate, it really spreads out. I’m not sure how many, maybe a third become physicians. A third go to business school. A third go to law school. I have too many thirds there. But, you know, they break themselves up. And some go into venture capital. So I’d say only about a third continue to go into medicine, but they all go into healthcare. 

AP  38:24  

In many ways the definition of healthcare is so much broader than it was back in the 60s, I’ll say. Why is it important to you to be close to those students, and to have a chance to be with them.

RS  38:40  

You know, I would say, more than anything else, it’s natural. It’s fun. I like people. I like engaging with people. Now that you asked the question, it may relate to that concept of impact and leverage. If you think about having an impact on a person that is at that stage in their career, and being able to pass on all those things that took you so many years to learn, and give them, I would hope, the benefit of it, for what it’s worth. I enjoy that a lot. But I enjoy their energy, their freshness, their enthusiasm. It’s a wonderful two-way relationship.

AP  39:24  

I think that’s a great answer, and it certainly explains why you’ve kept your hand in. It’s also energizing. At least that’s how I feel about it. I want to give you a chance too, to talk about some of the other Duke leaders in the years since you retired from being the Chancellor. Because you’ve been an observer of Duke all these years. Are there some people that stand out to you? Are there some particular achievements the University and Health System have had since the early 1990s that you feel like are important to point to and highlight as we’re looking back at Duke in this centennial year.

RS  40:12  

Well, I think since I stepped down — which is now 20 years, it’s hard to believe that that’s the case — Duke has continued, not only to develop and to grow, [but] continued to accelerate. The idea of impact is very, very important. There are many dozens of individuals. I have great reluctance to mention anybody. I’ll eliminate so many. I’ll just mention, let’s say, Bob Lefkowitz. Bob Lefkowitz — I stepped down in 2004.He and I were closest friends. He started at the very, very beginning of a whole field of understanding how receptors work. Just at the very, very beginning. And that would have been back in probably 1968, when he started. He worked it all the way through to a concept of what is a receptor. Is there a receptor? What is a receptor? All the way to not only understanding the mechanism, but with his colleague, Brian Kobilka, looking at the actual structure, [the] three dimensional structure, and he won the Nobel Prize in 2012. So I’m very, very proud of that. Paul Modrich, also from the faculty, is doing amazingly important work in understanding the regulation of DNA and how we protect ourselves against cancer. But another person that I think is worth talking about, because he’s already done a lot, but I think is just the beginning, is Barton Haynes, Bart Haynes. I had the honor of recruiting him to Duke probably in 1977. We created the Vaccine Institute. And his work in so many different areas is tremendous. Work with AIDS, but in general, understanding of vaccine development is going to be incredibly important. Rob Califf, [who] I mentioned with the DCRI, went on from Duke and [is] now leading the FDA. So there are many, many dozens of examples. But the main thing is the trajectory continues to be up, with an upward slope. And I feel very, very good about that.

AP  42:51  

May I ask you about the changes recently in the Hospital System, in the Health System? How do you feel about the shift from the Private Diagnostic Clinic, folding it into the [Duke] University Health System. It would be interesting to get your perspective.

RS  43:11  

Well, I think it’s terrific. In 2004, let’s say 2003, when I had already done three terms as Chancellor, if I had even a fleeting period of time when I thought maybe I should go for a fourth, one of my top goals would have been to integrate the Private Diagnostic Clinic into the Health System. I thought it was very, very important. So I think it’s a good thing. It’s still early. I’m sure there are kinks that need to be worked out, and they will be worked out. But I do think it’s a very good positive thing to get a more integrated care delivery system. No doubt about it.

AP  43:59  

And I think the opportunity to understand better how people spend their time, satisfy the grant makers, all those things, are elements of it. I don’t think there was any question that the quality of care was and continues to be very high. But let’s go back to when the PDC was created, that was early on in Duke’s history. And my understanding, and you can correct me, is we were trying to attract physicians to come to Durham, North Carolina, and be part of what everyone believed was going to be a great medical center. And it was a marketing tool. Is that overstating it a little bit?

RS  44:46  

No, I don’t think so. I think it was a marketing and retention tool. It created a very novel way of integrating a clinical practice — a really, as you said, outstanding, world-class clinicians that could spend most of their time doing clinical practice. Because, as you know, we have three core missions — education, research and clinical care. It enabled them to really focus 80% of their time on clinical care and be able to make their way. To be able to make their salary, and contribute to the academic mission. It started roughly, I think, in [1931]. A totally new concept, a private diagnostic clinic. It was a limited partnership. Very, very complicated to understand. And it functioned very, very well in a very hybrid way, to have a clinical practice that is independent of Duke. Duke had a contract with the PDC. It didn’t own it. It had a contract with the PDC, but every member of the PDC needed to be a member of the clinical faculty at Duke. So it was only for Duke faculty members. So it was tied to the faculty appointment, but independent in terms of the clinical practice and the revenues, part of the revenues, of the clinical practice. It worked well. It always worked well. But it became more and more difficult to manage once the institution needed to function as a single institution in delivering care. So if Duke wanted to deliver care throughout North Carolina, South Carolina, Virginia, the Southeast, the world, it has to deliver care [with] the clinical practice and everything else. If the clinical practice is independent, as much as we always work together, you have to contract with the independent entity. It just didn’t make sense in terms of how you want to fully integrate the clinical practice.

AP  47:04  

And as the world got more complicated with different payers, it all became —

RS  47:10  

It became very complicated. And it certainly didn’t serve — I think ultimately it didn’t serve anybody as well as it could if we had a unified entity.

AP  47:20  

It seems to be going well.

RS  47:22  

Yes. I’m optimistic.

AP  47:23  

Thank you for the history lesson [laughs]. It’s just an important change going on right now.

RS  47:31  

And it was always hard to understand — what in the world is the PDC? But anyway, I lived with it during all my time on the faculty, through my entire 15 years as a chancellor.

AP  47:47  

When you think about what comes next for Duke, and particularly for the Duke University Health System, what hopes do you have, what dreams, what would you like to see in the next two or three decades?

RS  48:01  

Well, it’s a wonderful question. And, let me say that I mentioned the word impact. That Duke Health, if we call the entire entity Duke Health, my feeling is that it should continue to strive to have the maximum positive impact on health. And here, let me regress for one moment. I think one of the most important things that I did and I learned as Chancellor, and this occurred, I think in year two or three is when I had this much broader understanding of what [this is] all about. There are three core missions for an educational entity, whether it be Duke University undergraduate [school], or the School of Medicine. Education, research, and in healthcare, it’s clinical care. In the university, it might be service. But those are the three core missions. It’s called the three-legged stool. As I started thinking about it, I started thinking about the institution I thought, “A three-legged stool is a great thing, but shouldn’t there be an overarching mission?” You know, you have this great mission of education, research and clinical care. Shouldn’t they draw off on the strengths of each other to create something else that is not a product of any of these alone? So we came up — and I think this has largely gone unnoticed — [with] a fourth mission. Education, research, clinical care, and to serve the health needs of the public. And that became the fourth core mission of Duke Health. To my knowledge, we’re the only institution that has a fourth core mission. So my goal for Duke, whether they call it a mission or not, is to use the strength of all the individual components, which are tremendous – world-class — but to go even more. Increase the leverage by having a way to combine them together for a greater good, but do it so you don’t mess up all the independent parts as well. So that’s my goal. For Duke to continue to have, as Terry Sanford said, I just love this, he said we should have outrageous ambition. That ambition should be [that] we should be unique amongst all the academic health systems and really focusing on creating new models of improving the care of the public.

AP  50:51  

I think that’s very well said. And in many ways, if you use the Duke Health name, which is the brand at this point, it does seem to be outward-facing to the community. And I know that even Medicare will measure some returns on their investment as when they look at the community. So, is that the vision, that at some point it’s the Health System, it’s Duke Health, that’s delivering personalized medicine to the people in the community around it? 

RS  51:32  

Absolutely. I mean, you said it beautifully. And I don’t want to get in the weeds too much, but I really do think that this is happening. The ability to deliver the type of care that truly deals with each individual at the point in their life where their health could be impacted, which is now for each individual, to be able to give them what they need to have the best health that they can. The current system of how healthcare is paid for makes that very, very difficult. Because it pays for the delivery of episodes of care. It doesn’t pay to think about what we do to make this better in the future. But as you implied with your question, there is a total change. It’s going to be still a number of years moving the reimbursement system to reward really favorable outcomes for the individual and for the community. So I think that, in a way, we’re pacing ourselves to a degree, to develop those capabilities and be able to implement them as soon as we [can] implement them. And we’re starting to see a crescendo. That’s happening more and more. So I think that we will be able to have that fourth core mission of serving the health of the public.

AP  53:01  

We’ve got vegetable delivery to help people make sure they’re eating healthy, mixed in with the antibiotics [laughs].

RS  53:11  

I mean what you say is so important, and that is, health is probably one of the most under-recognized resources that anybody has. It’s almost trivial to say health is something that we take for granted until we lose it. Enabling people to understand that that’s not the way it is, that they could play a very important role in their health, is also part of what we need to do. 

AP  53:41  

Well, you’re sitting here today, 20 years after your retirement, and you said you were a runner. Maybe you learned early on how to eat right and live right, because you certainly look great. 

RS  53:54  

Well thank you so much.

AP  53:54  

I’m glad that you were able to talk with us. And is there something else that we haven’t touched on either, Duke-related or otherwise? I know that Duke University is not your area of expertise, but you’re an educator. How about the university itself, aside from the Health System, is there something about the next century that you dream of for the university? 

RS  54:22  

Yes. And what I would say is that I’ve come to learn more and more the importance of a true synergistic relationship between Duke Health and the University. And it took me a while to really appreciate that. What I would hope for Duke — and I see it right now,  I really do see it — but stepping far enough back, in addition to everything that it is doing, same thing, education, research and service, it has an overarching mission of having impact on the good of the public, as it relates to education and culture and well-being. And I think Duke is doing that. I feel very proud of Duke. The fact that I’ve had an association with Duke for two thirds of my life is a blessing. So I feel very bullish that Duke has done that naturally. I mean, it’s done it naturally, and I suspect Vince Price thinks about this all the time. In addition to all the things that we’re doing, how do we go to that next step to really have an impact? But embracing the concept of impact as well as excellence in all you do, I think should be — and you’re on the Duke board — I think it is an overarching Duke University mission.

AP  55:52  

It certainly seems to be. And it means that your mission as a nonprofit is also broader, because there are advantages to operating that way. So you get some duty to the public good in that. So there’s a lot of synergy. Well, it’s been a real pleasure to talk with you. I’ve learned a lot, and we appreciate your willingness to talk about Duke in this year of the centennial.

RS  56:20  

It’s one of my favorite topics, and I enjoyed talking to you tremendously. Thank you so much. 

AP  56:25  

Thank you. Dr. Snyderman.