Strategic Planning Committee Presents an Integrated Plan for CUMC

The Dean's First Response to Planning Recommendations

The three academic planning reports tell us a great deal about the dedication and insight of those who participated in the process. Each one contains an enormous amount of information that will be invaluable in the coming years. I urge you to read them. Individuals gave generously of their time, their most precious resource, over a period of one year. On behalf of the entire community, I thank them.

You will probably agree with most of the recommendations in each report. But you must also wonder how much can be implemented in the current environment. There is a danger in raising unrealistic expectations, but as we move ahead, we welcome the challenge of a bold plan. We do not have the space, personnel or dollars to do everything right away. But we must begin. We must decide what to pursue in the immediate future and what to plan on a longer time scale. Within each area we will give priority to initiatives that:

• Build on strengths.
• Anticipate opportunities and future directions.
• Build bridges between pre-clinical and clinical research.
• Enhance activities that have broad impact throughout the Columbia University Medical Center.
• Attract and retain the best faculty, students, and staff.
• Take advantage of resources available within the Columbia University Medical Center Schools, the Morningside Heights Campus, the NYPH, and other affiliated hospitals.

Here are our first conclusions, offered with the full expectation that they will evolve as we discuss the plan further.

RESEARCH

The Research Committee discussed several cross cutting issues, including the need to improve the infrastructure of the research enterprise. The Office and Grants and Contracts and the Institutional Review Board will have our highest priority. Both groups labor under an enormous workload and both are vital for our success. They have been moved to new, expanded space, new personnel have been hired, automated submission procedures are under construction, and new training efforts have been initiated. Frequent updates will be posted.

Recommendations were made about specific areas of research in which we are strong and others that need strengthening. I recognize the merit of all of these suggestions. The Planning Committee called for the formation of task forces to explore each area in more depth and to develop plans for supporting each area, and I agree that careful thought must be given to any proposed expansion. Here, I will comment on only a subset of the highest priority recommendations. Compelling cases were made for new or enhanced programs in chemical biology, human genetics, immunology, neuroscience, and computational biology.

Chemical Biology. A strong case was made for recruitment of scientists working at the interface between chemistry and biology. Large libraries of small molecules have already proved useful in analysis of cellular processes and of gene expression. Several members of our superb Chemistry Department at Morningside Heights have expressed interest in such an effort. The intersection between chemists and structural biologists, and others who are engaged in clinical research, is certainly an area of great strength at Columbia and an extraordinary opportunity for recruitment. Scientists who can build and manipulate molecules are critical to the success of efforts to translate molecular and genetic findings to novel therapeutics.

The new effort should build on the strengths present in our departments of chemistry, biochemistry, pharmacology, and medicine, but it should also represent something new at the interface of all of them. A balance must be struck between specific research areas such as chemotherapy or cardiovascular pharmacology and an emphasis on methodologies such as small molecule combinatorial chemistry.

Because of the great strengths uptown and downtown, a new program in chemical biology raises, perhaps more immediately than other programs, questions about space, governance, compensation, teaching, and academic traditions at the two campuses. Resolution of these issues might serve as a model for other joint efforts as we respond to President Bollinger's call to enhance the life sciences at Columbia.

The new program would be expected to offer new courses in topics that are now missing at Columbia such as Methods of Drug Discovery and Computational Approaches to Drug Design. It would also be expected to promote collaborations and to establish core facilities and produce molecules of use to many individual researchers. Rocky Kass has initiated discussions with faculty in Chemistry and the Health Sciences.

Computational Biology and Bioinformatics. A new program in Computational Biology and Bioinformatics would make the considerable strengths that are already present throughout the University more coherent. This will enhance research and training, and it will also offer an invaluable intellectual partner as our efforts in genetics, genomics and proteomics and in chemical biology expand. There is no question that the biomedical scientist of the future will spend more time at a computer terminal and less at the bench. New methods of discovery will rely more on mastery of complex data bases and on computations based on novel theories. The need to eliminate barriers between clinical and preclinical science is urgent in this area. I have asked Barry Honig, Ted Shortliffe and Conrad Gilliam to plan a new program in this area.

Human Genetics. Columbia has not been part of the large-scale genome sequencing efforts. We should now make every effort to take advantage of this flood of information as we plan for an era in which medicine will become more proactive, guided by genetically defined susceptibility profiles rather than solely by immediate presenting complaints. This may be the most effective way to improve outcomes in the long run, and also control medical costs. The planning committee called for an emphasis on common, multi-genic disorders as well as on less common, single gene (Mendelian) mutations.

With complex, non-Mendelian disorders in mind, an expanded effort in human genetics must be closely connected to genomics, proteomics and informatics. Service as well as a research and education function will be essential. Service in this context refers to core support at a very high level, including the most advanced instrumentation and substantial intellectual input. A task force chaired by Richard Mayeux has identified many of the crucial components of an expanded program in human genetics, and they have begun a search for a scientist who might lead this effort.

A committee led by Qais Al-Awqati has identified candidates for the Chair of the Department of Genetics and Development. This individual will play a key role in furthering our already excellent programs in developmental biology, and in establishing model organisms that will aid in the analysis of normal and disordered development. We anticipate extensive interaction between this department and the new program in human genetics. A human genetics program will, of course dramatically increase the demand for additional space for mice as there will be even greater opportunities to create animal models of human disease based on studies of heritable disorders in humans.

Neuroscience. Because of the strength at Columbia across a broad spectrum of neuroscience research, and because of the continuing rapid growth of the field, studies of nervous systems including the human brain offer extraordinary opportunities. There is a need to attract scientists from a broad range of disciplines including biology, chemistry, chemical and biological engineering, mathematics, and physics.

Several of the building blocks are in place. The Center for Neurobiology and Behavior, established in 1975, was followed by the Sergievsky Center, the Taub Center, and more recently by the Mahoney Center. We must take advantage of these strong programs while moving toward a truly integrated neuroscience community.

One challenge will be to integrate preclinical and clinical neuroscience. Another will be to bridge the gap between molecular neurobiology and cognitive neuroscience. One way to achieve this goal is to organize the new program according to broad themes such as neurodegeneration, repair and plasticity, cognition and behavior, synapses and circuits, etc. Each theme would include laboratory scientists working on fundamental mechanisms, others focused on more translational or "applied" research, clinical investigators, and clinical scholars. Research teams might form and reform across themes, in a matrix with individuals at one or more intersections. If this can be accomplished, Columbia will be unique and all of neuroscience will benefit.

Immunologic Sciences. Columbia should regain the preeminent position it once occupied in immunology. Host interactions with extrinsic and endogenous antigens pose problems that are more exciting now than ever before, and they have clear implications for many fields of medicine.

A new Department of Immunology was recommended by a task force three years ago, but I believe that the interdisciplinary nature of cellular and molecular immunology and its ubiquity throughout many of our existing departments call for a different approach. I will appoint a committee to define more precisely the scope of a revitalized Immunological Sciences program, to recommend funding and space necessary to sustain it, and to search for an outstanding individual to provide leadership.

We will not postpone recruitment until a new program is established. An ongoing search for Diamond Professors has resulted in the appointment of one new faculty member, a second is expected in the coming months, and a new endowed chair is expected to strengthen further this critical field.

Clinical Research. The Research Committee also emphasized training in clinical research and support (financial and infrastructure) for clinical investigators. The NIH has done a good job in recent years providing new funding mechanisms for young and mid-career clinical investigators. We must find ways to lower the barriers to clinical research and attract more of our talented young physician-scientists to the urgent questions that must be addressed.

Global Health and Health Disparities. The Committee recognized, and I agree, that stronger programs would offer opportunities for faculty in the schools of dentistry, medicine, nursing, and public health to work together. The School of Public Health has initiated important programs in emerging infections in Africa and other regions. This is a particularly opportune time for collaboration with colleagues at Morningside Heights who are addressing global issues from the perspectives of economics, law, public policy, business, and the environment. All of the schools have focused on community health issues and this leads directly to studies of troubling health disparities and new opportunities for collaboration on needs at home and abroad.

Governance. As we plan in each area of research, it is important to consider what sort of governance, in addition to the traditional departments, can best support novel technologies and evolving modes of interdisciplinary collaboration. An important cross cutting issue identified by the Research Committee relates to barriers between researchers in clinical and preclinical departments. One way to overcome such barriers is to create Institutes or Centers that integrate research and education efforts across disciplines. University designated Institutes must articulate goals for education as well as research. They will also require a detailed business plan for approval by University Trustees.

PATIENT CARE

The centerpiece of the Patient Care Committee recommendation for an "enabling organization" is appointment of a Dean for Clinical Affairs. This recommendation was accepted immediately and the position was announced in mid-September. We seek a Columbia physician with significant leadership experience in the practice of medicine, who will be responsible for advancing, improving and maintaining the processes and systems that impact patient care at the Columbia-Presbyterian Medical Center and affiliated institutions. The new dean will report directly to me and will represent the entire clinical faculty in matters of significance as they relate to issues of patient care.

The Patient Care Report also calls for commitment to the highest quality medicine; a culture of caring; recruitment of the best people; and a supportive infrastructure. We share these values with the NewYork Presbyterian Hospital (NYPH), and we will work closely with the Hospital leadership on most of the new initiatives. The dean will focus on strategic issues and work closely with clinical departments, physician organizations, and the NewYork Presbyterian Hospital.

An expanded program of outcomes research will help set parameters for the goal of "highest quality medicine." A growing body of literature has made the case for the importance of outcomes research in promoting the practice of evidence-based medicine, improving patient safety, and providing the data needed for many decisions in the realm of health care financing. We endorse the plan for each clinical program, service, unit, or department to start by identifying at least one externally vetted outcome and tracking performance over time and in comparison with other institutions. Each program should identify one senior faculty member "champion" to lead the effort and build on existing quality assurance measures. Over time we should add more measures and publish our results both within and outside the institution. A strong program in the Departments of Surgery and Medicine, in collaboration with the School of Public Health, is already underway. The School of Nursing is developing expertise in this area and they will add to the efforts now underway in the College of Physicians and Surgeons and at the NYPH.

Promoting a "culture of caring" is a priority goal that deserves our attention. Patients and providers benefit when the clinical environment supports a patient-centered approach, backed up by clearly articulated values and standards. Building on the major initiatives already underway by the NYPH and by the Faculty Practice Organization in the area of customer service, we should seek ways to better promote the values of professionalism and altruism in all settings. We must find ways to engage faculty, staff, students, and trainees to achieve a higher level of awareness, commitment, and performance in this arena. As we train the medical leaders of the future, we must set the highest example possible in the practice environment.

"Best people" is a priority goal that should drive our efforts to recruit, retain, and recognize our faculty and staff in every aspect of our mission. It is a worthy and somewhat obvious aspiration, but the Patient Care Committee rightfully concluded that it represents a particular challenge in the complex environment of an academic health center. We are committed to the ongoing development of an environment that provides a satisfying quality of work life for all members of the health care team. I support the committee's recommendation to begin with an effort to determine what factors promote employee satisfaction.

The committee's call for a "supportive infrastructure" echoes the findings of the research and education planning committees. Providing such an infrastructure is one of our greatest challenges. In the patient care setting, it is critical to functions as diverse as efficient information systems, consolidated billing, and providing a welcoming environment for patients and families that allows them to navigate the physical and procedural challenges our campus presents. The most urgent issue identified for early action is the distribution and utilization of outpatient space. We will proceed immediately to evaluate space usage and redistribute as necessary.

Moving beyond the committee's report, I believe we must define and acknowledge the role of the true clinical scholar in our institution. As in the case of education, this may require a reexamination of titles and tracks in order to be sure that this pathway is both distinguished and honored.

SPACE

Each planning team emphasized the need for new space. No one thought of this solely as a long-range goal. The need is acute in most cases, desperate in some. The academic planning effort informed and "drove" an evaluation of space throughout the medical center. The findings of the space evaluation team, jointly sponsored with the NYPH, are described in an accompanying document.

The need for more space and for better space, along with the need to create critical adjacencies, was evident before the planning began. The academic planning process has made the needs more evident and more specific. We must develop a long-range plan, but we simply cannot put off the first steps. Significant delays will lead to loss of faculty, and paralysis of recruitment of faculty and students. Rather than consider each academic planning committee's recommendations in detail, a few comments are offered here.

In the immediate future, space will be assigned based on an evaluation of current space utilization. This information, coupled with ongoing reviews of departments and centers, will help with difficult decisions. We will continue to develop plans for new space expected to come on line in the next one to two years, and we will develop a more ambitious plan for the next five to ten years in close collaboration with the University and the NYPH. All of this will be in the context of a long-range vision that will transform the campus over a period of 20 to 25 years.

In January 2004, Audubon III, the Irving Cancer Research Building will be ready for occupancy. It will provide about 280,000 gross square feet of space for research, a breast cancer screening program, teaching, and animal housing. Audubon IV, a 240,000 sq. ft. building designated for the site adjacent to Audubon I, the Lasker Building, is destined primarily for biotechnology, for small start-ups and mid-sized companies. If our hopes are realized, it will open in approximately three years. We have engaged Hines Development Corp to help plan this building and coordinate it with the Lasker building. It is likely that Columbia will be asked to become the "anchor tenant" and occupy a significant fraction of the space.

On the five to ten year time scale we plan to build a large ambulatory care center (ACC) and a research building on the 165th street parking lot, in collaboration with the NewYork Presbyterian Hospital. A memorandum of understanding with the NYPH should be signed in the near future. At the present time, plans for the ACC include a heart institute, ambulatory surgery, and the neurology and neurosurgery programs now located in the Neurological Institute. Other surgical and medical subspecialties will be considered as space permits. In addition to clinical office space, sufficient space has been programmed for teaching, clinical research, and imaging.

The adjacent research building, now planned for the western edge of the 165th Street parking lot, can be large enough to house several research programs. Ideally, for reasons of science, education, patient care, and fundraising, the research should be immediately relevant to activities in the ACC. A home for an expanded neuroscience program is one compelling choice. This will bring a large number of neuroscientists together under adjacent roofs. Other programs, including a cardiovascular research unit, will be discussed in the near future.

A research building along Riverside Drive will facilitate interactions with the Morningside Heights campus and promote the coordinated growth of the life sciences across the University. Buses, bikes, and shoe leather will minimize the 1.5 - 2.0 mile span. A small leap of imagination connects an elevated plaza alongside the ACC and research building with Riverside Park, providing access to the waterside for the entire Washington Heights community. Flexible, interactive lab spaces will be constant themes. We can no longer afford to renovate ancient labs on the time scale of many months. Rapid change to accommodate new investigators and new opportunities must become the rule.

The 165th Street plan is the foundation for a suggested overall design that might make the campus more functional and more inviting. On the 10 - 20 year time scale, a series of elegant esplanades might "level" the campus and provide easier circulation patterns for the 15,000 - 20,000 people who come here each day. The "Framework Plan" envisioned in the Cooper Robertson-Vinoly study includes five campuses that will make up a functional and inviting whole: (1) the present 165th Street parking area; (2) the garden; (3) Audubon Science and Technology Park, (4) 168th Street; and (5) Haven Avenue. As a first step, we are working with NYPH on urgently needed upgrades of our signage and way finding.

In addition to new laboratories, we must provide more housing for animals, especially for mice. Advantages offered by the genetics of the mouse have made it the model organism of choice for studies of human disorders. We are searching for off-campus facilities for creating, breeding, and housing mice. In addition, we have begun a program to make the use of frozen mouse embryos more routine. Ultimately we must build first-rate facilities on or adjacent to the campus.

Housing for students and faculty is another critical issue. We have made some progress with a new building on Fort Washington Avenue for post-doctoral students and with rental of apartments for medical student couples in a close-in community in New Jersey, just across the bridge. Other sites in Washington Heights will be explored. In addition we will work closely with the University to identify new opportunities in other surrounding areas.

Other significant quality of life issues affect the recruitment and retention of faculty, students and staff. A number of initiatives are underway to address them. The beautification of 168th St. includes: the planting of trees and flower beds; the reworking of the steps leading up to Hammer Library; a kiosk on the corner of 168th St. and Fort Washington for security and information purposes; increased frequency of picking up trash; and working with the City of New York to reduce congestion along 168th St. by eliminating some parking spaces and having a full time policeman dedicated to moving traffic along the block.

MANAGEMENT

We will provide the Health Sciences with the kind of administrative leadership and infrastructure that will ensure the very best management and policy guidance. I am delighted with the developing team in the Executive Vice President/Dean's Office. It includes wise veterans and talented newcomers who share a commitment to individual excellence and teamwork, and whose devotion to this institution is palpable. In another document I will share more information on individual and planned positions and responsibilities.

We must pay particular attention to finances in the months and years ahead. We face enormous challenges, including the current economic downturn, increasing costs for research, a slower rate of growth of the NIH budget, new expenses for research compliance, reduction of royalty income, and reduced reimbursement for medical care and increasing cost of malpractice insurance. Our ability to achieve our strategic goals depends on our ability to address deficits in our central budget and overdrafts in individual departments. This will take great sacrifice and confidence that we will manage in a fair and open manner. New approaches to management of our daily operations are essential. We are recruiting for an imaginative, rigorous Chief Financial Officer to lead these efforts.

We shall renew our commitment to excellence across the board, including a strategic, systematic effort to recruit outstanding faculty. At the present time, searches are underway for chairs of Medicine, Physiology, Psychiatry, Genetics and Development and for a director of Human Genetics. The SDOS is searching for a Vice Dean for Research - a move certain to energize and expand its research presence at Health Sciences and on the national level. These efforts will be coordinated, as much of the research and education needs are interdependent.

Our first plan will not be our last one. We must allow for serendipity and unanticipated opportunities. With this in mind, I will create an Academic Program Committee to review and advise on major new program initiatives. This committee will evaluate proposals in the context of our overall priorities. Their recommendations will help set priorities for fund raising by the Development office. The committee will be broadly representative of our research accomplishments and goals, with members drawn from the basic and clinical sciences, all of the Columbia University Medical Center schools, the Morningside Heights campus, and my senior staff.

We have made a great start with an ambitious, exciting agenda. We can achieve our goals if we remain focused on our priorities and if we can marshal the human and financial resources required. The economic and political climate in which we now operate is very different from the atmosphere of optimism that characterized the late 1990s. It would be too easy to retrench, ride out the storm, and hope for the best. No one is in favor of that option. Our long range goals will guide our very first steps. As we approach Columbia's 250th anniversary, and CUMC's 75th, we must exploit all of the strengths offered by this great University.

Gerald D. Fischbach, M.D.
Executive Vice President for Health and Biomedical Sciences
and Dean of the Faculties of Columbia University Medical Center

Also of interest:

Letter from Dean Fischbach
Columbia University Medical Center Strategic Plan
Strategic Planning Committee Members and Contributors