1 Mulligan J, Rehman B. Med Humanit 2019;0:1–9. doi:10.1136/medhum-2018-011556 Corporate medical cultures: MD Anderson as a case study in American corporate medical values John Mulligan, 1 Bilal Rehman 2 Original research To cite: Mulligan J, Rehman B. Med Humanit Epub ahead of print: [please include Day Month Year]. doi:10.1136/ medhum-2018-011556 1 Humanities Research Center, Rice University, Houston, Texas, USA 2 Rice University, Houston, Texas, USA Correspondence to Dr John Mulligan, Humanities Research Center, Rice University, Houston, TX 77005, USA; jcm10@rice.edu Accepted 12 February 2019 © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ. ABSTRACT This paper contributes to the evolving body of literature diagnosing the ’business-like’ transformation of American medicine by historicising and recuperating the concepts of medical leadership and the corporation. In an analysis of the evolving uses of ’leadership’ in medical literature, we argue that the term’s appeal derives from its ability to productively articulate the inevitable conficts that arise between competing values in corporations, and so should be understood as a response to the neoliberal corporation’s false resolutions of confict according to the single value of proft (or consumer welfare for the business-like non-proft). Drawing on mid-century theories of the corporation to reframe dominant social histories of medical corporatisation, we go on to argue that large medical institutions are productive sites for deliberation over the medical profession’s social contract. Our primary case study for this longer historical and broader theoretical argument is the MD Anderson Cancer Center, the world’s foremost treatment hospital for patients with cancer. We hold that the historical trajectory that led to MD Anderson’s exceptional but exemplary place in the evolution of American corporate medicine is refective of historical trends in the practice. INTRODUCTION In March of 2017, Ronald DePinho stepped down as president of one of the world’s foremost cancer centres, MD Anderson. DePinho’s resignation came after only 6 years, marking his time as president as the shortest in Anderson’s history. His presidency was marred by a large lay-off, a number of finan- cial issues and an audit by the University of Texas (UT) system that questioned certain partnerships he made, 1 but in the video released announcing his resignation, DePinho attributes his failures to his ambition as an administrator: Nearly six years ago, I was granted the honor of be- ing your president and was challenged by the Board of Regents to take M. D. Anderson to new academic heights, drive decisive research, expand our national and global reach, foster an innovation culture, and promote long-term sustainability. It was a tough, tough job, and I pushed all of you, including the institution, very hard. But there was a cost for that change, and I have added to that cost. I could have done a better job administratively, a better job listening, a better job communicating. Forgive me for my shortcomings. 2 Pitting a single administrator against a monolithic institutional culture, DePinho obviously deflects personal criticism by posing as a tragic hero fatally flawed with a surplus of otherwise virtuous ambi- tion; but more importantly, this framing obscures an important cultural tension within this institution and American healthcare institutions more broadly. Anderson, like most American hospitals today, has two cultures: a patient wellness-centred ‘culture of care’ focused on quality of care, and a busi- ness-like culture focused on economy. The gambit (or conceit) of American corporate medicine since the 1970s has been that these two value sets, of efficiency on the one hand and quality of care on the other, converge at the scale of populations. In this view, more people, with their diverse needs, can be given high-quality, personalised treatment through the business-like administration of a complex system of specialised care, usually ration- alised through market-place competition. By ‘busi- ness-like’, we mean the elevation of efficiency not only to the status of a value but even above all other values, as the guarantor of their possibility. It is in this way that non-profit institutions ‘become busi- ness-like’, subordinating their non-economic values to the single measure of cost. 3 This managerial philosophy of aligning prosocial corporate values with the business-like value of effi- ciency can even be extended so far as to represent these alternative values as dependent on profit, as under particularly conservative strains of neoclas- sical economics 4 or, more appositely, the credo of Anderson’s former Chief Financial Officer (CFO), Leon Leach: ‘No margin, no mission’. 5 While our method and perspective partly align with and are indebted to the insights of recent critiques of market-based medicine by Christy Ford Chapin, who suggests that large-scale corporate medi- cine is inherently problematic, and that by Mark Schlesinger and Bradford Gray, who emphasise the tensions between efficient administration and quality medical care, our method differs in that we seek to shed light on the problem of conflicting values in contemporary medicine by revisiting the question of what it means to practise ‘corporate’ medicine in a contextualised case study of this particular institution at a moment of crisis. Drawing on the 20th-century history of institu- tionalist thought, especially as articulated by Peter Drucker, we suggest that a more historically tenable and rigorously theorised formulation of corporate cultural development would be ‘No mission, no margin’. From this perspective, which sees corpo- rations as mission-driven institutions, it is cultural legitimacy that guarantees the economic privileges that keep large-scale healthcare institutions like Anderson afloat, and this legitimacy derives from broad public consensus on the value of the institu- tion’s social mission and belief in the institution’s special ability to fulfil that mission. However, the on 26 July 2019 by guest. Protected by copyright. http://mh.bmj.com/ Med Humanities: first published as 10.1136/medhum-2018-011556 on 24 May 2019. Downloaded from