Western Psych a perfect place to start

In the 1970s, Thomas Detre and Jeffrey Romoff turned a stagnant psychiatric institution into the foundation for UPMC's growth

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EMPIRE BUILDING [Part 1 of a series]
Jeffrey Romoff and the ascent of the University of Pittsburgh Medical Center

Lake Fong, Post-Gazette
Jeffrey A. Romoff, 60, has spent 32 years with the University of Pittsburgh Medical Center, the past 13 as president. Under his guidance, the sprawling health system has become Western Pennsylvania's biggest employer with 2005 revenues of $5.1 billion.
By Steve Levin, Pittsburgh Post-Gazette

Dozens of photos from Sicily decorate the 11th floor of Forbes Tower, home of the University of Pittsburgh Medical Center's headquarters. Professionally shot and uniformly matted and framed, the photos are the most obvious sign of UPMC's extended reach -- its transplant facility in Palermo -- yet barely hint of the health care system's vast holdings and financial assets.

Jeffrey A. Romoff strides purposefully from a corner office, his tanned hand outstretched, a gold watch glinting from beneath the sleeve of his dark-blue suit. He wears the forced smile of someone bumping into an unpleasant acquaintance.

"I am not a public person," he says. "Intentionally so."

Mr. Romoff might not like it, but he is the face of the medical center. Many think of him as the medical center, such is the force of his personality and management style during his 32 years there.

Jeffrey Romoff and the ascent of the University of Pittsburgh Medical Center

Lake Fong, Post-Gazette

Jeffrey A. Romoff, 60, has spent 32 years with the University of Pittsburgh Medical Center, the past 13 as president. Under his guidance, the sprawling health system has become Western Pennsylvania's biggest employer with 2005 revenues of $5.1 billion.


Part One: How a stagnant psychiatric institution led to UPMC's growth

Part Two: Organ transplants put UPMC on the map, confirm growth strategy

Part Three: Consolidation and controversy at UPMC

Part Four: Clash of the Titans

Part Five: Expansions and Departures

Transcript: Read the transcript of an online chat with author Steve Levin about "Empire Building" and issues examined in this series.
Online Graphic:
UPMC's Hospitals and Facilities

Online Graphic:
The growth of revenue, employment and research funding at UPMC.

UPMC Timeline

Dr. Louise Wotring Lyle opens the five-room Louise Lyle Hospital on the North Side; renamed Presbyterian Hospital in 1895. Surgical and medical staff totaled eight. Average cost per patient per day was $2.32.
New six-story Presbyterian Hospital opens in West View Park.
Present Presbyterian Hospital in Oakland formally affiliates with the University of Pittsburgh and begins fund drive to raise $6 million for new hospital buildings.
Dr. Jonas Salk, 32, arrives at the University of Pittsburgh.
Dr. Francis Cheever joins the Pitt medical school faculty, becoming dean eight years later.
Dr. Albert Ferguson Jr., 34, comes from Boston to chair the Department of Orthopedic Surgery.
Presbyterian Hospital incorporates as Presbyterian-University Hospital, signifying transition from a community-oriented hospital to one focused on academic and scientific achievements.
Woman's Hospital and Magee Hospital combine.
Region's first organ transplant -- a kidney -- performed at Presby by Dr. Bernard Fisher.
Dr. Thomas Detre recruited from Yale-New Haven Hospital to chair Pitt's psychiatry department and Western Psychiatric Institute and Clinic.
Jeffrey A. Romoff hired as regional programming director at WPIC.
The Pain Control Clinic at Presby handles 4,000 patient visits annually, the largest such center in the United States.
WPIC chosen by the National Institute of Mental Health as a clinical research center to improve the diagnosis and treatment of depression.
WPIC designated as a NIMH Clinical Research Center for the Study of Affective Disorders.
WPIC gets $200,000 NIMH grant to study phobias and $1 million grant to treat depression.

Since his arrival in 1973, UPMC has grown from a loose federation of six hospitals with about 500 employees and annual revenue of $10 million to a sprawling 29-county system with 40,000 employees, $5.1 billion in revenue, a for-profit health insurance subsidiary with half a million members and a network of 19 hospitals; 17 nursing, retirement and long-term care homes; and more than 4,000 affiliated physicians.

As Western Pennsylvania's largest employer, and second largest in the state behind Wal-Mart, UPMC is a key player in Pittsburgh's economic livelihood.

By no means has Mr. Romoff been the sole driver of UPMC's ascent. In the early 1970s, he was an acolyte of Dr. Thomas Detre, the Hungarian-born psychiatrist who pointed the hospital toward the reorganization that would fuel its progress.

Mr. Romoff worked in Dr. Detre's shadow until, in 1992, he was named UPMC president.

His often abrasive personality and disregard for workplace niceties have made him a magnet for the ire of consumers, co-workers and competitors, earning him sobriquets such as "hatchet man" and worse.

His influence and power are such that many former UPMC physicians and officials, some gone for more than a decade, plus many current employees declined to be interviewed for this series. Others, including Pittsburgh business leaders, officials with rival health systems and some members of his own board of trustees, spoke only under the condition of anonymity.

Mr. Romoff, 60, charming and personable at times, is a ruthless businessman, unmoved by appearances or perceptions. He sees the world as friend or foe, and once he decides foe, look out. He seeks input from subordinates, but there's no confusion about who's the boss. His passion for his work is outstripped only by his ego. His view is simply that what's good for UPMC is good for the region.

It has been an abiding philosophy. UPMC's absorption of community hospitals during the mid- to late-1990s fundamentally altered Western Pennsylvania's medical landscape and left bruised feelings across the region.

UPMC's virtual monopoly has played a large role in stunting the growth of other health systems and the competition that produces lower health care costs.

But as UPMC's image has been burnished by acknowledgements of being among the country's best, Mr. Romoff's image, too, has been buffed by the hospital's continued success. The stories of the man and the institution are unquestionably interlaced; each has become essential to the telling of the other.

In the shell

Mr. Romoff uses an egg as a metaphor to describe UPMC: Academics are the vulnerable, vital yolk; clinical services are the nurturing albumen which attract patients and money; the administration is the shell, "the protector of the ecology of the egg, to keep it from getting cracked, broken [or] destroyed."

When Mr. Romoff says, "I live in the shell," it describes not only his place within UPMC but also how he has constructed his personal life.

He doesn't play golf or tennis, belong to clubs, bother with hospital-industry meetings or attend more than a few charity events each year. His annual compensation is $2.4 million. His spare time goes to his family, which includes his fourth wife, two grown daughters and five grandchildren. He met with a Pittsburgh Post-Gazette reporter four times for a total of six hours at his office this year, but refused to allow access to any aspect of his professional or personal life beyond the office walls.

Virtually everything Mr. Romoff does is framed by its impact on UPMC; anything else he sees as counterproductive. His goal is to make UPMC as essential to the region as steel manufacturers were during World War II.

In what he calls "the modern version of war," the region becomes a Silicon Valley-like incubator, with the hospital's research and clinical opportunities attracting the nation's best to convert intellectual capital into commercial products, instead of iron ore and coke into steel.

UPMC is a creation, Mr. Romoff says, which is still being created.


    UPMC has nearly 15 times as many employees as Alcoa, the largest Pittsburgh-based Fortune 500 company. Its regional economic impact is estimated at $10 billion, including $200 million in annual construction activity and 80,000 jobs beyond direct employment. Its affiliated companies, joint ventures and corporate partnerships account for another 3,000 skilled jobs.
    UPMC boasts internationally recognized centers in transplantation, cancer, neurosurgery, psychiatry, rehabilitation and women's health. Its cutting edge information technology makes it a leader in innovative corporate technology use.
    The organization provides $200 million in uncompensated care and spends $42 million supporting more than 3,000 community initiatives, charities and volunteer efforts.


North Side beginnings

UPMC's genealogy stretches back more than a century to its beginning as Presbyterian Hospital on the North Side. Presbyterian formally affiliated with the University of Pittsburgh in 1927, and, a few years later, joined Eye & Ear Hospital in constructing its buildings on Fifth Avenue in Oakland. By 1961, it was known as Presbyterian-University Hos-pital. Four years later, those institutions and Falk Clinic, Western Psychiatric Institute and Clinic and Magee-Womens Hospital incorporated to become the University Health Center of Pittsburgh.

There have been numerous luminaries at the hospitals: Dr. Jonas Salk in the 1940s, Dr. Benjamin Spock and Dr. Albert Ferguson Jr. in the 1950s, Dr. Henry T. "Hank" Bahnson in the 1960s. But the medical school's reputation was limited. Dr. Ferguson recalled that when he arrived to chair the department of orthopedic surgery in 1953, the school "was probably in the bottom 10 of medical schools" nationally.

That had begun to change by December 1972 when Dr. Detre was hired as chairman of the university's psychiatry department and director of Western Psychiatric Institute and Clinic.

Dr. Detre was the third choice for the position. The top choice, Dr. Enoch Callaway, now retired in California, said he turned the job down because of what needed to be done: "I didn't have the personality to make heads roll." He quoted Dr. Detre as later telling him, "I had to get rid of a lot of dead wood. I didn't mind that. I rather liked it." Dr. Detre denies saying it.

Dr. Detre had been chairman of Yale University's school of psychiatry, and he brought more than two dozen of his former employees, dubbed the Yale Mafia, with him.

Several built impressive careers at UPMC: Dr. David Kupfer is now director of research at Western Psychiatric Institute and Clinic, for example, and Dr. Loren Roth is associate senior vice president and chief medical officer for quality and care management. But none so radically transformed the hospital as Jeffrey Romoff.

A primary reason Mr. Romoff was hired was that his wife, Vivian, worked with Dr. Detre at Yale, and the doctor wanted her to be his chief psychiatric nurse at WPIC. Even now, Mr. Romoff jokes about being "the trailing spouse."

Dr. Detre had specific ideas about beefing up WPIC's research. He also was a leading proponent of using drugs to deal with certain mental health conditions, a philosophy that conflicted with WPIC's preferred focus on psychoanalysis.

But first he had to fight to keep WPIC open. In 1973, the state Legislature was considering halving its state appropriation of $2.5 million, roughly a third of the clinic's budget. Legislators were dubious that WPIC provided real benefits to people at the region's hospitals and mental health centers.

In the early 1970s, Mr. Romoff, 28, was executive director of a Connecticut mental health center whose annual budget was less than $60,000. The Central Naugatuck Valley Mental Health Association paid him $12,500 annually. He spent the first year there learning from Jack Miller, who handled the job on a part-time basis.

Initially resentful that his predecessor was being paid nearly twice his salary, Mr. Romoff was further shocked to find that Mr. Miller studied the Talmud, the Jewish compendium of law, ethics and custom, all day. The experience ultimately became what Mr. Romoff called "one of the most far-reaching and successful and meaningful" of his life.

"He would sit with me and basically teach me, quoting from the Talmud constantly, about politics, power, fund-raising [and] running a council, all in the context he cherished the most," said Mr. Romoff, who is Jewish. "He taught me, fundamentally, about values and their effect on behavior. He told me, 'You don't reach for power. It comes to you.' I've never forgotten that and I've never violated it."

Mr. Romoff tapped in to what he calls "focused intellectual activity," the type of reading and comprehension which had earned him admission to the elite Bronx High School of Science and later a full scholarship for graduate studies at Yale. Plus, he had chutzpah.

He decided the only way to increase the mental health center's funding was to turn it into a major drug-treatment facility. Over the course of several weeks, he read what he could, spoke with experts and wrote a $4 million grant proposal. He was not surprised when the center got the full amount.

"If you want to see a thread that goes through my whole career, since I was educated to do nothing I am doing now, I am constantly learning and using the information," said Mr. Romoff, who has a master's degree in political science from Yale. "I have a capacity to take on new things and to intensely study them and learn. For most of my career, including tomorrow, I'm doing something for the first time."

His wife made sure Dr. Detre saw the grant proposal. Impressed by its concepts and organization, he offered both Romoffs jobs at WPIC.

Fertile soil

WPIC was the perfect place for an ambitious man to make a name for himself. Nationally, it was an institution conducting little research and receiving few federal grants. Its administration was mired in internecine conflicts; morale was low. Dr. Detre put Mr. Romoff in charge of the Office of Education and Regional Programming and introduced him to key legislators. WPIC's funding ended up not being cut.

That was just the beginning. Dr. Detre needed his help in transforming WPIC from a psychoanalytically oriented in-stitution in the mold of Freud and Jung into one involved with research into the neurological and biochemical roots of mental illness and the incorporation of newer forms of psychotherapy. It would require changing not only the focus of research but also the corporate culture.

One tenured professor who had published nothing was transferred to conducting physicals and taking personal histories of new patients. A second professor had his office cleaned out while on vacation. Dr. Detre appointed a female nurse to head family therapy, a shock to the all-male leadership. To decrease the influence of the psychoanalysts, he restricted the amount of time they spent supervising medical residents.

The residency program itself was in shambles, declining from about 45 psychiatrists-in-training in the 1960s to about two dozen by 1971. The overhaul of the program fell to a three-man group which, in 1974, included Mr. Romoff, Dr. Rudolph Janosko and Dr. Roy Aruffo. Mr. Romoff had no clinical background, but his organizational skills were critical, Dr. Janosko said.

By the end of the first year, the group had doubled recruitment and changed the program's focus from a psychoanalytical to a biological model. Additionally, Mr. Romoff established himself as someone with administrative prowess, and the ear of Dr. Detre.

Dr. Detre's goal was to integrate WPIC's hospital and academic missions, transforming it into a clinical research institute that provided excellent patient care. The formula for making that happen depended on increasing the clinic's research funding. "That was the religion in which I was brought up," he said.

Before Dr. Detre arrived, WPIC and, by extension, Pitt's medical school and clinics, weren't players in the quest for federal research money, primarily from the National Institutes of Health and the National Institute of Mental Health.

He believed evaluative research was the key to clinical care and federal money. But it required recruiting researchers and fostering cooperation among university programs such as anesthesiology, neurology, pediatrics, pharmacology and surgery to pique the interest of the national institutes.

"We were constantly recruiting," Mr. Romoff recalled. Dr. Detre had him interview virtually all prospective hires, less to judge their academic prowess than to determine what types of resources they'd require in order to conduct top research.

The goal, Mr. Romoff said, was to cultivate a "critical mass of scientists." His job was to create and mobilize the resources which would allow Dr. Detre "to offer jobs that people couldn't refuse," Mr. Romoff said.

It was the beginning of the integrated delivery system which would become the foundation for UPMC's growth. It combined several elements in a seamless continuum, beginning with an efficient clinical setting serving more patients and generating more income. That money was channeled into academic medicine that lured more research grants. Those grants attracted hires possessing new skills, and those people, in turn, attracted more patients and more income.

The system's success owed much to Dr. Detre's dual positions as chairman of the psychiatry department and director of WPIC. He wielded full administrative power, and he and Mr. Romoff could hire people who shared their vision.

It was a model which would be used later to create UPMC.

Steve LevinAbout the author of this series

Steve Levin, 51, has been a staff writer at the Post-Gazette for eight years, after working for newspapers and magazines around the country.

Levin is a 1976 graduate of the University of North Carolina-Chapel Hill, and has reported on stories for the Post-Gazette ranging from Israel's 50th birthday to mortgage foreclosures and the homeless.

A native of Chapel Hill, N.C., he is the author of three nonfiction books. He lives in Squirrel Hill.

Steve Levin can be reached at slevin@post-gazette.com or 412-263-1919.


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