Healthcare Quarterly

Healthcare Quarterly 5(2) December 2001 : 72-76.doi:10.12927/hcq..16522

Dr. Alan Hudson

Cynthia Martin


Besides enviable success as a healthcare leader, primarily as President and CEO for 10 years at the University Health Network (UHN) in Toronto, Dr. Alan R. Hudson, is a neurosurgeon whose many awards and professional activities have helped to establish him as a world-class researcher and authority on the peripheral nerve. He has authored definitive books on the subject, has more than 130 publications and has made numerous presentations, including keynote addresses for major professional associations and universities. He has held key appointments, such as President of the Society of University Neurosurgeons, President of the Canadian Neurological Society and Honorary President of the World Neurosurgical Federation.
Between 1979 and 1989, Dr. Hudson chaired the Division of Neurosurgery, Department of Surgery at the University of Toronto, prior to which he was Professor and Associate Chair, Department of Surgery and Head, Neurosurgical Division at St. Michael's Hospital. During this time, he and his colleagues performed the world's first sciatic nerve transplant in September 1988. With a degree from the University of Cape Town, Dr. Hudson also holds many honorary degrees and fellowships. He completed a research year at Oxford University as a McLaughlin Fellow, an AMP from the Harvard Business School and has served on many boards.

Born in Cape Town, South Africa, Dr. Hudson was made an Officer of the Order of Canada in 2000 for service to health and medicine. Although Chair of the Ontario Ministry of Health's Cancer Services Integration Project, he still teaches, presenting the Hudson teaching awards named in his honour, and provides counsel to the Alan and Susan Hudson Chair in NeuroOncology at the University of Toronto.

When you retired in 2000 from UHN after almost 10 years as CEO, you must have felt some sadness. Do you miss the complexities in today's health environment?
Working with brilliantly innovative colleagues was exciting in addition to the respect I felt and affection for most of them. They all made me look good, which was ego gratifying. The pace was hectic and there were days of fears and occasional despair. Overall, it was unbelievably exciting to allocate a huge budget to support our vision and innovations, and then to execute. Do I miss the daily sparks of argument in shaping the future - you bet! My consolation was that my replacement was highly respected and able, but it was still difficult to hand over my tenure and walk away.

What benefit did you have by being a surgeon, professor and teacher in leading the UHN?
When you make the poacher the head gamekeeper, you can be sure he knows the rules because of playing before and inventing a few new rules. I knew who truly understood the vision of excellence, world impact and innovation, from those who merely mouthed these clich├ęs. I knew who were "real" nurses and "real" doctors; those who put their responsibility to their patients ahead of their responsibility to themselves. I knew who would shoulder the responsibilities of university and hospital life as opposed to those who achieved success by selfish devotion to their own area of interest. These were some of the many advantages, but a lack of real business experience made the institution of the CEO role somewhat exciting.

You led a consistently balanced financial budget during a period of downsizing, mergers and change, and oversaw many changes and essentially positioned the UHN for where it is now. What were you most proud of during your time at UHN?
A balanced budget on my watch was a source of great but misplaced pride. Misplaced because I had very little do to with it. I am most proud of creating and motivating the enormous team that achieved success (rather than endless discussion and complaint). It is easy for the CEO to say, "We will balance the budget," but extraordinarily difficult for the thousands who have to pull this off year after year, in stressed circumstances. It is truly difficult to decide where the credit is mainly due. Is it the numerous business units who had to make the front-line either/or decisions or the divisions and departments to whom these budgets rolled up, who had to ensure that the budget supported our vision and values? Is it the senior finance and management team who had to forecast the environment and drive the complex iterations of the entire machinery? Is the credit due to an extraordinarily talented and demanding Finance Committee of the Board or to the genius of successive chairs? The answer is that all these segments were of equal importance and they all take the credit for leading the hospital from the bottom to the top of the hospital efficiency league.

Are you excited at seeing the development of Project 2003?
The success of this $350 million project resulted from initial innovation followed by the arrival of expert help. I had no idea how hard it was to engineer a major bond sale or to coordinate business as usual during sequential building destruction and construction simultaneously on our two sites. Board members relinquished their day jobs to guide us through the intricacies of bond ratings, and some management staff changed roles to devote 24 hours a day to planning, coordination and execution. It is easy to be seduced by the on-time, on-budget unfolding of this grand scheme, but the key is that we are providing better, modern, purpose-built facilities for our patients and staff. The buildings are monumental, but they are the stage for our key asset - all who work there and share the values and vision of UHN.

After this, you chaired an operational review and in June 2001, you were appointed chair of the Cancer Services Integration Project to make recommendations to improve Ontario cancer services. What's the report's status?
Every distinguished individual invited accepted the responsibility. This meant a very highly qualified group, but also that there were as many opinions as there were committee members. I learned a lot from the talented participants. The brew of facts, politics, fiction, puffery and past history required careful analysis. The process of achieving consensus among the committee was quite different to the process of running a big company, such as UHN. I believe this is called "democracy." The concept of revolutionary change had to be modified by the fact that many boards are still digesting restructuring directives and many are still struggling with budget issues. The recommendation to Minister Clement is for evolutionary change.

You've been accused of sometimes being too honest. This is a good trait, but it seems one has to be conniving and perhaps manipulative. What's the balance?
I regard this as a compliment, but critics are pointing at bluntness, which might be interpreted as uncaring or hurtful. Attempting to establish a consistent record of trust undoubtedly resulted in communications that were less than sophisticated or mellifluous, which was a tough lesson to learn. When I agonized over the consequences of shrinking the workforce it was discouraging to learn that individuals felt that I had been too blunt, cold and unfeeling. The correct balance is achieved when honesty is expressed in terms that are carefully and thoughtfully tailored to a specific audience.

With all the mergers, can hospitals - health centres - get too big? Do they lose their sense of community or individuality?
One billion dollars always struck me as the ideal annual operating budget for UHN. There is no logic to that number but one I thought would be easily managed. The key is the competencies of the information technology system. Within that network, the smaller entities of Toronto General Hospital, Toronto Western Hospital and Princess Margaret Hospital retain their own specific personalities, and functions are related to their varied communities. Clearly, health centres are much more than their hospitals, but I believe the principle holds true: corporate efficiency while retaining personalized individuality of the components of the network.

In talking with some of your former/present students, you're pretty much a "God" among professors. Complementary to a student having exemplary marks, can you spot talent and a mindset in students who bring other skills to medical school?
My family long ago explained that God is a woman, so this is but one component of this gross miscalculation. Professors should be rated by their contributions to new knowledge, and I am way down the list compared to many of my colleagues.

I regard the high academic achievement required to be considered for entrance to medical school as merely the entrance fee to the contest. Top-notch students have serious hobbies. They are sufficiently on top of their work that they can additionally achieve distinction in music, sport, art or some other endeavour. Applicants are sufficiently mature that you can examine their life record, rather than listening to a pious recitation of their higher calling to the healing art. The results of selection are mixed. Some do brilliantly, despite your teaching. Others clearly do well with help. A minority don't succeed, regardless of your efforts. The biggest disappointments are those who fail on ethical or professional grounds - besides failing their patients, they really let down the profession as a whole.

You literally throw bones out in class and ask students for descriptions; what it's connected to, sometimes asking them to close their eyes. With anatomy so crucial, what other knowledge gain do you see through this exercise?
Anatomy can be excruciatingly boring or a wonderfully exciting introduction to a medical career. Much depends on how it is taught. By entering the game, students join the professional continuum stretching from themselves, just hatched, to retired has-beens. They begin to understand the tremendous privileges and hence responsibilities of their chosen vocation. What they are learning is essential and the standards of mastery are high. The neophytes progress and overcome their fears and embarrassment of operating on corpses. They are self-conscious as they stumble through their initial class presentations. Magically within a few months, they become proficient and eloquent, so we simply raise the bar to keep them at full stretch. These incredibly bright and fine young people ensure that teaching is a joyful and stimulating experience, and I hope their knowledge gain is as much about compiling enthusiasm with responsibility as it is about learning the dry facts of anatomy.

Although female/male admission to medical schools is roughly equal, why do so many women select or get steered to non-surgical specialties?
This is a Catch-22. I have worked with several outstanding female surgeons, but there are insufficient role models. A career choice is made by professional pre-adolescents, before they are sufficiently mature to truly understand the options. In this setting, students are heavily influenced by their preceptors. Meeting a woman who successfully combines personal, family and professional happiness is a great stimulus to other women. It can be done! Male-dominated surgical professions have become proactive because they realize that their candidate intake will be confined to half the class unless they change the centuries-old pattern. Nowadays, lifestyle questions head the inquiries from both sexes when career options are discussed, so surgical specialties will continue to review this issue as students of both sexes migrate to controllable life patterns.

Honouring your role at U of T, awards were established: the Alan R. Hudson Faculty Teaching Award and Resident Teaching Award, given annually in recognition of your contributions to neurosurgical teaching. These, with the $2 million chair in NeuroOncology, you must be especially proud of …
I was truly thrilled to be recognized. Professional development is best achieved on the job, and continuous learning and teaching is an intrinsic tradition of medicine. I was taught by outstanding physicians in South Africa, who made very substantial financial sacrifices to carry the teaching load at the University of Cape Town. The concept of perpetual learning and teaching as an intrinsic tradition has always attracted me.

In last year's speech to colleagues of the American Association of Neurological Surgeons, you compared health systems, offering advice for your beleaguered U.S. colleagues. Were you ever tempted to move?
The typical immigrant, $100 in pocket and no job, described me in 1962. St. Michael's, UHN, the U of T and Parry Sound have provided a home in which my family grew up and which has given me every professional opportunity. No one asked me who my father was, or to what school I went. Why would I leave? I admire many of my friends in the United States and feel very at home on frequent visits, but I can't think of any place that could have treated me so well as Toronto. We have never contemplated leaving.

If you could have a scotch and a chat with Roy Romanow, what would be the top three points you'd want to leave with him?
One - that 25 to 30% of provincial budgets spent on health is enough. Therefore, private capital must be brought to the table. A plan is needed to set some parameters around the needed increase in the current 30% private funding. Second - far too many services are being provided by overqualified providers; particularly by physicians and nurses. Specialists doing generalists' work, generalists doing nurses' work, and nurses doing clerical work, etc. The service should be provided by the least paid qualified provider. A market environment or payment systems should create incentives. Third - providers must be accountable for the quality of service and efficiency. You can't govern or manage without modern information technology, which enables data to be collected and analyzed. We must catch up with IT strategy and implementation, which in turn, will enable us to make more rational judgments and be accountable to the purchaser (public) and the payer (government).

Regarding your second point, although it's publicly a different argument, doctors seem to resist the establishment of nurse practitioners, since it's tied to revenue. Why is it taking so long for nurse practitioners to get into the system?
Of the many health policy issues beyond my comprehension, none has baffled me more than the relative failure of this concept. The matching of skill sets to the task at hand is so elementary, and the vigorous support of nurse practitioners would have enabled them to carry a large portion of the health service burden. Effortlessly, in Nova Scotia they've just expanded their role and legislated changes (Editor's note: see Quarterly Change, page 21). But, why have we only achieved limited success? I think the answer is that there are too many "black holes" in this debate. These individuals and associations give lip service to the concept and then make sure that progress is glacially slow. These individuals and groups suck up a lot of energy. The entire concept of skill sets matching tasks needs a thorough airing. We are not serving the public optimally with our current professional job descriptions in medicine and nursing.

What books are you reading?
I have been revisiting old friends; a sign of andropause! In the last weeks I've reread Winston S. Churchill's final volume of the History of the English-Speaking Peoples, The Great Democracies, and Nigel Hamilton's Monty: Final Years of the Field-Marshal, 1944-1976. Ryszard Kapuscinski's The Shadow of the Sun rekindled my dreams of Africa. On airplanes I'm reading Power, Privilege and the Post: The Katherine Graham Story, by Carol Felsenthal, a brilliant personal history, Matthew Kneale's hilarious English Passengers in bed, and The Importance of Being a Wit: The Insults of Oscar Wilde, in the lavatory.

Is your work pretty much your hobby?
My four children, all adding master's degrees, are happy, successful and gainfully employed, and my 12 grandchildren are more than a hobby. The success of this entire enterprise is undoubtedly due to the fact they were brought up by my wife while I was away at work! Sailing has always been a venue for relaxation and regeneration. Either crewing on the Bermuda race, in sailing the North Channel with four kids, a cat, birds, and mother-in-law in a 30-footer, or most recently, sailing with Susan from Toronto to Annapolis, peace and spiritual calm are created as the waters slip by.

What food do you always have to have in your kitchen or galley?
Mrs. Ball's Chutney; critical for most dishes. It's made from South African apricots, and combined with Van de Hum, a South African liqueur, it prevents malaria, frostbite, mothers-in-law and hangovers.

One of the people I spoke with said, "If you want a job done well and on time, give it to Alan." What else are you going to pursue in the years ahead?
Many successful businesspeople combine periods of public service with their main private enterprises. I am looking for the appropriate weave. Sixteen-hour days no longer attract me, but I would like to contribute in arenas in which I may have something to give. I'm not very good at listening to long policy arguments conducted by individuals who have never achieved much themselves. The authority to shape the future will not come around again to the extent that was at UHN. Many job opportunities require working with people whose judgment is clouded by perceived prestige, power and motivation. Politically oriented jobs require bending decisions to accommodate the democratic flavour-of-the month, but may also result in the modification of principles. I think I left the best job in the world, but I'm sure I'll find something at which I can be of service.


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