The Modern University: If You Build It, Will They Come? (#683)

The $327 Million Question Facing the UC Davis Veterinary Medical Complex

This is the third essay in this three part series:

1. Bigger, Better & Already Outdated? What If the Future of Veterinary Medicine Isn't a Building? (https://www.ricklecouteur.com/post/bigger-better-already-outdated-what-if-the-future-of-veterinary-medicine-isn-t-a-building)

2. The Modern University: Who Decided to Build the Future? Consultation, stakeholders and the decision before the decision. (https://www.ricklecouteur.com/post/the-modern-university-who-decided-to-build-the-future-682)

In the 1989 movie Field of Dreams, an Iowa farmer hears a mysterious voice telling him:

If you build it, he will come.

He builds a baseball diamond in the middle of his cornfield.

And they come.

The phrase has subsequently entered popular culture in a slightly altered form:

Build it and they will come.

It has become shorthand for an appealing idea:

Create something sufficiently ambitious, sufficiently attractive, sufficiently visionary - and the people will follow.

There is something of the Field of Dreams philosophy in every great institutional building project.

• Build the laboratory and scientists will come.

• Build the stadium and spectators will come.

• Build the student center and students will come.

• Build the hospital and patients will come.

UC Davis is now making an extraordinary investment in the future of veterinary medicine.

Its planned Small Animal Hospital alone is projected to cost $327 million and will form part of a much larger Veterinary Medical Complex.

It promises extraordinary facilities, sophisticated technology, increased patient capacity, advanced specialty medicine, clinical education and research.

But there is one rather important difference between a baseball diamond in an Iowa cornfield and a $327 million veterinary hospital.

At UC Davis, they must come.

A Hospital is not just a Building

It is easy to think of a new hospital as a capital project.

• Raise the money.

• Design the building.

• Construct it.

• Equip it.

• Open the doors.

But opening day is actually the beginning of the financial commitment, not the end.

A large veterinary medical center must then be operated.

• Every day.

• For decades.

• It must be heated and cooled.

• Cleaned and maintained.

• Equipment must be serviced.

• Technology must be upgraded.

• MRI and CT scanners eventually become obsolete.

• Operating rooms require equipment.

• Intensive-care units require staffing.

• Specialists must be recruited and retained.

• Veterinary technicians and nurses must be employed.

• Residents and interns must be trained.

• Administrative infrastructure grows around the clinical enterprise.

  
  

And all of this requires something fundamental.

Patients.

Not occasionally.

Not just interesting patients.

A substantial and continuing clinical caseload.

The larger the hospital, the greater that requirement becomes.

Build Capacity and You Create a Need to Fill It

This is the paradox of major hospital expansion.

At first, the institution asks:

How large a hospital do we need to serve our mission?

But once that hospital has been built, another question inevitably appears:

How much clinical activity do we need to sustain the hospital?

Those questions sound similar.

They are not.

The first makes the hospital subordinate to the mission.

The second risks making the mission subordinate to the hospital.

A $327 million hospital creates enormous clinical capacity.

Presumably that capacity is being built because UC Davis anticipates sufficient future demand to use it.

Which raises the obvious questions:

Will the patients come?

Where will the patients come from?

Historically, university veterinary hospitals occupied a privileged position.

If a veterinarian had an extraordinarily difficult neurological case, an unusual cancer, a complicated cardiac disorder or a patient requiring advanced imaging, the university was often the obvious destination.

• Much of the expertise was there.

• Much of the technology was there.

• The specialists were there.

• The residents were there.

• The clinical researchers were there.

That world has changed.

• Private specialty veterinary medicine has expanded enormously.

• Major specialty hospitals now employ neurologists, surgeons, oncologists, cardiologists, internists, radiologists, ophthalmologists, dermatologists, anesthesiologists and criticalists.

• Many possess MRI and CT.

• They have sophisticated operating rooms.

• They provide intensive care.

• Some train residents.

• Some conduct clinical research.

And they may be located considerably closer to the animal owner than Davis, California.

The academic veterinary hospital no longer has anything approaching a monopoly on advanced veterinary medicine.

So, if UC Davis substantially increases its clinical capacity, where will the additional patients come from?

That is not a rhetorical question.

It is a business question.

And increasingly, an academic question.

Will Referring Veterinarians Send Them?

The university veterinary hospital has traditionally depended heavily upon referring veterinarians.

But those veterinarians now have choices.

A veterinarian in Northern California considering referral of a complicated case may have access to several sophisticated specialty hospitals.

• Convenience matters.

• Distance matters.

• Waiting time matters.

• Communication matters.

• Price matters.

• Relationships matter.

• And increasingly, corporate veterinary networks matter.

If a general practice belongs to a veterinary corporation that also owns specialty hospitals, where will its complicated cases be referred?

Will they travel to UC Davis?

Or remain within the corporate network?

The answer could become increasingly important to academic veterinary medicine.

Because building additional hospital capacity does not itself create additional referral cases.

It creates additional competition for them.

Will Animal Owners Be Able to Afford to Come?

There is another assumption hidden within the Field of Dreams model.

Even if patients need advanced care, their owners must be able to pay for it.

Veterinary medicine can now do extraordinary things.

• Advanced imaging.

• Radiation therapy.

• Chemotherapy.

• Dialysis.

• Complex neurological and orthopedic surgery.

• Interventional procedures.

• Intensive care.

• Molecular diagnostics.

• Genomic medicine.

The boundaries of what is medically possible continue to expand.

But veterinary medicine has a characteristic that fundamentally distinguishes it from much of human medicine.

For most veterinary patients, sophisticated medical care ultimately depends upon the financial resources of the animal owner.

Pet insurance may mitigate some of the expense, but it is far from universal.

There is no universal third-party payer standing behind every dog, cat or horse.

So, while veterinary medicine's technological capacity continues to increase, another question grows alongside it:

How much veterinary medicine can society afford?

A hospital can possess extraordinary technology.

That does not mean every patient who might benefit from that technology can access it.

The future constraint on advanced veterinary medicine may therefore not be what veterinarians are capable of doing.

It may increasingly be what animal owners are capable of paying for.

That matters enormously if we are building hospitals whose economic sustainability assumes increasing volumes of sophisticated care.

Will the Specialists Come?

Patients are only half of the equation.

A great specialty hospital requires specialists.

And academic veterinary medicine is already confronting difficulties recruiting and retaining clinical faculty.

The problem is not mysterious.

• A board-certified veterinary specialist may have attractive opportunities in private practice.

• Compensation may be considerably greater.

• Clinical responsibilities may be more focused.

• There may be fewer committee obligations.

• Less administrative work.

• No expectation to publish.

• No requirement to pursue promotion through an academic system.

• No need to balance teaching, clinical service and research simultaneously.

Universities offer important things that private practice may not:

• Intellectual community.

• Teaching.

• Research.

• Complex cases.

• The opportunity to contribute to the advancement of knowledge.

For some veterinarians, those remain powerful attractions.

But constructing a larger hospital does not solve the clinical faculty problem.

Potentially, it magnifies it.

More clinical capacity requires more people to operate it.

So, another version of the question becomes:

If you build it, will the faculty come?

And will they stay?

Will the Veterinary Technicians and Nurses Come?

This question deserves equal attention.

Sophisticated veterinary medicine depends upon highly skilled veterinary technicians, nurses and other clinical personnel.

• An MRI scanner without trained staff is merely an expensive machine.

• An intensive-care unit without nurses is a room.

• An operating theater without technicians cannot function.

  
  

Expanding hospital capacity therefore creates workforce requirements far beyond faculty recruitment.

• Where will those people come from?

• What will it cost to recruit them?

• What will it cost to retain them in California?

  
  

And can a university compensation structure compete successfully with an increasingly sophisticated private veterinary sector?

The building may be the most visible component of a veterinary medical center.

But people make the building work.

Will the Students Still Need to Come?

Then there is the educational question.

For generations, veterinary education has been organized around the teaching hospital.

Students came to the hospital because the cases, specialists and technology were concentrated there.

But clinical education is becoming increasingly distributed.

• Students can learn primary care in community veterinary practices.

• Students can encounter emergency medicine in private emergency hospitals.

• Students can experience specialty medicine in sophisticated referral centers.

• Shelters provide enormous opportunities in population medicine and surgery.

• Rural practices provide experiences universities may struggle to reproduce.

• Modern communications technology allows expertise to move without requiring everyone to occupy the same physical space.

This does not eliminate the need for an academic veterinary medical center.

Far from it.

But it raises another question:

How much of a veterinary student's future clinical education needs to occur inside it?

If the educational model becomes increasingly distributed while the physical clinical enterprise becomes increasingly centralized, university strategy may eventually find itself moving simultaneously in opposite directions.

Will the Research Still Need the Building?

Clinical research is changing too.

Historically, investigators depended heavily upon patients physically presented to the university hospital.

That made the teaching hospital an essential source of research subjects and clinical data.

But imagine clinical research twenty years from now.

• Networks of veterinary practices could contribute cases to multicenter clinical trials.

• Electronic medical records could generate enormous clinical datasets.

• Artificial intelligence could identify patients meeting trial criteria across hundreds of hospitals.

• Wearable technology could collect information from animals at home.

• Remote monitoring could reduce the need for repeated hospital visits.

• Imaging could be transmitted electronically.

• Specialists could collaborate across institutions.

  
  

The most powerful clinical research infrastructure of the future might not be a building containing thousands of patients.

It might be a network connecting millions of them.

Again, the hospital remains important.

But perhaps in a different role.

What Happens If They Don't Come?

This is where the Field of Dreams analogy becomes more interesting.

• Suppose the patients do not come in the numbers anticipated.

• Suppose the case mix changes.

• Suppose more routine specialty cases remain in private hospitals.

• Suppose owners become increasingly resistant to the cost of advanced referral medicine.

• Suppose corporate veterinary organizations retain referrals within their own networks.

• Suppose distributed clinical education reduces the proportion of student teaching occurring inside the academic hospital.

• Suppose clinical research becomes increasingly network-based.

What happens then?

A large hospital cannot simply accept large amounts of unused capacity.

• Its fixed costs remain.

• Its staff still need salaries.

• Its equipment still depreciates.

• Its infrastructure still requires maintenance.

  
  

The institution must respond.

And that response may have consequences.

The University Becomes a Competitor

One possibility is that the academic veterinary hospital must compete more aggressively for patients.

That creates an interesting transformation.

The university teaching hospital traditionally existed partly because it provided services unavailable elsewhere.

Increasingly, however, it may compete directly with the same private specialty hospitals that employ its graduates and receive referrals from its alumni.

• Both may offer neurology.

• Both may offer oncology.

• Both may offer cardiology.

• Both may have MRI.

• Both may provide complex surgery.

• Both may provide emergency and critical care.

• Both need sufficient caseload to support specialists and expensive technology.

At that point the distinction between an academic medical center and a sophisticated specialty veterinary business becomes more complicated.

The university has additional missions - teaching, research and discovery.

But the patient generating clinical revenue may look remarkably similar in both institutions.

What happens when both organizations need that patient?

The Gravitational Pull of the Building

This is the larger institutional danger.

Buildings create gravity.

Once an institution has made an enormous capital investment, maintaining that investment becomes an institutional priority.

• This happens gradually.

• And quite rationally.

  
  

• The hospital needs patients.

• Therefore, caseload matters.

  
  

• The hospital needs specialists.

• Therefore, clinical revenue matters.

  
  

• The hospital contains expensive equipment.

• Therefore, utilization matters.

  
  

• The hospital requires staffing.

• Therefore, productivity matters.

None of these concerns is improper.

Indeed, administrators would be irresponsible to ignore them.

But over time, the logic can subtly reverse.

The university begins by building a hospital to serve its academic mission.

Eventually, parts of the academic mission may need to serve the hospital.

That possibility deserves serious thought.

Bigger Creates Its Own Definition of Success

Once a larger hospital exists, success will naturally be measured partly by its use.

• Patient numbers.

• Procedures.

• Imaging studies.

• Surgeries.

• Hospital occupancy.

• Clinical revenue.

• Referral volume.

• Caseload growth.

These are reasonable metrics.

But they may not be the metrics that best describe the future contribution of a public veterinary school.

• Perhaps another university might treat fewer patients within its own walls while educating students across a statewide network of hundreds of practices.

• Perhaps it might operate an extraordinary teleconsultation service supporting veterinarians in underserved communities.

• Perhaps it might build the world's largest distributed veterinary clinical database.

• Perhaps it might develop exceptional transition-to-practice programs for new graduates.

• Perhaps it might dramatically increase access to veterinary care.

• Perhaps it might create partnerships linking university specialists with private specialty hospitals rather than competing with them.

Such an institution might have a smaller physical footprint but a much larger intellectual and societal footprint.

Which is the greater veterinary school?

Our traditional metrics may not provide the answer.

Perhaps They Will Come

There is, of course, another possibility.

Perhaps UC Davis is exactly right.

• Perhaps demand for advanced veterinary medicine will continue to grow.

• Perhaps Northern California will support substantially increased referral caseload.

• Perhaps pet insurance will expand.

• Perhaps increasingly sophisticated treatments will generate entirely new clinical services.

• Perhaps UC Davis will recruit outstanding specialists attracted by its extraordinary research and teaching environment.

• Perhaps the new Veterinary Medical Complex will generate discoveries that could not have occurred within a distributed system.

• Perhaps its concentration of expertise will produce precisely the multidisciplinary medicine that increasingly complicated patients require.

• Perhaps students will benefit enormously from it.

• Perhaps the new hospital will be filled.

• Perhaps they will come.

  
  

  The point is not to predict that they won't.

  
  

The point is to recognize how much depends upon the assumption that they will.

The $327 Million Question

Field of Dreams is ultimately a story about faith.

Ray Kinsella builds his baseball field without knowing whether his extraordinary gamble will work.

That uncertainty is part of what makes the story beautiful.

Universities also require vision.

Great institutions cannot build their futures simply by extrapolating spreadsheets.

Sometimes leaders must see possibilities others cannot yet see.

Sometimes institutions must build for a future that has not arrived.

But a public university investing hundreds of millions of dollars in clinical infrastructure must combine vision with another quality:

Skepticism about its own assumptions.

• What if specialty medicine continues migrating into private practice?

• What if corporate referral networks become more powerful?

• What if veterinary care becomes unaffordable for increasing numbers of animal owners?

• What if faculty shortages worsen?

• What if clinical education becomes substantially more distributed?

• What if technology reduces the importance of physical proximity?

• What if the most important veterinary network of 2050 is digital rather than architectural?

• And what happens if the patients don't come in the numbers the building requires?

  
  

Those questions do not argue against building the UC Davis Veterinary Medical Complex.

They argue for understanding what building it commits the university to doing afterward.

Because, perhaps the most consequential question is not:

If you build it, will they come?

It is this:

If you build it, what will you have to do to make sure they keep coming?

And once the answer to that question begins shaping clinical, financial and educational priorities, we should ask one more:

Will the hospital still be serving the university's mission.

Or will the university increasingly be serving the hospital?

This final question is where I think this third essay really earns its place alongside the other two.

It shifts the issue from whether UC Davis can build an extraordinary hospital.

It clearly can.

To the much less comfortable question of:

What a huge hospital may require of UC Davis once it exists.

Glossary of Terms

Field of Dreams

The 1989 film starring Kevin Costner, based on W. P. Kinsella's novel Shoeless Joe. It centers on an Iowa farmer who inexplicably decides to build a baseball field in his cornfield.

Ray Kinsella

The film's central character, an Iowa farmer who acts on a mysterious instruction despite the financial and practical risks.

“If you build it, he will come.”

The mysterious message Ray hears. This is the actual wording in the movie - not the commonly remembered “If you build it, they will come.”

“If you build it, they will come.”

The popular cultural paraphrase of the movie's line. It has come to mean that if you create an attractive facility, enterprise, or opportunity, demand will follow. This is the version that provides the metaphor for this blog.

The baseball field

Ray converts part of his productive cornfield into a baseball diamond despite having no conventional economic justification for doing so. In the blog, the field becomes analogous to the new Veterinary Medical Complex: build the infrastructure and anticipate that users will come.

The cornfield

The Iowa cornfield surrounding the baseball diamond. Players mysteriously emerge from and disappear into the corn. More broadly, it represents the ordinary world from which something extraordinary emerges.

Shoeless Joe Jackson

Famous baseball player and one of the central figures who appears on Ray's field. His arrival provides the first confirmation that Ray's seemingly irrational decision to build the field had a purpose.

The Voice

The mysterious voice that tells Ray what he must do without explaining why. It represents intuition, faith and acting despite uncertainty.

Faith

One of the central ideas of the movie. Ray commits land, money and effort to a project whose outcome he cannot demonstrate in advance. This makes the analogy with major institutional capital projects especially interesting.

Risk

Building the field threatens Ray's financial security because productive farmland is removed from cultivation. In the UC Davis analogy, the risk is different but much larger: committing enormous resources to infrastructure based partly upon assumptions about future veterinary medicine.

“People will come, Ray.”

A later and important idea in the film: people will be drawn to the baseball field and will pay to experience it. For the veterinary-hospital analogy, this is particularly apt because the question is not simply whether a facility can be built, but whether sufficient paying demand will exist to sustain it.

Terence Mann

The reclusive writer whom Ray seeks out and who eventually articulates the idea that people will come to the field. He helps transform Ray's apparently irrational project into something with broader social meaning.

Moonlight Graham

A former baseball player whose story reinforces the movie's themes of missed opportunities, choices, dreams and the roads not taken.

The road not taken

Not a literal catchphrase from the film, but an important theme relevant to the blog: choosing to build something necessarily means choosing not to pursue other possibilities. This parallels the opportunity-cost question surrounding a major veterinary complex.

The spectators

At the end of the film, a long line of automobile headlights approaches the field. Ray's faith appears vindicated: people really are coming.

Field-of-Dreams strategy

A metaphor - not a term from the movie - for making a major investment first and trusting that demand, users, revenue or other benefits will subsequently materialize.

The UC Davis analogy

The provocative question underlying the blog: Does building a $327 million Small Animal Hospital assume that future patients, paying clients, referrals, specialists, technicians, students and research opportunities will continue to arrive in sufficient numbers to justify and sustain the expanded capacity?

The inversion of the metaphor

The blog turns the optimistic movie premise around. Instead of merely asking “If you build it, will they come?”, it asks the more consequential institutional question: “If you build it, what will you have to do to make sure they keep coming?”

#bunyipsbooksbeyond