Ohio State leaders are once again mediating a civil war over the direction of the university's sprawling health care operation.

Dr. Ali Rezai has nothing but good things to say about Ohio State. In late September, a day after news broke that the superstar neurosurgeon was taking his talents to Morgantown, West Virginia, Rezai explains that decision with great care and diplomacy. He adores his former Ohio State colleagues. He appreciates the support he received from the university. His decision to leave “isn’t about Ohio State,” he says, speaking over the phone from the campus of West Virginia University, his new employer. “For me, it’s about going to a new path, a new vision and an exciting opportunity.”

He makes just one comment that hints at a possible ulterior motive. Asked what attracted him to West Virginia, Rezai praises the university’s leadership—including former OSU President Gordon Gee, who now leads WVU—for being “very much aligned with vision and purpose.” Few would describe Ohio State’s sprawling—and brawling—health care operation in a similar way, as Rezai knows well.

In the spring, a coup d’état of sorts occurred from within the vast OSU medical network. More than 50 faculty members—including 10 department chairs, 14 division chiefs and three distinguished university professors—put their names to four separate letters sent to OSU President Michael Drake and other university leaders excoriating Dr. Sheldon Retchin, the head of the OSU Wexner Medical Center. The letters accused Retchin and his leadership team of a series of misdeeds: power grabs, rude behavior, inefficient hiring practices and the marginalization of the med center’s academic mission of teaching, research and public service in favor of more lucrative clinical programs.

University leaders responded quickly, especially after the Dispatch and other media outlets got their hands on the letters. Just eight days after the first one was sent, Retchin resigned and ultimately agreed to accept a different position within the university. The breadth of the insurgency made it difficult to ignore. This wasn’t just a couple of malcontents in an isolated unit. Senior staffers from all over the medical campus signed the letters, including clinical chairs, internal medicine leaders, cancer researchers, neuroscientists and the head of the university’s heart division.

Rezai’s subsequent defection to West Virginia underscores one of the greatest fears outlined in the letters—the loss of talented scientists and physicians due to the internal tensions. Rezai was perhaps the most famous physician at Ohio State, whose groundbreaking work in deep brain stimulation has been featured on the front page of the New York Times. Asked what role the OSU acrimony played in his decision to leave, Rezai—who signed one of the no-confidence letters—deflects the question. He reiterates his excitement about the new West Virginia opportunity while also predicting good things for Ohio State’s medical operation. “I think there is a strong foundation to build for the future,” he says.

Indeed, all sides seem to agree on that. Over the past two decades, the OSU med center has transformed itself from a financial albatross to the most important institution at the university that doesn’t sport shoulder pads—an economic engine powered by brilliant scientists, cutting-edge hospitals, top-notch clinicians and strong civic support. The med center is now thriving financially, and it appears the upheaval of recent months hasn’t slowed that down. Federal research funding is up 20 percent this year, as are admissions, surgeries and outpatient visits. In June, the med center closed the fiscal year with the best financial performance in its history, turning a record-setting $302 million profit.

Which raises a question: If everything is going gangbusters, why are so many doctors at each other’s throats? At play is the usual toxic mix found in large organizations with lots of smart, proud and ambitious people—money, egos, power. But the dispute is also about something more fundamental and important: What will it take to achieve even greater success in the coming decades? And despite the spring uprising, university leaders aren’t giving up on their quest to make the med center a more efficient, disciplined and unified organization, putting them on a collision course with the fiercely independent leaders of the university’s ultra-profitable cancer program, who’ve fought off attempts to wrest control from them in the past. The power struggle likely led to the resignation of Dr. Michael Caligiuri, the CEO of the James Cancer Hospital, on Nov. 15.

The stakes are high, to say the least. Careers and legacies are on the line, and plenty of people have placed big bets on the med center, not the least of whom is Les Wexner, the city’s most powerful man, who gave $100 million to the university in 2011 to transform the med center that now bears his name. He expects results. Stat.

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Academic med centers don’t get much bigger than Ohio State’s. The $3.4 billion operation includes seven hospitals, the college of medicine, OSU Physicians Inc. (a physician practice plan), several outpatient clinics and the OSU Primary Care Network. It encompasses about half of the university’s budget—and the percentage is growing.

The size and scope present major management challenges. The med center brings great recognition and prestige, generates significant research dollars and advances the cause of health care. But it also can drain resources. Leaders must expend lots of energy stroking powerful egos, while also spending big bucks on hospitals and research labs—a much more expensive proposition than, say, building a law school.

There are other financial risks, too. Med centers, in many ways, are held captive by decisions made outside their realm, such as what federal officials will pay for reimbursements for services. A sudden change could devastate the med center’s bottom line, causing a ripple effect. “If the med center catches a cold,” as OSU insiders like to say, “the whole university gets sick.”

The main engine of the med center’s financial success has been the cancer program, which hasn’t let the most cumbersome name in Central Ohio health care (the Ohio State University Comprehensive Cancer Center—Arthur G. James Cancer Hospital and Richard J. Solove Research Institute) prevent it from generating big profits and groundbreaking research. Dr. Steven Clinton came to Ohio State in 1998 just as the cancer program was taking off. He was recruited by Dr. Clara Bloomfield, the director of the Comprehensive Cancer Center (the research arm of the cancer program), whose arrival on campus the year before—along with her husband, cancer geneticist Dr. Albert de la Chapelle, and Bloomfield’s protégé, Dr. Michael Caligiuri, an up-and-coming leukemia researcher—was a watershed moment for Ohio State.

A transplant from the prestigious Dana-Farber Cancer Institute in Boston, Clinton was part of a game-changing wave of more than 80 cancer researchers recruited by Bloomfield during her six years as the cancer center director. “This was a place where talent was not being pegged to come and fill a little niche, but rather, ‘Come here and let’s make a great cancer center,’” recalls Clinton, a prostate cancer specialist. “The vision was boundless, and you felt like you were being recruited into a great pool of like-minded, very accomplished, visionary individuals in a place that seemed to be profoundly enthusiastic about supporting the mission.”

During her recruitment to Ohio State in the early 2000s, Electra Paskett spoke with Clinton about his experiences at OSU. He told her about his partnership with colleagues at the college of agriculture to grow tomatoes with certain concentrations of lycopene, a natural chemical that may help prostate cancer patients. “There are very few places in this country where you can get such a comprehensive array of scientists from different disciplines that want to work together,” says Paskett, a cancer epidemiologist who joined Ohio State in 2002.

That cooperative spirit, however, seemed to have one exception. Bloomfield and David Schuller, the first director of the James Cancer Hospital, the other main component of the university’s cancer program, were fervent guardians of their program’s unique independent position within the med center, a tradition that continued under Caligiuri, who replaced his mentor Bloomfield as the cancer center director in 2003 and then became the leader of the James five years later when Schuller retired.

Unlike other leaders within the med center, Caligiuri and his predecessors have reported directly to the university president and the provost rather than the med center CEO or the dean of the college of medicine. The arrangement is unusual; few other cancer programs are organized in such a manner. But there is a good reason for it, as cancer leaders and supporters have long argued. Partial independence helps the James qualify for a valuable exemption to a complex federal payment system. The exemption makes longer hospital stays affordable, a key to the James’s profitability and recruiting success, and is available only to free-standing cancer hospitals.

In fact, an independent streak is part of the James’s DNA. Its founding fathers agreed to make the hospital part of the university at the behest of Ohio State professor Arthur G. James, the institution’s namesake. But the founders did so reluctantly, especially the powerful J.W. Wolfe, the late Dispatch Printing Co. patriarch. “He said, ‘We’ll be independent at the university, but that damn University Hospital will take us over if we’re successful,’” the late developer Dick Solove told Columbus Monthly in 2007, eight years after he gave $20 million to Ohio State to support its cancer program.

Wolfe wasn’t wrong. Since he, Solove and other influential civic leaders founded the James in 1990, periodic turf wars have broken out over its independence. And history provides a lesson to those who challenge that arrangement: Do so at your own peril.

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What turned many physicians and scientists against Retchin were doubts about his commitment to the med center’s “academic mission”—the three-part ideal (education, research and clinical care) that drew so many of them to Ohio State in the first place. Retchin and his team seemed more focused on the accountant’s ledger, pushing physicians to treat more patients and allowing less time for research and education. “If I’m working with clinicians, and their clinical load is increasing, they have no time to work with us,” says Paskett, who leads the division of cancer prevention and control at Ohio State. “So they’re not getting the benefit of the academic side of being in academia, and we’re not being able to work with them to accomplish our goals.”

Such concerns led Clinton, the oncologist, and his cancer colleagues to write the first no-confidence letter, which was then quickly followed up by letters from not just the cancer program, but neuroscience leaders, clinical department chairs and internal medicine faculty from the Wexner Medical Center as well. In total, 25 professors in the divisions of hematology, medical oncology and neuro-oncology signed the initial letter, including Bloomfield, the former Comprehensive Cancer Center director; Dr. Peter Shields, the deputy director of the cancer center; and Dr. John Byrd, one of the med center’s most talented researchers, whose scientific discoveries have saved the lives of thousands of leukemia patients.

“If you want to bring the best people here, you have to invest in them,” Clinton says. “They have to have a shared sense of mission and vision, and it can’t be just a business. If someone came here only to practice medicine, why would you choose to do it at OSU? You would go up the road and go into private practice and do the same amount of work and get paid 50 percent to 100 percent more.”

Indeed, some faculty members say the current environment has hurt recruitment. Burdensome hiring processes and uncompetitive salaries, in addition to the lack of commitment to research, are making it more difficult to fill critical openings, they say. The division of medical oncology is an example, says Clinton, a professor in the division. He says his group has struggled to hire 20 to 25 more oncologists over the past couple of years to meet increasing demand. As a result, Clinton and his medical oncology colleagues are forced to fill the hole themselves, leaving less time for research and education. He estimates his clinical workload has doubled over the past couple of years.

A similar phenomenon appears to be occurring in the department of internal medicine, the largest in the medical school, with 450 faculty members in 15 divisions. Paskett, a professor in the department, and 16 of her colleagues outlined their concerns in another letter. They pointed to a “disturbing upward trajectory of faculty attrition” (from 37 departures in 2014 to 51 in 2016, a 38 percent increase), while also citing “operationally inefficient systems” for filling those openings. “You have to move fast, and you have to give a market-value offer,” Paskett says. “The market is not just Ohio when we’re competing for faculty. The market is the U.S. and sometimes even the world.”

For old OSU hands, the fall of Retchin, who declined to comment for this story, inspired a feeling of déjà vu. The cancer doctors accused Retchin of attempting to “assert his leadership” over the cancer program—a “fatal blow” that could threaten the future success of the thriving program and put at risk the federal reimbursement exemption that fuels the James’s profitability.

A decade earlier, high-profile supporters of the Ohio State cancer program made the same charge against another med center CEO, Fred Sanfilippo, who put the institution on the path to profitability. Ambitious and aggressive, Sanfilippo made his share of enemies during his seven years in Columbus, but he didn’t find himself packing his bags until he challenged the sacred cow that is the cancer program.

Though he didn’t play a public role in either turf war, Caligiuri, the OSU cancer leader, was a prime beneficiary both times. His name didn’t appear in the May letter from the cancer doctors, but a med center source says he supported the effort. “As a senior leader, he shouldn’t be perceived as trying to organize it or be in the middle of it,” the source says. “He was like, ‘I’m going to step back and let faculty do what they think they need to do.’” A cultivator of university donors and influential supporters, Caligiuri, who declined to be interviewed for this story, has been the one constant in the med center’s leadership, outlasting (and outmaneuvering) deans, CEOs, even presidents.

Following the Sanfilippo brouhaha, Gordon Gee, returning to Columbus for his second run as OSU president, vowed to bring more unity and “alignment” to the med center. In reality, however, the atmosphere didn’t change much. If anything, the cancer program became more independent and powerful with the construction of the new James Hospital in 2014—a 21-story, $750 million behemoth, the third-largest cancer hospital in the country. What happened? “Mike Caligiuri is a very skillful bureaucratic politician,” says a former OSU insider.

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Since Retchin’s resignation, the med center’s interim leaders—Dr. Craig Kent, the dean of the college of medicine, and David McQuaid, the chief operating officer—have embarked on a listening tour of sorts. They’ve engaged around 2,500 faculty members, staffers, students and patients in interviews, planning meetings, faculty forums, four large town halls, department meetings and small-group gatherings.

In response to what they heard, Kent and his team launched an ongoing review of clinical faculty salaries that has resulted in raises for 600 to 700 underpaid clinicians. Meanwhile, med center leaders are addressing two concerns mentioned in the May no-confidence letters. Kent formed a committee of department chairs to explore ways to streamline personnel processes, making it easier to adjust contracts and recruit in a timely manner. And for physicians struggling to balance clinical work with scientific research, Kent hopes a new a $15 million fund he created will subsidize more lab time.

Dr. John Kissel, a co-author of one of the no-confidence letters, says he’s happy with the changes in recent months. Communication has improved as Kent and his team have made a good-faith effort to understand the concerns of neuroscience faculty members, says Kissel, the chair of the department of neurology. In particular, Kissel is excited about a proposal from Kent to create an Alzheimer’s research center at Ohio State, with the goal of becoming one of the top 15 Alzheimer’s programs in the country. “That’s a really good example of where the medical center’s leadership, despite all the sturm and drang, has identified this major area for us to go forward and to really change things nationally,” Kissel says.

The work is not done, however. Two more letter-writers, Clinton and Paskett, aren’t ready to pass judgment yet, saying they need to see what happens in the critical coming months. Others—especially in the cancer program—remain frustrated and angry. “I recognize that there are still faculty who are unhappy, and for us at the medical center, we take that very seriously,” acknowledges McQuaid, the med center COO.

In June, OSU leaders crafted a strategic plan for the med center that includes a goal of becoming a top 20 academic med center by 2024 (OSU is currently ranked 31 by U.S. News & World Report). That leap won’t occur unless harmony returns to the med center, OSU leaders say. “If we are going to achieve this huge, very ambitious new level of success, we have to engage our people and make them feel valued, create an environment where they can be incredibly successful, make them want to be part of the Wexner Medical Center,” Kent says.

So how to achieve that peace? The easiest way might be to let things slide back to the way they were before, which is essentially what happened during Gee’s presidency following the last major turf war. However, Gee’s successor, Drake, an ophthalmologist who’s spent much of his career in academic medicine, was brought to Columbus in large part to lift the university’s health system. The status quo might not suffice in this instance.

Retchin touched the third rail of OSU politics by challenging the independence of the cancer program. Is that idea off the table now? During an interview in his Bricker Hall office in late October, Drake dances around the topic. Asked whether the Ohio State cancer program should be less independent and more integrated into the med center, Drake doesn’t directly answer, though he does say “alignment and integration” benefit the university. “I think that’s efficient and effective, and we want to use best practices and share them broadly,” he says.

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In early November, Drake offered a significant hint at his future direction. Speaking to the OSU board of trustees, he announced the creation of a new position—a “chancellor” who will oversee the med center. The new position (OSU officials have launched a nationwide search) will have broader responsibilities than Retchin had as a CEO. Ohio State isn’t saying what those additional duties will be yet, but speculation focused on whether cancer could fall under the new hire’s jurisdiction, which could start another turf war.

What’s more, the news came on the same day the university announced that Caligiuri was stepping down as the director of the Comprehensive Cancer Center. Sources say Caligiuri requested the change, which had been in the works for 18 months, and at the time he remained the leader of the James Cancer Hospital, the clinical arm of the cancer program. (The jobs are split in most academic settings, as they were at Ohio State until 2008.) Perhaps the oddest thing about the news was the way it was announced. The press release devoted just one sentence to Caligiuri, hardly a warm valedictory to such a significant figure in the history of the cancer program and the med center, focusing instead on his successor, Raphael Pollock, who was named interim director. “The press release they put out makes it sound like they fired Mike,” says a faculty member.

Tensions were rising between cancer leaders and those at the university—including Drake—who were challenging  the cancer program’s independence. On Nov. 15, those issues came to a head with a turn of events that seemed improbable not that long ago: Caligiuri, long the med center’s most entrenched—and, it could be argued, most valuable—leader, resigned as the CEO of the James Cancer Hospital. The news was unexpected, a med center source said on the day it was announced. “I only spoke with Mike for five minutes,” the source said. “What he did say is that it is clear he has lost the ability to lead here at OSU.” (About two weeks after Caligiuri resigned, he took a new position at City of Hope National Medical Center in California.)

So what changed? In his announcement of Caligiuri’s resignation, Drake didn’t offer an explanation. But the power dynamics within the med center appear different from previous turf wars. A decade ago, the main defenders of the cancer program were Judy and Steve Tuckerman, longtime James fundraisers and close friends of Les and Abigail Wexner. Though the Wexners didn’t get involved in the dispute, it’s doubtful the Tuckermans would have spoken out without the Wexners’ blessing, and both sides of the brawl likely realized it. This time, however, Les Wexner, now the chair of the medical center board, appears to be taking a stand of his own.

Following the chancellor announcement, Wexner agreed to an interview with Columbus Monthly, after declining a few weeks earlier. Over the phone on a Sunday afternoon, he talked about the med center’s improved oversight, thoughtful financial stewardship and lower-than-average turnover rates (which counter the attrition fears of faculty members despite the high-profile defection of Rezai and a handful of others). “I’m more excited today than I was a year ago or two years ago because we’re really doing better and better,” Wexner says. “All the metrics are just terrific.”

The latest turf war also hasn’t scared him off the idea of more unity and structural changes. The powerful chancellor position could be a more attractive opportunity to a leader with the talent, charisma and vision to drive cultural change, connect factions and eliminate the fiefdoms of the past. “It’s one university,” Wexner says. “It’s one medical center. The way we look at medicine in the present and in the future, it must be integrated. There’s no Plan B.”