By occupying this “best product” position for decades, academic medical centers have been able to enjoy a robust position of advantage. Ed Miller, M.D., the former CEO of Johns Hopkins Medicine, reflected on that position when he suggested that what made Hopkins different, particularly compared with community hospitals, was innovation: “We have to innovate if we are to stay in the lead.” The differentiated position of academic medical centers reflects their legacy of leading-edge capabilities, the momentum of which is still considerable.

Collegial commitment. Faculty physicians in academic medical centers tend to have a stronger sense of shared purpose and common values than the physicians who comprise the medical staffs of most community hospitals. As Joseph Simone, M.D., once commented, “We in academic medicine are blessed in many ways compared with those in most jobs. We have the privilege of working in a profession that helps the sick and dying while we are engaged in intellectual inquiry.”

While faculty are certainly not immune to rivalry, conflict and dysfunction, their shared commitment to research, teaching and patient care gives them a greater potential for the collaboration that is essential to delivering high-value care. Arthur Feldman, M.D., summarized the advantages that accrue from such collegiality in his book Pursing Excellence in Healthcare: “Academic specialists and subspecialists concentrate their efforts, innovate rapidly, develop dedicated teams rather than relying on part-time practitioners, have dedicated facilities, and have multiple colleagues in the same practice with whom to discuss difficult cases … .”

They also tend to demonstrate more interest in association with a strong institutional reputation. Thus, they are much more likely to think of themselves as “Hopkins doctors” or “Duke doctors.” This shared identity further enhances the potential for productive collaboration. An edge in collaboration is likely to yield a significant competitive advantage. In his book Antifragile, Nassim Taleb writes, “Collaboration has an explosive upside, what is mathematically called a super additive function, i.e., one plus one equals more than two, and one plus one plus one equals much, much more than three … .”

Proximity. Academic medical centers concentrate lots of talent and resources in close proximity. In this, they are like cities. Cities enjoy significant efficiencies as well as economies of innovation. According to Geoffrey West and Luis Bettencourt, theoretical physicists at the Santa Fe Institute and Los Alamos National Laboratory, “Rather than unnatural human conglomerations blighted by pathologies … cities do more with less … because they concentrate, accelerate, and diversify social and economic activity.” Bettencourt and West’s research indicates that while a city may double in size, its infrastructure — roads, sewer lines, retail — does not. In fact, the bigger the city, the more efficiently it uses resources.

The keys to “virtuous cycles of innovation and the creation of wealth” are “a spirit of local entrepreneurship, a reputation for cutting-edge novelty and a culture of excellence and competitiveness … .” “Concentrated population,” say West and Bettencourt, “promotes more intense and frequent social interactions, occurrences that correlate with higher rates of productivity and innovation as well as pressures that weed out inefficiencies.” Academic medical centers with concentrated citylike campuses have the potential to benefit from the same advantages.

Loose coupling. “Loose coupling” describes elements that retain a comparatively high level of independence despite operating as part of a broader system or organization. The strength and relative autonomy of departments in academic medical centers result in their operating as loosely coupled organizations.

Often criticized as being disorganized and unfocused, organizations that are loosely coupled arguably generate more advantages than disadvantages. One attribute of loosely coupled organizations, including academic medical centers, is their inherent sustainability. Loose coupling yields sustainability over time because it permits greater flexibility than more rigid command-and-control models. Rigid things are prone to fracture in volatile environments, while flexible things can absorb a blow. They can “take a licking and keep on ticking.”