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The Duke University Medical Center when Ralph Snyderman took over as Chancellor of Health Affairs in 1989 was a well-recognized academic medical center, a sprawling, complex, and large academic, clinical, and educational institution. But, like similar institutions with the development of managed care, it faced a challenge to its longstanding organization and business model wherein margins earned from clinical activities subvented other essential aspects of the institution. As clinical margins declined, fundamental adjustments to the departmentally based organizational structure became imperative. A more centralized management and budgeting system was needed and this in turn created tumult and resistance among some constituencies reluctant to part with traditional ways.

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