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Not long into his first term, initiatives were developed to enhance the basic sciences through recruiting outstanding chairs and faculty. Major organizational changes were needed to prepare the medical center for managed care. Duke University Medical Center needed be able to act in a coordinated clinical environment necessitating integration of clinical departments, the hospital, and the administration. A new method of evaluating departmental chairs and the process of replacing several key chairs including the chairs of the powerful Departments of Medicine and Surgery ensued. A certain degree of unhappiness and even acrimony accompanied this necessary process, thus setting the stage for confrontation.

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