The standard model of a hospital affiliating with the university across town could be set for a shake-up. Reports that the Cleveland Clinic’s Lerner College of Medicine is in negotiations to drop its affiliation with nearby Case Western Reserve University and align with Columbia University -- nearly 500 miles away in New York City -- suggest that teaching hospitals, seeking prestige and strategies for standing out, might be ready for some long-distance relationships.

“When it comes to hospitals these days, especially teaching hospitals, the profit margins are so low; they have to find a way to strategically compete,” said James R. Langabeer, an associate professor at the University of Texas School of Public Health and co-author of Competitive Business Strategy for Teaching Hospitals (Greenwood, 2000). Rather than accept the local university as the default unquestioningly, hospital boards are more aware than ever, he said, of the need to shop around and forge an affiliation with a college that can help distinguish their services from those of competitors -- maximizing prestige and profits.

“The medical school affiliation is one of the most crucial decisions a hospital can make," Langabeer said. "To make it based on geography….is probably not the best strategic decision.”

The Plain Dealerreported Wednesday that the Lerner College of Medicine “has been shopping its medical school to a number of universities but that Columbia seemed the most interested.” Officials at Columbia and the Cleveland Clinic declined to confirm the negotiations in interviews with Inside Higher Ed Wednesday, and, in a statement, Case Western also declined to comment on the substance of the Plain Dealer article. But a clinic spokeswoman, Eileen Sheil, released a statement implying the hospital’s qualms about Case Western’s close ties to a competing hospital, and the clinic's openness to collaborating with other institutions.

“Recently, Case announced a new, 50-year, primary affiliation with University Hospitals of Cleveland that strengthened the relationship between those two organizations. At this time, it is unclear how that relationship may impact the clinic in the future. The clinic has a number of relationships with colleges and universities across the country and will continue to explore other opportunities as they arise," the statement said.

Cleveland Clinic’s unique and very young medical college, established in 2002, is geared toward training a small number of students -- about 30 per year -- for careers as physician investigators. Students graduate from the Lerner College of Medicine after five years with an "M.D. with Special Qualification in Biomedical Research" from Case Western.

Case Western also maintains a much older medical school if its own, and in April 2006 reached what the university described as a “historic primary affiliation agreement” with University Hospitals -- “the most comprehensive agreement in their century-long relationship.”

“The two health systems are in direct competition for patients and for physician affiliations…. They’re only a mile apart,” said John A. Kastor, author of The Governance of Teaching Hospitals: Turmoil at Penn and Hopkins (Johns Hopkins, 2003) and a book on the two competing Cleveland hospitals, Specialty Care in the Era of Managed Care: Cleveland Clinic versus University Hospitals of Cleveland (Hopkins, 2005). “There always was something a little peculiar about this relationship" between the Cleveland Clinic's medical college and Case Western.

“I have no idea whether it’s going to become fashionable to do this,” Kastor, a professor of medicine at the University of Maryland, said of hospitals dropping their affiliations with local colleges and looking more broadly. “Looking back on my whole career and the many places I’ve worked at, it’s a really disruptive thing" to switch affiliations. "The principal teaching hospitals and the medical schools are linked up very closely.”

Experts could think of only one example so far of a hospital splitting from a nearby institution and going the distance to find a new partner – the messy 2004 divorce of Baylor College of Medicine and Houston’s Methodist Hospital. Rather than look to another Texas college for a new affiliation, the hospital remarried the Weill Medical College of Cornell University, based, as Columbia is, in New York City. Kastor described that particular situation, however, as “highly political” (marred by Baylor-Methodist disputes) and “idiosyncratic” (Cornell’s dean, for instance, formerly worked at Baylor).

“I don’t know how it’s working, but if you think about it, it’s kind of weird because very few students in New York are going to go to Methodist Hospital for their training,” Kastor said.

Antonio Gotto Jr., dean of the Weill Medical College at Cornell, described a number of collaborations with Methodist Hospital in terms of faculty appointments, recruitment and research, and said the two entities are collaborating on a new imaging institute that's in the planning phase. Although exchanges have been limited so far while Methodist reestablishes its residency programs, Gotto, the former chair of medicine at Baylor and Methodist for 20 years, said he anticipates increases in the number of exchanges involving residents and medical students alike. His personal relationship with Methodist, which approached him looking for an affiliate after the separation from Baylor, helped make the partnership seem possible, he said -- in addition to Cornell's experience successfully setting up a branch of its medical school in Qatar 7,000 to 8,000 miles away.

Langabeer, of the Texas School of Public Health, said that while he also is unaware of any long-distance affiliation aside from that of Cornell and Methodist, the option seems to be coming up more and more as a possibility at the board level. "I think it's a trend we'll see more of," he said. "It's on the radar."

“What we’re seeing happen is that people are saying [geography] is not a limitation,” Langabeer explained. “For the most part, these affiliations have lasted for decades. It’s really a chance to come back now and say, ‘Should we be doing this or is there an opportunity to do something different?’ ”

“Only time will tell if it makes sense.”