100 years of group care at Cleveland Clinic

Cleveland Clinic's evolution from a single hospital on Euclid Avenue, opened in 1921, to a global healthcare powerhouse has given it both the ability and responsibility to care for its communities in ways not possible 100 years ago.

"When we were founded, we were a single small hospital, so it was impossible to contribute to community at an integrated level," said Dr. Tom Mihaljevic, Cleveland Clinic president and CEO. "But now, with a large integrated healthcare system, we have a big responsibility."

As the largest employer in Ohio, the Clinic has a responsibility to maintain those jobs and ensure they are well-paid, family-sustaining jobs, which then contributes to the stability, health and wellness of communities, he said. The Clinic can help address community stability, racial disparities and other societal problems, which is what the system will focus on through the second century of its existence, Mihaljevic said.

The Clinic's model of care — group practice, physician-led, nonprofit — has not changed, said Dr. Toby Cosgrove, former president and CEO of the Clinic.

"I think (Cleveland Clinic) will be one of the continuing leaders in research, education and clinical care in the world, which it is now recognized generally as the number two hospital in the United States and around the world," Cosgrove said. "That's a pretty fine distinction."

Though the scale and reach of what is now an international, integrated healthcare system was unfathomable in 1921 when the Clinic opened its doors, the principles set out by its founders have been the backbone of its work in the century since. Cleveland Clinic is a "substantially different organization" than the one founded by Drs. Frank E. Bunts, George W. Crile Sr., William E. Lower and John Phillips, but the core tenets have remained.

"Our mission for many years — caring for the sick, researching their problems and educating those who serve — those basic tenets of patient care, research and education, continue to live with us to this day," Mihaljevic said.

Clinic co-founders Bunts, Crile and Lower served together in World War I and later recruited Phillips.

As the first truly modern war, World War I and the considerable number of casualties and injuries caused by new weapons meant that the medicine practiced had to be more regimented and organized, said John J Grabowski, Krieger-Mueller associate professor of applied history at Case Western Reserve University and the senior historian for the Western Reserve Historical Society.

"That's where (the Clinic founders) picked this up, and I think particularly Crile, looked at a way not only of group practice but how to make medical care more efficient," he said. "And I think that's what we see in the Cleveland Clinic. ... "I think it's hard for us to imagine what a leap that was from hospitals or physicians who operated very much independently at one point rather than in a team."

The idea that a team of providers can better serve patients was "revolutionary" at the time, Mihaljevic said.

The Clinic's history of clinicians working together to solve problems was evident on a large scale during the unprecedented pandemic that capped its 100 years of growth. Clinic caregivers worked together within the system, as well as with other health systems in the region and beyond at unprecedented levels.

From Northeast Ohio systems working together to hospitals across the state collaborating to coordination across levels of government with health providers, the cooperative spirit of the Clinic's founders framed the pandemic, said Dr. Robert Wyllie, the system's chief of medical operations.

Although the Clinic is a large health system, employer and anchor for Northeast Ohio, "there are some things which are too big for us on our own," he said, listing infant mortality and the opioid epidemic as two other examples that have fostered collaboration in recent years.

May 15, 1929, became known as the Cleveland Clinic Disaster, when volatile nitrocellulose X-ray films in the basement of the original outpatient clinic combusted. The explosion sent poisonous gas throughout the building, and 123 patients, visitors and caregivers died from gas inhalation, including co-founder Phillips.

"The Clinic is started, and it gets rolling during a very prosperous decade," Grabowski said. "At the end of the decade, it is hit with this tragedy, and then it goes into the depression and it survives through all of that, which I think is something of a great consequence."

The 1950s and 1960s were transformative for Cleveland Clinic in its research milestones, Mihaljevic said, highlighting a few key discoveries.

In the 1950s, Dr. Irvine Page made groundbreaking research in the area of hypertension. Dr. F. Mason Sones discovered moving cine-coronary angiography at the Clinic in 1958, allowing to see inside the blood vessels of the heart as never before possible. This laid the path for the work of his colleague, Dr. René Favaloro, who in 1967 pioneered coronary artery bypass surgery. These cardiac discoveries transformed how not just the Clinic, but the entire world takes care of patients with heart disease, Mihaljevic said.

"That work really put Cleveland Clinic on the world's map," he said.

In the mid-1970s, the Clinic began acquiring land and by 1986 owned nearly all of the land between East 88th and East 105th streets and Chester and Cedar avenues — roughly 140 acres and much of today's main campus. The Clinic's growth in the 1970s and '80s occurred as Cleveland's industrial economy and population were plummeting, Grabowski said.

"I think it becomes apparent within the city at that point that the future of the community is going to be in substantial part linked to medical care and to general innovation," he said.

The founding of Cleveland Clinic Florida in 1988 made the Clinic the first academic medical center to establish full-service hospital and clinic facilities outside of its home state.

In 2004, the first class entered the Cleveland Clinic Lerner College of Medicine, a partnership between the Clinic and Case Western Reserve University. The two institutions in 2019 opened their joint Health Education Campus, a four-story, 477,000-square-foot building designed to encourage multidisciplinary interaction and collaboration among students.

Education and research are key parts of the Clinic mission, Mihaljevic said.

"As one of our founding fathers said, we do not just have a commitment to our patients of today, but we also have a commitment to our patients for tomorrow," he said. "So that's the reason why this year, we made the largest investment into research and education in our history."

The Clinic committed $300 million to the Cleveland Innovation District, a public-private partnership that aims to create 20,000 jobs and billions of dollars of economic impact in Cleveland over a decade. The $565 million partnership announced earlier this year was forged by the Clinic, University Hospitals, MetroHealth, Case Western Reserve University and Cleveland State University with the support of JobsOhio.

The 1990s brought a decade of mergers to Northeast Ohio as both the Clinic and University Hospitals were in an effective hospitals arms race, each bringing independent hospitals into their networks. During that time, the Clinic transformed from a single hospital to a vast network of hospitals in Northeast Ohio, adding Marymount, Lutheran, Fairview, Euclid, South Pointe, Hillcrest and Lakewood hospitals.

In the early 2000s, the Clinic set its sights abroad, opening Cleveland Clinic Canada downtown Toronto in 2007 and signing an agreement to provide care in Abu Dhabi in 2006, which laid the groundwork for Cleveland Clinic Abu Dhabi — a hospital that opened in 2015.

The Clinic has since continued its international reach, partnering with a medical group in China in 2018 to open a hospital in Shanghai; forming a strategic advisory council with a health system in the Bahamas to improve care delivery and building a hospital in the United Kingdom — Cleveland Clinic London is slated to open in early 2022.

As the Clinic enterprise goes global, it remains proud of its Ohio roots, Mihaljevic said.

"Cleveland is in our name, so our attention to our presence in Ohio continues to be very strong," he said, pointing to the hospital it is building in Mentor, which will expand the system's footprint in that portion of Northeast Ohio. Its acquisitions in the past several years of Akron General Health System, Union Hospital in Dover and as of this year, Mercy Medical Center in Canton, collectively stretched the Clinic's boundary south.

Asked if the Clinic plans to continue broadening its geographic footprint from its Northeast Ohio base, Mihaljevic said the Clinic sees Ohio as a broader state. The system is "very cognizant" of its privilege and responsibility to care for fellow Ohioans, he said.

The Clinic's tri-point model of care, research and education has been a powerful model, said Beth E. Mooney, chair of the Clinic's board of directors.

Together, the three pieces have kept Dr. Wilma Fowler Bergfeld, a senior staff dermatologist at the Clinic, with the health system for decades. She first joined the Clinic in 1964. The ability to do clinical research, teach and practice, while having the flexibility to assume leadership roles both in and outside of the Clinic have made her career a fulfilling one. All of this was underscored by a community of supportive physicians, she said.

The Clinic, its mission and expertise have "honed, grown, matured and become world-class" in the past century, said Mooney, who joined the board in 2007 and became chair a little over two years ago.

"It's larger, it's different, it's probably nothing that anybody could have envisioned 100 years ago," she said. "But what I think is really exciting is we are the stewards, I like to say, of the next 100 years, and so how we invest in technology, how we invest in care protocols, how we invest in new treatments is going to be the launching (pad) for what I think is going to be an incredible and distinguished next 100 years."

This story first appeared in our sister publication, Crain's Cleveland Business.