Despite the economic headwinds, there are many 2008 clinical program highlights to share. One of the underlying themes that emerged in the midst of these difficulties is the ingenuity, perseverance and creativity that, across the board, our physicians and our staff have demonstrated. At a time when even recession-resistant health care is reeling from global crises, their efforts make our achievements that much more significant.

Notably, we continued to see growth during 2008 in ambulatory care and outpatient services in both patient visits and the number of procedures provided. Our revenue grew as well, though the rate of growth slowed as the mix of patients changed with the rise in unemployment (see charts below). Part of our ability to grow revenue came from controlling costs and reducing investments-no small feat for a department already tightly managed from a financial perspective. Two administrative changes helped drive this.

First, we transitioned more control of the outpatient area via newly created "ambulatory care units" to individual physician/nurse/administrator teams. Accompanying this change in oversight, the faculty group practice ambulatory care staff, working with the hospital finance department, developed a suite of reports that provide in-depth insight and analysis of costs and expenditures and enable projections of proposed investments. Now we have the ability to factor in facilities costs and administrative overhead, and to compare total costs against varied revenue scenarios such as those that may occur with changes in our patients' insurance. These analyses allow better decision making and enable us to create the best match between quality, efficiency and cost, and to drive real value. As we work through the economic slowdown these tools are proving invaluable.

With regard to program development and physical space changes, we are progressing with renovation work at the Taubman Center, to accommodate the development of three marquee-level programs in gastroenterology, pulmonary and nephrology. In addition, we have designed a new facility for the Metabolism, Endocrine & Diabetes Division at Domino's Farms that will open in July, freeing up additional space in the Taubman Center.

We are also planning a combined musculoskeletal program that will leverage our expertise in rheumatology, orthopedic surgery, physical medicine and other related specialties. Though still in its infancy, stage one of the plan entails these groups working more collaboratively to take advantage of one another's capacities and to leverage our financial and staffing resources. Stage two will likely include co-locating some clinics in an existing facility. And stage three should see the construction of a new facility to house the combined programs in a new center for the treatment of musculoskeletal disorders.

Our existing centers are fulfilling expectations. The Comprehensive Cancer Center continues to demonstrate success. It is one of only 39 centers in the United States to merit the National Cancer Institute's "comprehensive" designation. The recently created Cardiovascular Center is also well established, and we're seeing excellent synergies with the various departments that are working together there.

In summary, though the economy has presented unprecedented challenges, our department's clinical enterprise continues to grow. No doubt further challenges lie ahead, but with our strong and motivated team, we remain confident of maintaining our reputation as one of the top clinical departments of academic medicine in the United States.