If you peer out the window of Ed Miller’s expansive office suite in the dean’s wing of the new Broadway Research Building, you can glimpse the future: Taking shape up Madison Street is the steel superstructure of the new biotech building, first of five structures that will make up the huge Science and Technology Park soon to occupy the once-decaying city blocks north of campus.

This scene also greets Miller every morning as he flicks on his computer. A camera trained on the construction site webcasts a live image onto his screen, so the dean and chief executive officer of Johns Hopkins Medicine can monitor the building’s progress as he checks his e-mail. Miller is on the job well before the first workers mount the bare girders—6:30 most mornings. As the sun rises, the screen brightens.

Now, it’s 9 o’clock on a mid-January day, and as traffic under the window thickens, the winter light remains a reluctant grey. Already, Miller has several coffee refills under his belt as well as two lengthy meetings—a 7:30 confab with dermatology faculty followed by an hour-long strategic report from orthopedics. In the brief pause before the next appointment, he works the phones. One call goes to his stepdaughter, Betsy, who’s complaining of a backache; another to his friend Paul Rogers, the former Florida congressman, who wants advice on his brother’s spinal stenosis. There’s not much that one of the most powerful physicians in American health care can do for either of these people. Miller tells Rodgers to fax over his brother’s MRI results so he can forward them to a specialist, but he’s careful not to promise much. As for Betsy, she gets some less-than-cutting-edge treatment advice. “Just put hot and cold on it,” he tells her. “You got any muscle relaxant?”

> The dean/CEO is known for making highly visible rounds—from security and construction workers to vice deans.

This sort of informal referral and consultation business comes with the job. “I feel like a clearinghouse some days,” Miller says, dialing his wife, Lynne. The two are going to a movie tonight, a rare night off from obligatory business dinners. The final call goes to trustee emeritus and prominent local businessman H. Furlong “Baldy” Baldwin, former Hospital board chair. “I don’t need money from you, Baldy,” Miller begins, typically blunt. “I need money from other people.”

Miller is seeking Baldwin’s advice on re-energizing fund raising, so he spends a few moments talking up the ambitious slate of new facilities under construction. Not counting the biotech building out his window—which represents the leading edge of a larger East Baltimore redevelopment project—there is a new medical education building going up and two 12-story clinical towers that will transform the heart of the medical campus. Additionally, the Wilmer Eye Institute is soon to break ground for a new research building. The price tag for this expansion will land well north of a billion dollars by the time the dust settles. Hence the renewed call for donors. “Have you been over here recently?” Miller asks. “Oh, you gotta see it, Baldy.”

The conversation turns to Miller himself, who is celebrating a decade as dean/CEO of Johns Hopkins Medicine, a two-headed monster of a job born of the 1996 blending of the School of Medicine and the Health System. It’s a role that Miller originated, and that he plans to leave when the current building boom ends. “I’m 64 on February 1,” he tells Baldwin. “I’m going to get out when I finish these buildings. Don’t you think?”

A day in the life of Hopkins’ medical czar reveals certain information about the DNA it takes to do this job. This top doctor must be an early riser, a good listener, and a glutton for lengthy meetings. Indeed, Miller wasn’t selected to run Hopkins Medicine for any credentials as a bold visionary. He was meant to be a steady navigator who would avoid making waves. And on that front, he has proven brilliantly successful. The School of Medicine and the Health System, embattled a decade ago over different priorities and separate cultures, have worked in almost seamless harmony under Miller’s leadership.

But Miller could leave an even more indelible stamp on health care. By presiding over a period of massive expansion and transformation—both physical and cultural—at one of the world’s most honored medical institutions, he should affect Hopkins, Baltimore—and potentially the world—for generations. “The campus of the future will be his design,” proclaims one of his lieutenants, Vice Dean for Education Dave Nichols. “That will be his legacy. In a sense, you could call this the Miller Campus.”

At 9:30, Otolaryngology Director Lloyd Minor, neuroscience professor Gabrielle Ronnett and Vice Dean for Faculty Janice Clements troop into Miller’s office. The business at hand is big. The three are bringing the final decision on the search for a new director for the top-ranked biomedical engineering department. But the mood is light. The day before, Miller attended a meeting with the full search committee on the three finalist candidates, so he begins by explaining why he stayed so conspicuously silent. He didn’t want to sway the voting.

Now, Miller is more forthcoming. The top vote-getters, everyone agrees, are superb scientists, but their personalities could not be more different. As the meeting begins, most of the talk is coalescing around one front-runner. In the interview, this candidate impressed everyone as well-spoken, hyper-prepared and possessing sterling research credentials. But, with a few pointed questions, Miller reframes the issues. Biomedical engineering is a department with one foot in the School of Medicine and one uptown on the University’s Homewood campus, where the Whiting School of Engineering resides. Will the research interests of this person balance those two distinct faculty groups and locations? “I’m afraid the focus wouldn’t be over here,” Miller says. “Am I wrong?”

The others chew on this for a moment. The question, having been introduced, seems to shift the center of gravity. Aspects of this finalist’s presentation had suggested a top-down management style. Will that approach mesh with Hopkins’ culture? “This was certainly the most articulate candidate,” Miller says, “but I heard a very self-centered view of the world.”

Similar points are raised about another finalist—also a brilliant researcher, also a strong personality. “This is a very direct person,” Miller says. “Is this someone who can be a uniter? Would this appointment be a good fit for us?”

Maybe not, they agree. Which leaves one final candidate, a well-known quantity with terrific credentials who put in several years as a laboratory director. Miller quizzes the room about likely faculty reactions, finds no red flags, and briskly steers the group to a decision. “You’re in this camp? And you agree, too?” he asks everyone in turn. He pauses for a beat, like an auctioneer with his gavel in mid-air. “I’m going to call this person and start discussions.” The whole process has taken less than 15 minutes.

“I’m not sure that everyone understands what a leader in this institution needs,” Miller says later. “Style is a big issue. We’re consensus-built. If it’s all for me, it’s dead in the water here.”

He speaks here from some experience. When this unassuming anesthesiologist was tapped for office a decade ago, tensions between the dean of the medical school and the president of the Hospital and Health System had erupted into open warfare. To try to ensure that such conflicts would never occur again, trustees stepped in and imposed a new unified governance over the two historically distinct institutions. A virtual entity called Johns Hopkins Medicine was born, and a single administrative position was concocted to helm this new creation.

Miller was new to Hopkins then. He’d arrived just two years earlier from Columbia to chair the Department of Anesthesiology, which was in the midst of its own minicrisis after a lengthy interim period between directors and a series of financial woes. Nichols, a full professor in that department, remembers that Miller quickly displayed a knack for deft diplomacy as he cut faculty and imposed belt-tightening. “The department had to be stabilized,” Nichols says. “He did that, very effectively. And it wasn’t a particularly easy experience for some people.”

Picked as interim dean of the medical school in early 1996 as the board searched for a big name to take on the new dean/CEO position, Miller defied conventional wisdom and landed the top job itself. He quickly set about calming the waters and negotiating a rapprochement with the Hospital. “My job,” he says, “was to be more than the dean of the medical school—it was to mesh the cultures of the two institutions and sometimes play referee.”

Once a week, Miller lunches with his executive staff and others in a small conference room. It’s an informal affair: As the assorted vice deans fill their Styrofoam plates with sandwiches and chips, Miller sits at the head of the table, the white-haired paterfamilias. He extols the virtues of crab soup, makes small talk about his old hometown of Rochester (“My mother once had tea with George Eastman”), and listens to—and occasionally indulges in—the collegial buzz of workplace gossip. “Everybody takes their egos off when they get in that room.” Miller says.

Then there is an hour spent strategizing with Vice Dean for Research Chi Dang and other faculty about plans for the basic science departments. As they discuss the size and makeup of the leadership group for the new interdisciplinary Brain Science Institute, Miller takes a few notes and listens intently. Then an unfamiliar word trips him up. “Help me on epigenetics,” he says sotto voce to the scientist next to him and gets a quick basic course on the complex new field that has recently gained a center. “You can see that I sometimes falter,” Miller acknowledges later with a small grin.

The School’s research engine has received increasing attention from the dean/CEO in his decade on the job. Early on, some faculty grumbled that he didn’t divide his attentions evenly among disciplines, with the research side often losing out. “There was a perception that I was too clinical-centric,” Miller agrees, “but I thought there were more issues on the clinical side.”

“Initially, I don’t think people were aware of his research background,” Clements says. “I think he got a bad rap for that.” Part of the problem, she notes, may have been his no-nonsense manner. “You’re not working for a pushover who doesn’t have strong opinions—which I like,” Clements says. “But at the beginning it wasn’t as clear that he was open to other ideas. He’s learned that he needs to listen and let things evolve.”

But most of all, Clements adds, “if you disagree with him, do it to his face.” She cites an example from her own dealings with the dean: Soon after joining his staff, she raised the issue of the dearth of women in leadership positions. Miller was convinced this was no longer a problem. Clements knew otherwise, and showed him the numbers. The dean listened and has since become a key proponent for more gender diversity on the faculty.

“You really can persuade him,” Clements says, “but he doesn’t like confrontation, doesn’t like being backed into a corner. So, if I’m going back, I’m going back with data.

“We’ve had leaders who were brilliant, but if you don’t engage other people in the process, it doesn’t work here,” explains Clements, who was on the search committee that hired Miller away from Columbia in 1994 and who has been at the School of Medicine for 33 years. “Things can fall apart fast.”

> When not working the hallways, Miller keeps the watch with Hospital President Ron Peterson.

Miller learned this lesson quickly and over the years has developed a clear approach to conflict resolution. He’s now typically hands-off. “Generally, the parties at the table are able to reach a consensus on their own,” Nichols explains. “He sort of nods at the end of it, and we’re done. I’ve modeled myself on him. I realized early on that I was talking too much.”

Only when Miller senses that a basic element of the value system here is being challenged does he visibly show irritation. “That, frankly, makes him angry,” Nichols says.

At 6-foot-5, Miller can dominate a room before he opens his mouth. His deliberate manner suggests a man who knows how to underplay his size. He seems to carry himself with a faint crouch, and his deep voice is a flat Upstate rumble that is rarely raised. Hospital president Ron Peterson, who has weathered his share of crises alongside Miller, lauds his steady nature.

“It’s rare to see him get emotional about anything,” Peterson says. “The only time I’ve seen him riled up was when someone overtly did something against the institution. Otherwise, he’s pretty hard to rattle.”

Peterson would know. During this decade of partnership, he’s stood by as Miller confronted some grave challenges to Hopkins’ reputation. The dean/CEO’s annus horribilis came in 2001. In that one year, he had back-to-back catastrophes to deal with: first, the death of a healthy research volunteer who was taking part in an asthma study at Hopkins Bayview, and then the accidental death from dehydration of a toddler at the Children’s Center. In the aftermath of those incidents, as sole spokesman for an institution under siege, Miller discovered the flip side of his exalted post. With national headlines assailing Hopkins’ patient safety and research protocols, “Ed bore the brunt of it,” Clements says. “That’s what he does as a leader. He steps up.”

Miller doesn’t leap at the opportunity to discuss that period. “It was pretty grim,” he says simply. “You couldn’t imagine it getting any worse. We were getting shot at from every direction.” He sits quietly for a moment, then adds, “but I know the institution is stronger now because of it.”

He lists a raft of protection measures for patients that Hopkins implemented in its hospitals in response to the two deaths. These include a $20 million computer prescription system that prevents errors in ordering medication and a huge unit-based program that has changed the very culture of patient safety here and also become a model nationwide. Still, in assessing his own decision making in this top post, Miller acknowledges that his sole real regret is having failed to anticipate the need for these safety initiatives.

In a very fundamental way, Miller doesn’t like playing defense. Whether it’s bad publicity—today it’s a Los Angeles Times story on construction problems at the new NIH lab facility being built at Hopkins Bayview—or a critical report from an outside committee on medical education—which gave the School of Medicine mixed reviews on the diversity of its faculty after a recent site visit—the dean responds with visible irritation and a singular determination to return fire.

Like Atlas carrying the world on his shoulders, Miller has become the protector of this unwieldy institution. The blue-ribbon Hopkins brand, he says, makes us a fat target. Then, he adds, with a glint of steel in his voice, “But you can’t sit down and let them roll over you, or you’ll be in big, big trouble. Fame is wonderful, but sometimes it’s a set-up. There seems to be this idea out there that if you get the alpha-dog, everyone else will get in line.

“You really love this place or you hate it,” Miller says. “Your work is never quite good enough—the standards are pretty damn high. The loners don’t do well.” He also has little patience for ego-driven infighting among top people and prefers open debate to whisper campaigns or muttered hearsay.

“Ed doesn’t like leaders who try to undermine each other,” Clements says,

Since he took office, the directors of nearly every School of Medicine clinical department have changed. Accordingly, the institution’s leadership has been transformed. The new Hopkins is less patriarchal, less white, and far less rigid. “The faculty is much more independent minded,” he says. “The chiefs now have to be managers. ‘My way or the highway’ just doesn’t work anymore.”

The internal transformation has been accompanied by the campus expansion now under way. It was Peterson, during his earliest conversations with Miller, who impressed on him the need to modernize. “He embraced that right away,” the Hospital president says.

The two have a relaxed rapport that reflects their well-matched personalities. Miller is the hands-off, big-picture guy; Peterson is the low-key Hopkins lifer (he began as an administrative resident in 1973, three years after graduating from the University) known for his ability to keep an eye on the bottom line.

“We complement each other’s skill set,” Peterson says. Early on, he served as Miller’s lead cost-cutter and institutional memory. Now, when they gather around a coffee table in Miller’s office for a midafternoon sit-down, the two men hash out construction issues like a pair of suburbanites comparing notes on a runaway home renovation.

The cost escalation for the twin clinical towers is just frightening, Peterson says wearily. “And there are so many moving parts.” The numbers he reels off include up to 1,200 workers on site every day, many of whom are brought in from other states at considerable expense.

“Trust me,” Miller says. “This is a not a business you want to get into now.”

To pay for the building surge, Miller has had to learn fund raising. “His success,” Peterson says, “is largely a function of the fact that raising money is about cultivating people—friend-raising. And Ed’s very good at that.”

“It’s become fun,” Miller says. (See Asking for Money 101) “I know how much money is out there. I’ve got a great product. If you can connect potential donors to the institution, the Ask is easy.”

After Peterson leaves, Miller has a few moments to himself before a marathon two-hour meeting with the medical faculty advisory board that will occupy the rest of his day. He uses the time to chat on the telephone with one of his counterparts, Harvard Medical School Dean Joe Martin, who recently announced he would retire in July 2007. The two veteran administrators exchange high-level pleasantries for a few minutes, then conversation comes around to Miller’s own plans.

“Naaah, I gotta stick around for a while,” Miller says into the phone. “I’m still building buildings.”

But Miller’s plans after stepping down are pretty definite. “I’ll leave,” he says. “I’ll have accomplished what I wanted to: The senior faculty is in place; we’ve got a pretty good philanthropic engine running; we solved some problems. That will be the right time to go.” He and Lynne are building a waterfront home in Stewart, Florida, where Miller can ply the waves in his 28-foot Sea Ray and keep his distance from East Baltimore. “It will be better for the next leader,” he says firmly, “if I’m not around.”

In the meantime, he still has some unfinished business. As the afternoon light wanes and the hardhats across the street climb down for the day, Miller hunts for some paperwork on his desk, tightens his tie, and girds himself for the stretch. “Yes, that will be about the right time for me,” he repeats and heads for the boardroom. “It’s been quite a run.”

Writer David Dudley has just joined the staff at the Bloomberg School of Public Health.