Healing academic medicine

By Michael B. Gorin, Ph.D.

Enormous changes have been occurring in academic medicine, both at a national and local level. Academic medical centers (AMCs) are scrambling to ensure their competitiveness and access to patient populations. Reductions in surplus resources that originally came from clinical revenues have threatened the support of research and teaching. To those of us who are full-time academicians, these changes have at times seemed cataclysmic, leading some to speculate that the very existence of AMCs may be threatened. The truth is that, regardless of the changes in the health care system, academic medical programs will survive. Our society readily recognizes the need for these institutions to train new health providers and serve as the developers of new medical treatments and technologies. There is general agreement that research, both basic and clinical, is essential for our health care system to continue to provide a better quality of life to our nation.

The question is not whether or not AMCs will survive, but what form will they take in the 21st century and what will be the environment for current and future academic physicians? Will academic physicians be able to pursue research and teaching, as well as provide clinical care? How will physicians be able to balance the demands by their departments to generate clinical revenues and still have the time to pursue research and teaching, particularly as it becomes increasingly more challenging to secure research funding? What will it mean for an academic physician to be an educator as AMCs move toward a greater decentralization of the clinical experiences for their students? The answers to these questions are certainly not clear. The exodus of physicians from AMCs would suggest that many clinicians feel that the future of our academic centers will not allow for these pursuits, which in the past have differentiated academic physicians from their full time clinical colleagues. Ironically, the departure of these academicians has been mirrored by the acquisition of private clinical practices by many AMCs.

The answers to these issues are in many respects the same as those facing full-time clinicians. We will be forced to sacrifice a greater degree of autonomy as the institutions demand higher levels of accountability and a more “corporate” mentality. As discretionary resources become more scarce, clinical researchers will be increasingly forced to justify, not only the scientific merit of their research, but also the fiscal appropriateness of the studies. The competition for research funds, both from within the institution and from other funding sources including NIH, will place an increasing importance on the potential cost benefits of research and its impact on medical care. Faculty who wish to pursue basic or clinical research must have the time and backing from their institutions to develop and apply for grants, attend research-related conferences and prepare their work for publication. Without adequate safeguards and resources, academic physicians will be increasingly unable to develop and manage significant research programs. There is a critical need for academic centers to have sufficient financial resources to provide coverage to faculty who are initiating research programs or who might be experiencing a lapse in funding support. Without a safety net, few clinicians will be able to undertake the potential risks to their livelihoods to pursue research. Every academic center should be aggressively pursuing a policy of building endowments to support teaching and research. We can no longer expect this support to extend for the career lifetime of any faculty member, as has been the tradition at many institutions. In these times of accountability and employment vulnerability in the medical profession in general, academicians cannot reasonably expect that they will be covered by lifetime endowments, let alone by traditional tenure, if they fail to fulfill their obligations.

For the academicians who wish to be strongly involved in education, it is clear that the traditional role of mentor to medical students, residents and fellows will undergo dramatic changes. As we decrease the number of residency and fellowship positions, more faculty will find that their contact with residents and fellows will be increasingly limited. The full-time faculty will have to adopt the role of developer of curricula and assume primary responsibility for the integration and evaluation of medical education, as an increasing amount of clinical education will be done in remote settings with full-time clinicians. This entails a new level of responsibility and accountability that has previously been the domain of only a handful of academic clinicians.

Academic physicians who are attempting to maintain a portion of their professional time devoted to clinical care will need to be far more knowledgeable about the health care systems in which they provide medical care. They must be willing to adapt to provide efficient and cost-effective care. Although clinicians in AMCs are often confronted with challenging and complex patients, we cannot use that argument as a rationale for being inefficient, insensitive to our patients or colleagues, or having a lack of cost-conscious behavior. Generally, the academic faculty have had little or no control of the clinical environment in which they provide care. Office systems and personnel are usually controlled by specific departments and increasingly by the medical center. AMCs and the faculty have been remarkably poor at addressing the challenges of providing efficient clinical care in a teaching setting. Except for the recent concerns regarding the Medicare audits, few institutions have adequately addressed how to provide appropriate documentation of medical records by both residents and attending physicians in a cost-effective manner. There has been a consistent lack of recognition that academic physicians who are heavily engaged in research and/or teaching are essentially part-time clinicians with many of the same fixed costs as full-time clinicians. The institution must establish a means of not penalizing these part-time clinical activities in the distribution of clinical expenses, even though they may account for a disproportionate share of the fixed costs.

If there is a single critical aspect of what an institution must do to ensure the vitality and success its academic physicians, it is how that institution prioritizes, evaluates and rewards the efforts of its faculty. Just as it is clear that academic medicine will survive in some form in the 21st century, there is no reason to doubt that there will be individuals who will choose to pursue an academic career in medicine. However, the extent to which these faculty will continue to lead the world in medical research and serve as leaders in medical education will be determined by the value systems that are built into the evaluation and reimbursement programs of medical centers. There must be a de-emphasis on salary levels associated with seniority and academic rank. Financial values must be established for activities including research, teaching and administration. Clear-cut measures of effort, productivity, scientific achievement and teaching quality must be established, and the implementation of faculty evaluations must be fair and consistent. We must balance the need for careful scrutiny of our activities with reasonable safeguards for intellectual independence. Academia cannot be simply pasted onto a health care provider system, it must be an integral part of the entire mentality of the institution. At the same time we must be careful that our legacy of AMCs is not lost as we redefine the roles of the AMCs in the evolving national health care system.

Michael B. Gorin, M.D., Ph.D., is associate professor, Departments of Ophthalmology and Human Genetics, University of Pittsburgh School of Medicine and Graduate School of Public Health.