Cohen, Jordan J. MD
We in academic medicine pride ourselves on our commitment to meaningful pursuits: We educate the world's best doctors; we care for the most desperately ill; and we find the cures for tomorrow's patients.
We also pride ourselves on the phenomenal growth our institutions have enjoyed over the past several decades. All of that sounds wonderful, of course. But embedded in all that wonder is a nagging question that I think deserves our attention: Has our quest for growth begun to obscure our quest for meaning? Is our “drive for size” in danger of displacing our deep-seated aspiration to contribute in meaningful ways to the improvement of the human condition?
Our Unprecedented Growth
Clearly, by just about every measure, our institutions have enjoyed unprecedented growth in recent decades. The number of full-time basic science faculty in our medical schools has expanded dramatically—a 2.5-fold increase in just 30 years. Far outstripping even that impressive growth, the number of full-time clinical faculty has grown a whopping five-fold over the same period. In less than half that time, our medical schools have acquired at least 50% more space for faculty to conduct their research. And to top it off, as everyone knows, our clinical enterprise has grown like Topsy; hospital discharges, clinic visits, emergency room visits all are on the rise in the typical teaching hospital.
What's been our secret? How has our enterprise been able to grow at such a phenomenal rate? Part of the explanation, of course, is that we provide services of great value for society. As engines of progress, medical schools and teaching hospitals have, indeed, made wondrous contributions to the welfare of people everywhere, and we've been encouraged along the way to do more and more.
But there is no doubt that another part of the explanation behind our growth is that we have followed a simple and very effective strategy. Stated most succinctly, we've followed the money. And the money has certainly been there, at least until recently.
Imagine where our research mission would now be had our faculty not secured a 4.5-fold increase in National Institutes of Health (NIH) awards over the past three decades—and that's in constant dollars. Imagine how much smaller our clinical programs would be were it not for the advent of third-party reimbursements and for the phenomenal 40-fold, constant-dollar increase in practice plan revenues. Imagine how our academic missions would have fared had it not been for the so-called cross-subsidies from all those clinical dollars. Imagine how less well off our state-supported institutions would be were it not for a 3.5-fold increase in their annual appropriations, not to mention their access to tax-exempt bonds. And imagine how much smaller and shabbier our campuses would be were it not for the generous philanthropic support we have received from our alumni and grateful patients, as well as from numerous private foundations and corporations.
No question about it, we've mastered the art of following the money, and we have a huge enterprise to show for it. Huge, and still trying to grow, despite emerging constraints.
Indeed, we have become so accustomed to getting bigger that we have come to regard growth as a principal metric of success. Right in line with mainstream American culture. Growth is king. The bigger the better. Everyone competing to be in the Top Ten.
▪My fear is that we've become so focused on getting bigger that we're missing opportunities to get better.
▪As our clinical enterprise continues to expand, large gaps in quality remain.
▪As our research enterprise continues to grow, physician scientists are still an endangered species.
▪We have bigger departments, but fewer colleagues.
▪We have more things to do for patients, but less time to listen to them.
▪We have more opportunities to improve, but we're too busy to seize them.
▪Education is our core mission, but research and patient care consume our time and energy.
As Bob Watson at the University of Florida College of Medicine and others have noted, the school—as in medical school—is in danger of becoming a vestigial appendage of an ever-enlarging academic medical center. Getting bigger, after all, is not, ipso facto, the paramount measure of success for an academic enterprise. How large do we have to be to do the unique things that society requires of us? Shouldn't we be seeking better ways to use the capacity we now have to make meaningful contributions without spending so much energy trying to get even bigger?
Seeking Meaning through Our Missions
Let's look at each of our three fundamental missions with an eye toward our quest for meaning. Our first and foremost mission is to educate and train future physicians to fulfill their responsibilities to their patients and to society. Second, we have a major responsibility to advance medical knowledge through research. And last, but hardly least, while delivering high-quality, cutting-edge care and providing access to needy populations, we have a primary responsibility to make advances in medical knowledge and translate them into useful, affordable, and safe strategies for improving health.
First mission, education: Let's put aside for the moment the possibility, as some are suggesting, that a doctor shortage looms on the horizon and that more medical schools may be needed. The question is this: Do we need to get bigger to address the challenges of today to prepare our present students and residents for their future responsibilities? I don't think so.
Which is not to say that we can continue as we are. As a first order of business, we need to seize on the recent Supreme Court rulings in the Michigan cases to do more to achieve appropriate racial and ethnic diversity in our classrooms. Having removed the uncertainty that has shrouded the use of affirmative action in higher education admissions ever since Bakke, the Court has clearly defined the elements of a narrowly tailored process for attaining the educational benefits that flow to all learners from having a critical mass of underrepresented minority students. By carefully adhering to the guidance provided, admission committees can steer clear of the legal pitfalls that remain. We don't have to get bigger to close the unconscionable diversity gap that still plagues our profession; we only need to get smarter about what we do.
Equally important is the need to realign our education with the new realities our graduates will face in coming decades. Given the major changes that are occurring, and the even greater changes needed in the way health care is organized and provided, the responsibilities of physicians will undoubtedly undergo significant change as well. Among the realities facing future physicians will be greater accountability for the outcomes of the care they provide, much less tolerance for medical errors, much more emphasis on cost-effectiveness, and much more willingness to function in teams with nonphysician professionals.
We don't have to get bigger to address those needs. But we do have to expand our strategic partnerships with other health care professionals and with other venues for education. And we certainly have to elevate the importance of education among the many responsibilities that tug on faculty time. The new Academies of Medical Education, first established at the University of California, San Francisco, School of Medicine and at Harvard Medical School and now springing up in a number of places, are creative examples of how we can use existing resources more intelligently to advance our educational mission. We need to get smarter about what we do, not bigger.
Without getting bigger, we also can take full advantage of new information technologies to increase the efficiency and quality of our educational activities. Sharing educational resources via the Internet is one obvious approach, and one that is already well advanced. An example is HEAL, the Health Education Asset Library, a Web-based resource designed to provide free, high-quality, multimedia materials to teachers to use as they see fit in their own educational offerings. Another example with exciting potential is the sharing of computer- and mannequin-based simulations. These powerful and rapidly improving technologies offer exceptional promise, enabling students to gain realistic experiences with a wide range of conditions, and allowing students, residents, and practitioners alike to hone their diagnostic and procedural skills without risk to actual patients. Every medical school and teaching hospital need not—indeed, cannot—develop these expensive approaches independently. But, by pooling resources and collaborating with one another, every institution can have access to these improvements.
We don't need to get bigger ourselves to give our students and residents the experiences they need in a wide variety of clinical settings. Instead, we should look for ways to partner with those who are already functioning successfully in the settings we need to access for our students’ and residents’ benefit. The opportunities afforded by the increasing number of regional medical school campuses exemplify the kinds of collaborative relationships we should be actively seeking.
To provide a platform for all stakeholders across the entire continuum of medical education to collaborate in addressing agreed-upon shortcomings in our present educational programs, the Association of American Medical Colleges (AAMC) has recently launched the Institute for the Improvement of Medical Education. We'll never be able to address those shortcomings effectively simply by enlarging our already fragmented undergraduate, graduate, and continuing medical education enterprises. Only by getting smarter about coordinating our efforts can we hope to make real progress toward a shared vision of what medical education ought to be.
Second mission, research: Do we need to get bigger to continue to advance medical knowledge through research? I don't think so. Which is not to say there's not a lot more work to do. We are clearly in an age of unprecedented scientific opportunities for unlocking the deepest secrets of human biology. Our job is to ensure that those opportunities for discovery are explored as quickly and as fully as possible. We need to link our newfound genomic knowledge with the power of modern information technologies and with the unique capabilities of scientists in other disciplines who have a crucial role to play, but with whom we have not worked before. We don't need to get bigger to do that. But we do need to expand our strategic partnerships with cross-campus and cross-institutional colleagues.
We also need to recognize the inefficiencies inherent in the current, dominant model of university-based research: the investigator-initiated grant. No one would deny the extraordinary advances that have flowed from a commitment to this prototypical U.S. invention. Coupled with unimpeded peer review, individualism in the pursuit of new medical knowledge has unleashed enormous creativity and resulted in history's most productive scientific era. No question. In our present circumstances, however, I'm convinced that we need to augment—not replace—that inherently competitive model with a set of more collaborative arrangements.
Given that NIH budgets are not likely to grow appreciably, if at all, in the foreseeable future; given that much of modern science requires extremely expensive instrumentation that few institutions can afford; and given the magnitude of the task required to take full advantage of available genomic data, the time seems ripe for the academic medicine community to adopt a more explicitly cooperative posture in pursuing its research mission.
Rather than compete with one another to acquire reduplicated research capacity, like-minded institutions should pool their resources, avoid unnecessary redundancy, and pursue questions that all agree are now susceptible to answers. A case in point is the recently announced agreement by two long-standing rivals, the Mayo Clinic and the University of Minnesota, to join forces on a number of prospective research projects. Such collaborative approaches have the potential to expand enormously the aggregate impact of our research mission without the need for individual institutions to grow one bit.
The NIH is clearly prepared to support novel cooperative efforts among stakeholder institutions. The NIH's provocative new Road Map for Medical Research, recently announced by Director Elias Zerhouni, is replete with calls for our institutions to collaborate—with one another, with the private sector, and with the NIH itself—to more rapidly exploit the unique capabilities of modern science.
Third mission, improving health: The success of our teaching and research missions depends, of course, on ready access to robust clinical programs that provide both routine and specialized care. An additional critically important obligation of our clinical activities is to translate advances in medical knowledge into useful, affordable, and safe strategies for improving health. Do we need to get bigger to do that? I don't think so. Which is not to say that the task is getting any easier. Health care in America is in need of a major overhaul. Wasteful inefficiencies continue to squander our limited resources; avoidable medical errors reflect our fragmented, unsystematic system and are threatening to undermine public support; inexplicable variations in the processes and outcomes of care are increasingly indefensible.
Among our jobs as the wellspring of medical progress is our responsibility to use our knowledge to create better models of health care—models that are capable of providing care with the dimensions advanced in the Institute of Medicine's report entitled Crossing the Quality Chasm; care that is patient-centered, efficient, effective, equitable, safe, and timely. We don't need to get bigger to do that. We do need to redirect our energies away from defending the status quo and toward adopting innovations that produce measurable enhancements in patient care.
We need to get smarter about what we do, not bigger.
My nominee for a smart strategy for medical schools and teaching hospitals is to lead the transformation of clinical care. I have always thought that academic medicine is in a unique position to take that step. No academic medical center, as large as many are, could do it alone. But think about what a sizable group of such centers could accomplish if they coordinated their efforts. Without any one institution having to get bigger, collaborative arrangements among many could create units of accountability large enough to have a real impact.
Such collaborative arrangements could, for example, persuade third-party payers to structure novel financing arrangements for managing patients with chronic diseases. They could demonstrate the true capacity for new information and communication technologies to expand access, improve quality, and cut costs. And they could transform our learning environments for students and residents to prepare them to implement continuous, evidence-based improvement strategies throughout their careers.
Indeed, the only way to immortalize medicine's commitment to crossing the quality chasm is for students and residents to acquire their normative professional expectations exclusively in settings that always strive for the highest-quality care attainable.
Some of you may recall my 1999 annual meeting address, entitled “Collaborative Care,” in which I made a similar appeal to medical schools and teaching hospitals to seize the opportunity to lead the transformation of our country's health care system by working together to create more cost-conscious, quality-driven, evidenced-based, and patient-centered clinical care models. To help those institutions that wish to take up that challenge, the AAMC recently announced the establishment of the Center for Clinical Care Improvement. By seeking out the best evidence-based strategies for enhancing the care we provide, the Center hopes to facilitate collaborations among AAMC member institutions in an effort to promote large-scale innovations that can measurably improve the health of individuals and communities.
The Key: Collaboration
There is a common theme running through these suggestions for getting smarter about what we do without needing to get bigger. That theme, of course, is collaboration.
When I look at the AAMC's constituents across the country, I see a wide variety of institutions of various sizes, complexities, and governance arrangements, but of uniform commitment to the same three missions. All are working hard to advance those missions, but are doing so, for the most part, independently. I ask myself, Wouldn't the aggregate impact of all that effort be multiplied several-fold if only those institutions had a way to coordinate their efforts, to collaborate more effectively, to give up just a little of their jealously guarded independence and allow themselves to join forces to achieve goals beyond their individual reach?
Then I begin to wonder: Is it time to envision a new, more interdependent model for academic medicine, one in which our measure of success would include not only the sum of the accomplishments of individual member institutions but also the aggregate achievement of goals attainable only by deliberate, collaborative efforts involving the entire academic medicine community? Then I begin to fantasize about the kinds of audacious goals such a functioning network of like-minded institutions might dare to accomplish.
▪We could form a nationwide clinical research collaborative designed to ensure that the promise of the postgenomic era is fully and rapidly realized. What's needed to translate our basic knowledge into better health is a well-functioning and well-integrated clinical research enterprise that can acquire directly from human beings the information necessary to make appropriate correlations between genetic endowment, environmental influences, and disease outcomes.We could meet that need. A well-integrated collaborative effort among medical schools and teaching hospitals across the country could take collective responsibility for ensuring the steady supply of well-trained physician scientists required by such an enterprise; it could identify the most pressing research priorities, facilitate the enrollment of patients in clinical trials, and greatly reduce the time needed to answer agreed-upon questions.
▪Here's another example. We could totally transform our country's antiquated and ineffective continuing medical education enterprise—first by purging the field of the biased influence of commercial sponsors, and then by taking explicit, communal responsibility for the continuous professional development of all of our graduates throughout their professional lifetimes.Rather than view our former students solely as targets of fundraising efforts by individual alumni associations, we could address their continuing educational needs as practitioners with the same rigor and sense of duty as when they were students in our classrooms. We teach our students about the need for life-long learning; we could fulfill that need by being our students’ life-long teachers.
▪And a final example. We could partner, as a nationwide collaborative, with public and private payers of health care services to establish mutual targets for clinical care improvement, common standards for recording and transferring clinical information electronically, and appropriate payment mechanisms for the long-term management of patients with chronic diseases. As the mother of all provider networks, we could assume real leadership in helping to rationalize our irrational system.
Are these examples unrealistic? Maybe. Would they be difficult to accomplish? No question about that. Collaboration is hard going under any circumstances, even within a single organization, let alone across a complex web of proud institutions. Collaboration is the veritable antithesis of individualism—one of the most deeply rooted American ideals. But as they say, “If it were easy, anybody could do it.” My contention is that we are not just anybody. We are a privileged community, self-selected to be of benefit to society. We measure our worth as individuals and as institutions by how much we accomplish in the service of others. If we can find ways to leverage our service by collaborating within and across our institutions, our quest for meaning can be that much more triumphant.
I am convinced that our community's quest for meaning—in other words, our deep-seated aspiration to contribute meaningfully to improving the human condition—can, in fact, be supremely realized only by shifting the dominant paradigm of academic medicine from one in which individual institutions compete with one another, each seeking to grow their own programs, to one in which a network of allied partners collaborate with one another, all seeking to maximize the societal benefits for which the entire community is responsible.
As I look to the future of the AAMC, I see an organization continuing to provide a host of vital services to academic medicine, but one that has taken on an additional obligation—to help its members evolve toward that new paradigm of collaboration. The AAMC of the future, in my view, will create maximum value for its constituents to the degree that it can catalyze the creation of a collaborating community. A community of more interdependent institutions that are committed to using their combined talents and capabilities to accomplish bold objectives. Objectives unachievable—even unimaginable—under present circumstances. For me, the opportunity to lead the association on that quest for meaning is a challenging and intoxicating prospect.
I welcome readers’ suggestions about how the AAMC can help our community meet the challenges of a growth-constrained future. Specifically, what do you think those challenges are? What do you see as barriers impeding progress, and how do you think we can overcome them? And most important, what can't be accomplished by any single institution, but could be achieved by academic medicine acting in concert?
We need not grow larger to get better. We need only be smarter, and do it together.