Whitcomb, Michael E. MD
Just a few short years ago, prominent individuals within the academic medicine community were predicting a rather gloomy future for academic health centers (medical schools and their associated teaching hospitals).1–3 Their predictions were based on the belief that academic health centers (AHCs) would not fare well in the emerging health care delivery environment, primarily because managed care organizations would be unwilling to pay the extra costs associated with providing patient care in institutions that were also conducting education and research programs. In addition, federal policymakers were intent on decreasing over time the level of funding teaching hospitals were receiving through the Medicare program's Indirect Medical Education Adjustment. Those concerns led the leaders of some AHCs to adopt very aggressive strategies for positioning themselves more favorably within their local health care markets. Without a doubt, the most dramatic of those strategies were the mergers that occurred between teaching hospitals and other hospitals or health care organizations.4,5
Needless to say, the widespread closures of medical schools and teaching hospitals that were being hinted at did not occur. Quite the contrary: available evidence suggests that many AHCs are substantially better off financially now than they were during the 1990s. One could conclude that the favorable financial status of these institutions validates the aggressive strategies that their leaders adopted in response to the market forces operating at the time. More important, however, is the fact that the threat to the financial viability of AHCs posed by managed care was greatly exaggerated.
Be that as it may, there was a positive side to the perceived threat to the continued viability of AHCs. The threat prompted individuals within the academic medicine community, as well as others concerned about the future of academic medicine, to seek a better understanding and appreciation of the very nature of AHCs. Thoughtful individuals began asking two very important questions: What had these institutions become in recent years? And were the institutions being true to their unique missions? In many respects, it was those questions that prompted the Commonwealth Fund and the Institute of Medicine to convene special task forces to examine the future roles of AHCs in the 21st century.6,7
In my view, the attention focused on the nature of AHCs has been a very good thing. It has prompted those in leadership positions to examine more closely the environments of the institutions they lead. And in doing so, they are seeking to understand how the environments and cultures of their institutions affect those who are there to receive care (patients) and those who are there to learn how to provide care (health professions students, including residents). During the peak of the concerns being expressed about the future of AHCs, Roger Bulger, president of the Association of Academic Health Centers, wrote that the greatest challenge facing the AHC community was not to solve the perceived financial or organizational crises the institutions appeared to be facing, but instead to restore the marriage between humanistic concerns and scientific and technical excellence in health care delivery practices.8 He suggested that for the institutions to survive as “legitimate” AHCs, they needed to become teaching and learning institutions that reflected the characteristics of the therapeutic clinician. He went on to say that the institutions should define goals and set standards that would guide their efforts to achieve that goal.
This issue of the journal includes seven articles that provide evidence that AHCs are taking seriously the need to examine themselves and the impact they have on patients and learners. Three of these articles—by Bellin et al., Agrawal et al., and Wazana et al.—provide insight into what institutional leaders are doing to address growing concerns about the relationships that exist between representatives of the pharmaceutical industry and students and residents receiving training in medical schools and teaching hospitals—relationships that may adversely affect their future prescribing practices. Three others—those by Wander and Malone, Chervenak and McCullough, and Fife and colleagues—address challenging ethical issues that institutional leaders need to focus on as they strive to ensure that their business and management practices are always consistent with the underlying mission of their institutions. And finally, Delva and her colleagues suggest that the very nature of the clinical environment that students and residents are exposed to may affect their learning in ways not previously appreciated.
There is no way to know how many AHCs are presently focusing on the kinds of institutional environmental issues represented in the articles published this month. Based on the experience I have gained during frequent visits to AHCs, I believe this focus is becoming widespread. Granted, it takes different forms in different institutions, and is more pronounced in some than in others. But I believe that an increasing number of the leaders of academic medicine are asking serious questions about how the environments of medical schools and teaching hospitals are affecting the individuals who work there, the students who are there to learn, and the patients who are there seeking care.
Of course, none of those aspirations will have practical meaning if, in the end, the institutions are not financially viable. But one of the lessons we all should have learned from the experiences of recent years is that it is important to make sure that the assessment of financial viability is based on good data and logic, and that expressions of financial insolvency are not used to rationalize the adoption of aggressive strategies that put the institution at even greater risk. In the end, all management decisions should be required to meet the test set forth by Chervenak and McCullough: Is the action under consideration consistent with the institution's mission, or is it being considered solely to increase the institution's revenue and profits? And if a particular decision is deemed necessary, how will it affect the lives of the individuals who work, learn, and receive care there? We should all be striving to make AHCs the kinds of institutions they must be if they are to remain viable teaching and learning institutions in the years ahead.
On a day-to-day basis, everyone is likely to benefit if institutional leaders follow the recommendations set forth by Tom Inui in the impressive report he wrote at the end of his time as a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC).9 And in keeping with Tom's call to action, can anyone seriously doubt that everyone involved will not benefit from striving to make AHCs the kind of institutions envisioned by Roger Bulger and others?
Michael E. Whitcomb, MD
1.Pardes H. The perilous state of academic medicine. JAMA. 2000;283:2427–8.
2.Fein R. The academic health center: some policy reflections. JAMA. 2000;283:2436–7.
3.DeAngelis CD. The plight of academic health centers. JAMA. 2000;283:2438–9.
4.Kastor JA. Mergers of Teaching Hospitals in Boston, New York, and Northern California. Ann Arbor, MI: University of Michigan Press, 2001.
5.Mallon WT. The alchemists: a case study of a failed merger in academic medicine. Acad Med. 2003;78:1090–104.
6.Commonwealth Fund. Envisioning the Future of Academic Health Centers. New York, NY: The Commonwealth Fund, 2003.
7.Institute of Medicine. Academic Health Centers: Leading Change in the 21st Century. Washington, DC: National Academies Press, 2003.
8.Bulger RJ. The quest for the therapeutic organization. JAMA. 2000;283:2431–3.
9.Inui T. A Flag in the Wind: Education for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges, 2003.