The article by Ovseiko and colleagues,1 “Organizational models of emerging academic health science centers in England,” raises important issues for the fields of academia, medical research, and clinical care not only in England and in the United States, but throughout the world. Coherently linking academic and clinical activities delivers obvious benefits, but are some models for organizing these relationships better than others? Is there a “best” way to structure an academic health science center (AHSC)? First, some “goods” produced by AHSCs.
Recognizing the Good
Obviously, any clinical enterprise should strive to deliver the very best care. But AHSCs have larger responsibilities. They are expected not only to serve their local community but also to provide leadership in clinical care and innovation for their region and the nation. Moreover, academic centers are designated to aggregate the greatest depth and the widest coverage to deal with any medical problem presenting to their door. These types of problems have grown increasingly severe and complex with medical situations that are formidable unto themselves and often accompanied by coexistent conditions. Addressing these problems generally requires health care providers to work as a team that incorporates professionals from multiple disciplines with multiple skills. The team concept is also being extended beyond the direct patient-care level to an organizational level with various forms of collaborative partnerships across the time and space of varied inpatient and outpatient settings.
Thus, AHSCs should strive to model the very best care—in addition to excellence in primary and secondary care, AHSCs should have in their capacity the ability to respond to emergent, tertiary, and quaternary situations.
A second major “good” is AHSCs' capacity to train the very best health care providers possible. This requires both exposure to the mass of authoritative information about medicine and medical care delivery and grounding across the full spectrum of translational sciences, from basic to clinical to population science, with a continuing awareness of the evolution of health care in the general community. AHSCs provide this exposure for trainees from multiple disciplines across the full developmental pathway extending from partnerships with grade schools in their communities through undergraduate and professional schools to continuing education of senior health professionals. These trainees ultimately evolve in various directions with career trajectories encompassing the educational aspects of health care, direct clinical care, research, and, conceivably, leadership roles in the administration and direction of AHSCs or other health organizations.
Finally, AHSCs provide to all societies the good of medical research, which has produced countless improvements in diagnosis and treatment strategies for a wide range of medical problems. It is one of the great accomplishments of modern medicine and health care that many conditions such as congenital heart disease, eroding and failing function of major organs, and the erosion of the utility of joints have been addressed by innovative and increasingly effective techniques to correct those conditions with a direct impact on both the quality and the length of people's lives.
These several functions come together in the various centers around the world that address the “tripod” of care, education, and research functions in various organizational frameworks. It is our opinion that the closest juxtaposition of these three parts of the tripod in an AHSC has many distinct values.
Striving to Be Better
It is widely accepted that clinicians are energized by having an educational role within a clinical care setting. Kept on their toes by young students who challenge and raise questions, experienced clinicians and clinical teachers are stimulated to stay on top of the latest developments in medicine and to think through many problems that emerge in medical care. Absent these challenges and educational responsibilities, seasoned clinicians might be less motivated to remain on the cutting edge.
In an AHSC, research is informed by the clinical environment and continually challenged to translate the excitement of discoveries in basic processes into useful products within medicine and health care. Importantly, this translational process does not stop at the development and successful testing of a product or intervention. AHSCs are a critical locus for the translational step of effectively implementing and disseminating effective diagnostic and treatment interventions and improving health outcomes.2 In the United States, the National Institutes of Health has fostered these partnerships through the major investment of Clinical and Translational Science Awards.
Education is improved when it is in the context of a research environment because the researchers bring systematic approaches of inquiry to problems being dealt with clinically. This exchange augments informed clinicians' skills and broadens their thinking for addressing clinical challenges.
One could find many other ways of illuminating this “virtuous circle”3 that can result from the interchange among these functions, but we use the above as simple representative examples.
Pursuing the Best
As Ovseiko et al1 have documented, there are multiple approaches to collectively organizing these functions, and their associated organizations and international comparisons are illuminating. The United Kingdom and the United States each has its own set of governance, representation, and legal, financial, and health care organization principles that control these functions. The U.K. government's greater control and funding responsibility of both the health care system and the academic enterprise may be seeing its emerging counterpart in an increasing government role in the U.S. health care system. Even before the recently passed health care reform is implemented in the United States, the government already oversees or supports a very large proportion of health services, graduate medical education, and biomedical research. Competition and the role of the private sector are important points of influence in the U.S. system, and this will continue with health care reform.
There are many different organizational models for AHSCs in the United States—some in which centers are relatively independent of universities, others in which centers are part of the universities; some in which hospitals and medical schools are integrated under one governance, others in which they are separate—and all have ways of handling the organization of the clinical practice portion within the overall system. These variations in organizational structure are most often the result of the local institutional situation and context in terms of history, geography, tradition, the health care market, and often-changing strategic decisions by leadership over time.
Organizational models are also influenced in the United States and the United Kingdom by a relatively worldwide economic strain that most societies are experiencing. Thus, in the United States, discussions of consolidated payment, accountable care organizations, integration of hospital and doctor enterprises, and governance are all parts of the attempt to streamline, potentially consolidate operations, and hopefully reduce costs while improving quality.
We feel that one should identify the “goods” that are the goal and try to design the organizational and governance strategies in such a fashion as to maximize the accomplishment of those goods. So, in the end, the best organizational models enable the very best care delivered to the overall population by the most skilled and up-to-date practitioners in a setting where research can prosper and, therefore, deliver new ideas and new diagnostic and treatment advances in the kind of virtuous circle described by Wartman.3
We believe that the Flexnerian principle of learning best by “going about” may be worth considering in this discussion. Perhaps it might be valuable to foster an exchange of visits by leaders both in the United Kingdom and the United States to respective centers in both countries and glean from each other best practices, which may be mutually informing.
There is no question that in both countries external forces are stimulating changes in the systems and their functions. Given the many common interests and orientations of the United Kingdom and United States, a thoughtful and somewhat systematic interaction between AHSC leadership may illuminate best practices in both places and, perhaps, generate insights influenced by the experience of interaction between the enterprises or new ideas stimulated by the exchange. One of the outcomes may be an understanding of how to respond to the common external forces that affect the organization, governance, and functioning of AHSCs and develop new organizational approaches that are in the interest of providing the best health care, training the best clinicians, and stimulating the most productive research.
Health care is important, not only for the benefit of the patients but also for the respective nations' economies and productivity. Pursuing the best models for providing that care should be at the very top of national priorities for both countries.
Dr. Pincus reports funding from the Irving Institute for Clinical and Translational Research at Columbia University (UL1 RR024156) from the National Center for Research Resources, a component of the National Institutes of Health.