Wartman, Steven A. MD, PhD, MACP
Academic health centers (AHCs) represent a unique combination of teaching, research, and patient care. Their strength results from the intertwining of these central activities working in concert to improve health and well-being as they expand the boundaries of knowledge. This combination is doubly powerful as a vital contributor to health security and as a significant engine of economic growth. However, the fulfillment of these goals requires, in my opinion, a recalibration of the AHC enterprise.
Recalibrating Institutions to One Mission
It is no longer enough to say, as is commonly done, that the AHC mission is to
* educate the next generation of health professionals,
* conduct cutting-edge research, and
* deliver a broad spectrum of comprehensive care.
Rather, these “missions” must be viewed as functions, the means by which the true mission—improved health and well-being—is accomplished. By focusing the mission sharply on improved health and well-being, the entire enterprise is given enhanced meaning and direction, not to mention markedly improved political viability. In its most tangible form, the new emphasis implies that an AHC takes responsibility for the health and well-being of the community in which it plays a central role. In some instances, this community may be a specific part of a city; in others, it may be a larger region. But instead of simply coexisting, the AHC and the community must develop a viable partnership that brings direction and value to both entities.
This partnership is particularly important in light of studies that have shown that an individual's health prospects are shaped by five broad factors, including genetic and gestational endowments, social circumstances, environmental conditions, behavioral choice, and medical care. There is, of course, a rather complex interplay amongst these domains, but it is generally estimated that medical care accounts for less than 25% of a population's health status. Because factors such as education, employment, poverty, housing, crime, income disparities, and social cohesion are also powerful influences, AHCs must take a broader view of health.1
Traditionally, the AHC has focused, understandably, on the medical care domain, the rationale being that this realm is what it knows best and that there is little it can do about these other factors. This narrow focus is, in part, a reflection of the siloed nature of many of our health professions schools within the AHC. For example, schools of public health have long recognized the need to place more attention on the social determinants of health, but the lack of emphasis on interprofessional education and training has limited their impact on the programs of other schools. If AHCs are to be leading organizations of the future, they must be demonstrably effective in achieving this expanded mission. The education, research, and patient care functions that serve the AHC mission must be focused more directly on their communities and regions. As noted in a recent report, “Scrutiny of the community benefit offered by academic health centers is growing. Helping to address the social determinants of health is one way centers can demonstrate their value and sustainability and stay relevant to the communities they serve.”2
Recalibrating education to meet changing societal needs
In the education realm, recognition of the need for substantive curricular change is growing. For example, the new “Genes to Society” curriculum at the Johns Hopkins University School of Medicine has as one of its cardinal tenets that “[the] basic structure of medical curricula is not suited to the nature and pace of scientific and societal changes.”3 This new curriculum includes a special “societal component” that emphasizes how individual patient phenotypes may affect the family or community. Similarly, the increasing emphasis on interprofessional health education speaks to the development of a new paradigm for care delivery. AHCs must take the lead in recalibrating their educational programs to target evolving societal and patient needs.
Linking research to improved health
Recalibration of the research realm will assist the transition from the current very highly leveraged model to one that is broader in scope and function. Indeed, the link between research and improved health requires development and support, including new research tools and infrastructure. Another important element for recalibration in the research arena is the relationship between academe and industry. A positive, mutually productive relationship will likely prove vital in the years ahead, not only to sustain quality research but, more importantly, to enhance the commercialization of needed health breakthroughs.
Transforming patient care
Patient care delivery must also undergo transformation and redesign. As noted in a recent paper, AHCs “need to transcend traditional academic and geographic borders and engage in global public-private partnerships, not only to fill gaps in research domains, but also to build the final essential component of the discovery-care continuum.”4 These authors envisioned the evolution of the AHC into a full-fledged academic health system.
Challenging Leadership to Be Visionary
Given the recalibration of teaching, research, and patient care, there is the additional, and perhaps pivotal, administrative challenge of managing the overarching alignment of these efforts; for, without alignment, much of the synergy is lost. This effort is ultimately a test of leadership, as the challenge will not be easy to meet. Numerous difficulties and barriers exist at virtually every level, including leadership, faculty, staff, governance, economics, and political considerations. Because AHCs are finely tuned to the current environment, they are not easily changed. AHCs depend on growth in specific areas to sustain their momentum and allow the needed subsidization of various core aspects of the enterprise. The model that has been embraced to date is so highly leveraged with specific funding streams—streams that are likely to diminish in purchasing power—that its sustainability is in question. This delicate ecology likely will be upset in the future, and strong, visionary leadership will be necessary to move the enterprise ahead successfully.
Sustaining the Effort Globally
As AHCs adapt and change in response to the new environment, it is critical that they look outward as well. The global health environment is increasingly interconnected as diseases, patients, students, and professionals cross international borders with greater ease and frequency. The Association of Academic Health Centers International was established to facilitate the AHC's role as an agent of change, embodying the ideals of enhancing health and well-being worldwide through the promotion of best practices and international networking and collaboration.5
Pursuing This Mission: Guiding Principles
Despite significant economic, cultural, and historical differences, the academic health community has much in common. As AHCs begin the careful recalibration of the enterprise to sharply focus their mission of improved health and well-being, there are three guiding principles to follow.
* Alignment of the functions of teaching, research, and patient care will ensure that all three areas work synergistically within the AHC.
* A tangible commitment to a partnership with the communities they serve will demonstrate that AHCs are devoted to improving the health and well-being of both individuals and populations.
* Collaborative engagement with other AHCs on a national and international scale will create an open framework for mutual improvement and problem-solving.
By realigning the AHC enterprise around these principles, the value proposition—Advancing and Applying Knowledge to Improve Health—can be demonstrated clearly.
The author is grateful for the assistance of Lynn Bentley, administrative assistant at the Association of Academic Health Centers.
The views expressed represent those of the author.
This commentary has been adapted from the Presidential Address at the 2010 International Forum of the Association of Academic Health Centers.
1 Koop CE, Pearson CE, Schwarz MR, eds. Critical Issues in Global Health. San Francisco, California: Jossey-Bass; 2001.
2 The Blue Ridge Academic Health Group. The Role of Academic Health Centers in Addressing the Social Determinants of Health. Atlanta, Ga: Emory University; 2010.
3 Wiener CM, Thomas PA, Goodspeed E, Valle D, Nichols DG. Genes to society—The logic and process of the new curriculum at the Johns Hopkins University School of Medicine. Acad Med. 2010;85:498–506.
4 Dzau VJ, Ackerly DC, Sutton-Wallace P, et al. The role of academic health science systems in the transformation of medicine. Lancet. 2009;375:949–953.
5 Wartman SA, Hillhouse EW, Gunning-Schepers L, Wong JE. An international association of academic health centers. Lancet. 2009;374:1402–1403.