Clancy, Gerard P. MD
The moral obligation to serve those in need is at the very core of academic medicine1 and is a commitment of medical professionals at all stages of medical education and practice. At the same time, academic health centers (AHCs), which serve as important economic engines for their communities, have annual operating expenses in excess of $1 billion. As the Patient Protection and Affordable Care Act (ACA)2 of 2010 is implemented, the drive to provide more efficient, higher-quality health care will accelerate, requiring medical schools and teaching hospitals to incorporate ever more sophisticated business practices to remain financially viable in the health care marketplace. Therein lies potential for increased tension between the core service values of the medical profession and those of the highly competitive health care industry.
This tension can be eased if a view is taken that working to improve underserved populations’ health, education, and job opportunities makes sound business sense for regions that are competing in the global marketplace. As businesses consider expanding into a region, they look for a healthy, educated workforce. Some U.S. universities and AHCs are engaged in initiatives to increase area employment opportunities by improving the health of the local workforce, particularly in environments with daunting health, education, and economic disparities. Notable examples include the University of Pennsylvania, which is doing extraordinary work in West Philadelphia by supporting area public schools, safety initiatives, and economic development.3 Montefiore Medical Center in the Bronx, New York, is also highly regarded for its innovative work with local neighborhoods.4
Among the medical schools undertaking such initiatives is Tulane University School of Medicine,5 which is leading efforts to re-create a community-based health system after Hurricane Katrina disabled several of the region’s teaching and safety-net hospitals. Florida International University’s new Herbert Wertheim College of Medicine6 developed its curriculum in partnership with the neighborhoods of Miami, one of the most ethnically diverse cities in the United States, through employing residents to conduct neighborhood health needs assessments.
If these and other medical schools’ efforts succeed, they will bridge the gap that exists between the virtue of service to the poor and the need for economic development beyond the walls of the AHC. They will help create healthier workforces in minority neighborhoods, stronger public school systems, increased public safety, and new small businesses.
In this commentary, I will describe the University of Oklahoma’s (OU’s) community outreach efforts in Tulsa and share the insights I gained about linking health equity with economic development during the year I served as both president of the OU-Tulsa campus and chairman of the board of the Tulsa region’s chamber of commerce.
Tulsa, Oklahoma: Divided and in Poor Health
Oklahoma, like many other states, includes areas of significant poverty and coinciding health disparities. The state ranks poorly in virtually all health status comparisons7,8 and was recently listed among the “most challenged” states in terms of its capacity to provide primary care as Medicaid expands under the ACA.9
In-depth public health data generated by OU show there to be a 14-year difference in life expectancy between residents of Tulsa’s predominantly African American north and predominantly Caucasian south regions. Although almost 40% of Tulsa’s population lives in the north, east, and west regions, only 4% of Tulsa’s clinicians practice in those areas. Public schools in north, east, and west Tulsa suffer the same dismal student test scores and high school dropout rates as public schools in many other urban districts.
A blight on Tulsa’s history is one cause of the disparities. In 1921, the city erupted in one of the worst race riots in U.S. history, creating a legacy of mistrust among some within the African American and Caucasian populations that continues today. Compounding the problems that arise from this mistrust is a complex web of poor access to care, an insufficient health care workforce, unhealthy behaviors, poverty, and public safety issues.
OU’s Outreach Efforts in Tulsa
Working with underserved populations
The OU College of Medicine’s work with underserved populations in Tulsa has been driven primarily by a strong sense of moral obligation shared by its leadership, faculty, staff, and students. We have partnered with Federally Qualified Health Centers (FQHCs), built new clinics, and started outreach programs in areas with shortages of health professionals. To further build the area’s health care infrastructure, we have applied for and been awarded federal health information exchange and complex patient care team grants. We have also collaborated with the University of Tulsa to create a new physician assistant program.
In 2008, the OU College of Medicine’s regional campus in Tulsa was renamed the OU School of Community Medicine, making explicit our commitment to improving the health of entire communities. Our campus’s academic programs join us in community-based initiatives that go beyond traditional health care, including early childhood education programs, urban redesign of struggling neighborhoods, graduate degree programs in urban leadership for school principals, nutrition education (through our nursing program), and family stabilization (through our social work program).
Serving as university campus president and chamber of commerce chairman
In 2009, as our community engagement efforts accelerated, leaders of the Tulsa Metro Chamber (TMC) invited me to serve as chairman of the board for 2011. The TMC has a membership of some 3,100 organizations and more than 180,000 individuals. Its board of directors is composed of 70 chief executive officers from businesses of all sizes, area public and private universities, and private foundations. The TMC is well run and was named the U.S. Chamber of Commerce of the Year in 2006, 2008, and 2010.10
In asking me to assume leadership of its board, the TMC emphasized the importance of health and education for all in the economic viability of the Tulsa region. It was the first time an academic officer had been asked to lead the organization.
Six Insights From Working as a Chamber of Commerce Leader
With support from the OU president, I accepted the TMC’s offer. My personal goal was to close the gap between regional strategies for access to health care for underserved populations and regional strategies for economic development. The work was interesting, and I gained new insights on an almost daily basis, much as I did during my early years of residency training.
Although I had worked with the TMC for almost 10 years in my capacities at OU-Tulsa, my day-to-day responsibilities as chamber board chairman delivered new lessons on economic development, organizational effectiveness, legislative processes, and regional cooperation. These insights, which I share below, will be helpful to our work as an AHC for years to come.
1. The business sector has substantial influence with legislators.
I quickly discovered the strength of the TMC’s legislative advocacy efforts. Each year, the TMC builds lists of its state and federal legislative priorities, compiled from the efforts of theme-specific task forces whose members include representatives of many of the area’s hospitals, universities, and nonprofit clinics. With the priority lists in place, the TMC focuses its full efforts on meeting these goals; it has an impressive 90% success rate on the year-to-year lists. Over the past three years, the priority lists have included initiatives to support health care and medical education infrastructure—primarily for underserved populations—with numerous successful outcomes. A recent proposal by law enforcement leaders to curb methamphetamine production by restricting the purchase of pseudoephedrine did not receive support from state legislators, partly, according to a local official, because “it was not on the chamber’s legislative priority list.”
2. Access to state and federal leaders offers important opportunities to build a case with those who can effect change.
As I worked with the TMC’s well-funded legislative affairs staff, I was impressed with the increase in my access to our area’s city councilors, mayor, state representatives, lieutenant governor, governor, and federal congressional delegation. This improved access provided me with opportunities to explain in greater detail the specific needs of underserved populations as the legislative affairs staff and I made the business case for diversity, inclusion, increased health workforce, and clinical program infrastructure. I also gained a much better understanding of the constraints that elected officials face in performing their duties.
3. The business sector strongly supports initiatives targeting poverty, health, and education.
I was pleasantly surprised by the TMC’s quick, unanimous adoption of and enduring support for programs focused on the broader social determinants of health, increasing access to health care for the poor, and expanding the health workforce to care for underserved populations. Initiatives included supporting Medicaid financing, growing medical student class size and graduate medical education program training positions, stabilizing the finances of a city-owned teaching hospital, obtaining start-up funds for a new cancer clinic in north Tulsa, expanding FQHCs and early childhood education programs, and establishing the Teach for America program in the Tulsa Public Schools system.11 Many of these initiatives were proposed by other TMC members and board members. I found that OU’s efforts to improve the health of the region had a powerful partner in the business community, which had the skills and resources to aid our work.
4. Business leaders see diversity and inclusion as key components of local strategic plans.
The TMC recognized the importance of diversity and inclusion in building an effective regional workforce and made them part of its long-term strategic plan. That commitment was tested by a proposal that would have streamlined local government but carried the potential to create a voters’ rights issue in Tulsa’s African American areas. The TMC board took a strong position to protect voters’ rights. Toward the end of my year as chairman, the TMC created a new program designed to educate area business leaders on the economic development advantages of an inclusive, diverse workforce.
5. Supporting economic development and engaging with the community can change business leaders’ perceptions of a university or AHC.
During my year as TMC board chairman, Tulsa’s corporate, small business, and philanthropic leaders developed an appreciation for OU-Tulsa as a business peer. There was growing awareness of OU’s contributing significant time and effort in direct support of the business sector and the greater community’s needs. I predict that this new relationship will enable us to collaborate with the business community on complex initiatives that may take years to complete.
6. AHCs are part of a larger effort.
At times, academic medicine leaders fall into the trap of thinking that most national, state, and local activities revolve around the AHC. As I worked closely with government officials and CEOs, my eyes were opened to a larger perspective. AHCs are not the center of the universe or even a solar system—but we are an important planet. Working in isolation limits how effective we can be in meeting the needs of our patients, students, institutions, and communities. I found the business community to be more than willing to collaborate with AHCs if we are willing to work alongside them to improve the well-being of the entire community.
Bridging the Gap
Medical schools and teaching hospitals care for the poorest and most complex patients. At the same time, AHCs are significant economic engines for any community fortunate enough to host one. At times, the commitment of caring for underserved populations and the responsibility of driving regional economic development may appear at odds. Yet there exists an opportunity to merge these core strategies for strengthening the community. I believe that AHCs are at an important crossroads, where they must take on the tasks of working daily with the underserved and also serving as significant corporate forces in their business communities. Physicians and AHC leaders have the opportunity to act as bridges between the clinical and business worlds.
My experiences as a civic leader allowed me to span this oft-perceived gap. I learned that the moral obligation to serve the poor should not be taken on in isolation but, rather, shared with leaders in the community. Similarly, we in academic medicine should commit to working with leaders of local businesses and philanthropic organizations to develop strategies targeting diversity and inclusion as well as education and economic opportunities for underserved populations. By doing so, we can help accelerate local economic development. As I have experienced firsthand, the business sector will be supportive of academic medicine playing this important leadership role.
Other disclosures: None.
Ethical approval: Not applicable.