National and global events (e.g., declining state funding for higher education and the resulting tuition increase that well exceeds any rate of household income increase; the emergence of online/distant learning options; Affordable Care Act mandates, made worse by the frequent state–federal misalignment around incentives; and the need to develop and implement extensive and expensive information technology infrastructures for distance learning, big data analysis, and electronic health records) are rapidly and irrevocably driving transformation in both academia and health care. One result is an increase in the pace of institutional restructuring, consolidations, and mergers. In many cases, medical schools and their clinical enterprises—or, more commonly, academic medical centers (AMCs)—will be at the epicenter of these forces, because in most universities with an AMC, the clinical enterprise represents either a significant source of support and branding for the university as a whole or a significant burden on university finances.
As an example, Georgia Regents University (GRU) has been on an aggressive, transformational path for the past four years—here, the term “transformational” is not exaggeration. In this short time, the institution has successfully undertaken a series of major initiatives that have increased alignment; enhanced size; driven growth in, and the development of alternative sources of, revenue; fostered administrative integration, quality, and efficiency; and improved brand recognition. We first integrated and consolidated our clinical enterprises into one health system, closely aligned with the university. Secondly, we created a shared administrative structures across the entire enterprise—the university and its health system. Thirdly, we consolidated the resulting health sciences university and AMC (then the Georgia Health Sciences University [GHSU], previously known as the Medical College of Georgia) and a proximate public masters-level regional university (Augusta State University) to create GRU.1
GRU’s leaders and administrators placed the institution on this aggressive transformative path for several reasons: first, to ensure long-term competitiveness and sustainability in a rapidly changing and increasingly more competitive global marketplace; second—recognizing the increasing need to leverage partnerships, alliances, and synergies—to make the institution a partner-of-choice for training, research, and clinical care; and finally, to ensure a better return on investment, not only for the university and local communities but also for the state, its citizens, and its taxpayers. We are striving to achieve these goals while decreasing administrative and operational costs and dependency on state dollars.
We are not alone. Other universities and systems of higher education (e.g., Rutgers / University of Medicine and Dentistry of New Jersey) have undertaken consolidations or mergers, and other institutions (e.g., College of Charleston and the Medical University of South Carolina) are seriously considering them. Still other AMCs are striving to enhance their size and reach either through partnerships with various teaching hospitals (such as in the case of Clarian Health Partners/Indiana University Health as reported by Handel et al2 in this issue of Academic Medicine) or through various mergers (as discussed by Thier and colleagues,3 also in this issue). Still Some other AMCs are enhancing their footprint and aiming to become a regional referral center, as in the case of the University of Kentucky, reported in this issue by Edwards et al.4
To a great extent these initiatives are new territory for both higher education and academic medicine. GHSU was one of the few remaining stand-alone health sciences universities in the nation. Its consolidation with a smaller (in terms of faculty and budget, but not in terms of number of students), more comprehensive university has provided us with the opportunity to examine the role of academic medicine vis-à-vis other nonmedical disciplines in university-wide transformation. Our experience with the development of GRU highlighted the need to answer the question “What is the value and role of academic medicine and the AMC in the life (and transformation) of its university?” Formulating a clear response might allow other universities with an AMC—or universities contemplating melding with an AMC—to better prepare for and manage needed growth and change; such a response may also be illustrative for the leaders of any university that already has an AMC who are trying to better leverage academic medicine for the advancement of the entire institution.
To begin to answer the question about the role and value of the AMC to the parent university, we must consider two general issues. First, while the culture of academia in general does not lend itself to easy transformation, the nuances within the culture of academic medicine may be useful to facilitate the process and success of such initiatives. Second, and in contrast, leaders from academic medicine may be at a disadvantage when faced with university-wide issues and initiatives. What follows is a brief review of my thoughts around these issues, based on our recent experience at GRU.
Culture of the Faculty
The decision-making structure in higher education is typically one of shared governance, academic freedom, extensive consultation, and widespread agreement before action—with limited tolerance for risk and mistakes. This structure tends to be highly and deliberately heterogeneous, and to attend closely to minority voices. Academics generally value preserving tradition over embracing cultural innovation. Further, academic faculty are skeptical by nature, a characteristic fostering robust research and intellectual exploration, although this “show me” attitude makes the task of leading the institution into an uncertain future more difficult.
A strong sense of urgency is needed for successful change and transformation. However, in academia, while a sense of urgency is growing around economic constraints and faculty and staff salaries, there is limited urgency to effect widespread transformation. Rather, there is a strong desire to “get back to normal.” This tendency to look to our past for answers is compounded by the aging of higher education faculty. To illustrate, in the academic year 2000–2001, 21.7% of higher education faculty were over 60 years of age; by 2010–2011, this figure had risen to 34.5%.5
In addition, the GRU experience confirms that “it is effectively impossible to overcommunicate” during transformative change.3 But the segmented environment and culture of universities—departments and colleges, laboratories and institutes—means that they rarely have robust, broad-based, effective communication systems in place when transformation begins.
Overall, the culture of academia today has a limited sense of urgency around the need for transition and, alternatively, favors an incremental, cautious, measured approach to change, strongly supporting the status quo and the return to a past “normal.” Thus, transformation on university and college campuses is riskier and more difficult than in other settings.
Academic medicine faculty are also generally highly skeptical and status quo-oriented, but the experience at GRU brought to light notable differences among AMC faculty that may be leveraged to facilitate and implement needed change. For example, compared with university faculty in general, AMC faculty tend to be more understanding of and comfortable with risk; more entrepreneurial; more willing to operate in teams; and more ready to accept, understand, and respond with action to data. They tend to have a heightened sense of urgency and a better understanding of the need for a “new normal.” These qualities, likely resulting from the significant economic pressures that have been squeezing this sector over the past decade, may make AMC faculty an asset in fostering and implementing transformation. Although we did not initially know that academic medicine faculty may be more transition-ready, the experience at GRU has highlighted the great value that AMC faculty and leaders can play in helping to lead change in the university as a whole.
Alternatively and unfortunately, academic medicine faculty and students often engage less with the life of the broader university (e.g., cultural and educational offerings, athletics, student activities), and they are less likely to appreciate the current challenges facing higher education (e.g., issues around student access, success, affordability, or the growing demand for distance learning) than faculty in other disciplines. And academic medicine faculty, particularly clinical faculty, are less likely to perceive their careers as highly dependent on the sustainability of the greater university or the availability of tenure, as they generally have a greater number alternative career opportunities available to them.
In turn, nonmedical faculty and nonmedical academic leaders have also been less willing to embrace or engage academic medicine faculty. This distance may be in part a reaction to the self-segregation of AMCs. But also operant is the higher compensation received by AMC faculty versus nonmedical faculty and a general disregard in higher education for the intellectual value of “professional” degrees. Combined, these cultural attitudes make full engagement of AMC faculty in university-wide change and transformation more difficult.
The Nature of the Leadership
Successful transformation of any complex enterprise requires the right type of leaders, as noted by Thier et al3 in this issue. In higher education, generally it it requires leaders who are strategic-minded with an ability to understand, respect, and drive toward the bigger picture of academia; who are able to articulate compelling, vivid, short- and long-term visions; who are skilled operating in an extremely ambiguous and uncertain environment; who are able to ensure widespread, multidirectional communication; and who are widely respected by the academic community. Transformative leaders must also have a high tolerance for risk, because change management is inherently risky—even more so in higher education, which makes enjoying significant and transparent support by governing boards critical.
However, leaders in higher education, most of whom come from faculty, generally have low tolerance for risk and limited experience ensuring widespread, repetitive, and continuous communication. In addition, academic administrators must ensure continued compliance in the highly complex, intensely regulated environment that is higher education today, which rightfully further increases their risk aversion. Consequently, like their faculty, higher education leaders often feel a limited sense of urgency to implement rapid or significant change, preferring instead to embrace change incrementally.
Alternatively, leaders in academic medicine, like their faculty, tend to be more risk tolerant, more innovative, more metric and quality driven, and more ready to embrace transformation, which positions them as useful allies in driving change. However, AMC leaders often do not demonstrate the greater understanding of higher education necessary to effect successful university-wide transformation. In fact, the GRU experience showed that AMC leaders, like those in other research-oriented enterprises,6 are typically respected specialists who have driven specific sectors to success, often with short-term deliverables and often at the expense of other units. These individuals tend to be strongly tactic minded and action and results oriented; the incentive for them has been to protect the areas they are accountable for—too often, sadly, with limited respect for and understanding of the skills and contributions of other faculty who, in their view, provide less revenue and may have less relevance to the day-to-day survival of humanity.
Overall, while academic medicine leaders may more readily embrace and drive transformation, the very features that make academic medicine leaders successful in their sector may diminish their ability to lead university-wide initiatives.
The Lack of Clarity Concerning the Role and Value of the AMC Within the Larger University
The relationship of the AMC to the greater university has always been an ambiguity that requires addressing, even more so in times of change, such as now. In many institutions, the AMC budget consumes a significant, even majority, portion of university resources. This reality, combined with the AMC’s cultural detachment noted above, potentially leads to real or perceived inequities across the institution that come into play in academic or administrative dialogue. In addition, AMC operations are often deliberately segregated from those of the university as a whole, both to increase the competitiveness and maneuverability of the AMC enterprise and to reduce fiscal risk to the university.
Regrettably, these combined factors tend to reduce the university’s ability to benefit from the rich experiences and administrative innovations inherent in academic medicine. These factors also limit the development of transdisciplinary, interdisciplinary, and interprofessional programs in education and research and further diminish AMC engagement with university-wide transformation. Finally, they work to ensure that medically trained leaders are actually—or and perceived to be—insufficiently skilled for the management of higher education enterprises.
The need for rapid response and change in higher education and academic medicine will only accelerate as the models for both higher education and health care turn away from state-supported financing, bricks-and-mortar teaching-and-learning settings, and unlimited tuition increases. The cultural insulation of academic medicine from the broader university creates risk and lost opportunity for both the AMC and its university, especially as the needs for greater alignment, shared administrative services, and the leveraging of economies of scale continue to increase.
At GRU we are deliberately working to mitigate the tendencies of AMC and broader faculty to silo themselves. For example, the entire university is benefiting from the AMC’s prior experience with performance metrics and quality measures to create robust dashboard and monitoring systems that enhance and create incentives for university-wide administrative and leadership effectiveness. We are leveraging the AMC research machine for the benefit of nonmedical faculty development and scholarship and for the promotion of undergraduate student learning. We are also leveraging AMC clinical expertise to provide better staff and student health services, and we are developing pipeline programs around health sciences, which will attract more diverse and higher-caliber students to undergraduate programs.
In turn, our AMC faculty members now have access to a wider platform of intellectual thought and collaboration and to greater opportunities for faculty development through tailored programs in the arts, humanities, business, and education. And we have been able to leverage our greater size by creating a shared system of administrative support across the AMC and the university as a whole. Other institutions have also strived to better leverage the AMC for the growth and benefit of the broader university; one such institution is the University of Alabama at Birmingham, which has a university similar in structure to that of GRU., although I am sure they would also agree that much remains to be done.
The GRU experience suggests that significant value lies in fostering greater synergy between the university and its AMC, and that this synergy, in turn, will better ensure the ability of those universities with an AMC to undertake and meet future transformative challenges. University and AMC leaders should work together to proactively develop strategies both to enhance AMC leaders’ engagement with, exposure to, and education regarding the operations and challenges of higher education and the broader university, in general; and, likewise, to increase nonmedical faculty’s understanding of and experience with the value and unique challenges of academic medicine.