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Perspectives |
1 From the Department of Radiological Sciences, University of California, Irvine Medical Center, Orange. Received April 12, 2001; accepted April 16. Address correspondence to the author, 18961 Castlegate Ln, Santa Ana, CA 92705 (e-mail: rmfriede@uci.edu).
Index terms: Perspectives • Radiology and radiologists, socioeconomic issues
Ask any professor in academic medicine what the mission of an academic health center is and the answer will be research, teaching, and clinical practice. However, over the years, the balance of these three core missions has been uneven, and only the mission of teaching is peculiar to academic health centers. Research is also a core mission of the pharmaceutical industry, and clinical practice is the core mission of community hospitals.
In a way, the goals of academic health centers and managed care are similar—to provide for healthy lives. The methods and motivations may differ. Managed care offers health security at a stated price and under contractual arrangements. Academic health centers provide practitioners to care for patient health, offer research toward future health, and provide certain types of specialty care. Theoretically, the two groups should function symbiotically. The problem has been that managed care has a vested interest in denying services, and academic health centers have a habit of overuse of service. In the future, we must couple cost analysis with outcomes of clinical decisions to try to provide proper methods of delivering services (1). However, we know from previous experience that rules and regulations relating to patient treatment are difficult to establish and enforce, since we are dealing with enormous variabilities in disease processes and with variations in the human characteristics of practitioners.
Prior to the Flexnerian era, there were few truly academic centers. Their mission was primarily clinical practice, with education and research as minor appendages. After the Flexnerian revolution in the early 1900s, education became the primary mission, with research and clinical practice the appendages. This was the era of the scholarly physician-teacher, a concept that was supported and almost revered by the public.
After World War II, the emphasis changed. Huge amounts of research money became available through the National Institutes of Health and other federal agencies, and academic centers followed the money trail, which led to a change in emphasis; the main mission of the academic center became research. With the initiation of Medicare and Medicaid in 1965, the United States made its first foray into the arena of nationalized health insurance, although in this case for special subgroups of society. Academic centers began to receive clinical payments for patients whom they had previously treated for free, and clinical income, although still minor, became a substantial part of the academic center budget.
In the 1970s and 1980s, as health costs spiraled to unacceptable heights, support for academic centers decreased, and, for the first time since the pre-Flexnerian era, the primary mission of academic centers became clinical care. As an illustration of the importance of clinical care in the medical school budget, in 1970 at Johns Hopkins, the clinical income of the full-time staff amounted to $1,900,000. By 1983, it was $60,000,000. By 1980, practice income had become the largest source of revenue for medical schools (2).
As Ludmerer pointed out in his excellent book Time to Heal (2), in the mid-1980s a new paradigm arose emphasizing that there are limits to what the country could spend on health care. The pass-through era of reimbursement of medical care in which all costs were paid by insurance carriers came to an end. The new paradigm focused on prospective payment, regulated prices, and restricted use of hospitals and specialized services. In the preceding generation, medical schools had grown dependent on clinical income as their primary source of revenue, but now it appeared that the 21st century would be the era of resource constraints. As academic health centers fought for survival, education and research were all too often overlooked, and academic health centers were rapidly losing their academic quality.
With the exception of the few centers that had large endowments, the bulk of academic centers are now struggling not just for survival but also to accomplish their prime mission. Research support from clinical income has almost disappeared. The clinician-teacher is pushed to devote more time to clinical care, and teaching efforts have decreased to a degree where some physicians felt that they were penalized if they devoted too much time to academic pursuits. Researchers have to support themselves from their grants, and in many cases their incomes have decreased well below those of their clinical colleagues. Young individuals who might have chosen research go into clinical practice because of the need for additional income. Academic centers realize that their financial security now depends on seeing a larger number of patients more rapidly, with fewer costs per day. In some cases, physicians receive incentive pay for increased clinical effort, which further reduces their efforts in teaching and research.
For-profit hospital chains grew enormously in size and market share. Since the prime mission of such hospitals was profit, they saw no need to provide charity care. Indigent patients were sent to the academic centers, as were many Medicare patients who were covered by diagnosis-related groups, or DRGs, who had severe illnesses and where the costs would far exceed the income, a practice referred to as "dumping." Hospitals were now providing the bulk of income to the academic health centers, which allowed hospitals to dominate the medical school.
From 1986 to 1995, the number of full-time clinical faculty members had increased 52% at public medical schools and 64% at private schools (2). Ludmerer (2) stated that the signs of eroding scholarly atmosphere at medical schools were the reduction in the level of research, the decline in the intellectual atmosphere with the conversion of scholarly faculty to clinical faculty, deterioration in the quality of learning, and the blurred distinction between teaching hospitals and community hospitals. Students who learn medicine in this environment in which the bottom line is cash flow are different from those educated where the bottom line is the satisfaction of the patient’s needs and problems.
Here is the problem facing academic health centers: They are being asked to provide the research necessary to maintain the prominence of U.S. medicine; maintain the scholarly physician-teacher to ensure proper education of the next generation of physicians; and compete with private and community hospitals for the clinical dollar, which has become their major means of support. This just demonstrates the confusion of the U.S. public health policy—a policy that is dangerous in that we are teaching our next generation how to cut corners and reduce costs, not how to maintain a physician-patient relationship that will assist in proper diagnosis and therapy. The changes of managed care have moved academic medicine toward becoming a commercial enterprise.
This commercialization of academic medicine has not helped the 43 million uninsured. In the past, Congress has expected the academic health center to provide care for the uninsured population, in effect expecting the academic health center to substitute for a nationalized health insurance policy that Congress was not eager to embrace. These patients are mainly treated at academic health centers, which must bear the costs without sufficient support.
Fein (3) thought that in the 1970s and 1980s, academic centers satisfied with the dollars earned through clinical income tolerated a financing system that made little sense and made them vulnerable to any change. When managed care imposed cost controls that severely reduced clinical income, academic centers had no other resources and were forced to compete in a competitive marketplace. Reinhardt (4) thought that academic centers should have delineated their different product lines and put in place a cost accounting system linking cash flow to each product line. Various product lines would include undergraduate education, graduate education, basic research, applied clinical research, insured medical care, uninsured care, and care of last resort. With this method, academic medicine could define those product lines that should be self-supporting from those requiring public subsidies.
If academic centers had had the foresight to do such cost accounting, they might have avoided some of today’s problems. Such accounting would clearly state which items are covered by academic medicine’s social contract with society. Academic health centers have always had an implied contract with society. Society expects academic centers to educate future physicians, provide continuing education, and perform cutting-edge research. Society delegates the methods of accomplishing these missions to the faculty of academic centers. These missions incur substantial expenses, which society supports. In return, medical centers must accept society’s oversight; society has the right to ensure that academic centers use their privileges wisely (5). Producing physicians, therefore, is not just the responsibility of medical centers; it is a shared responsibility with society, and, therefore, society must pay its share of the cost.
One of the major problems resulting from the onslaught on the academic medical center has been lack of mentoring for students and residents. Ethics lectures are no substitute for the student-teacher relationship from which students obtain the moral compass that governs their actions for the rest of their lives. It would appear that there is no longer a place for the scholar-physician-educator. Students have lost their role models and are in danger of being taught a way of care organized like an assembly line, since academic centers are being forced to act like other profit-making enterprises. One of society’s most effective instruments for societal good is being damaged (5).
Society must provide academic centers with sufficient resources to maintain their non–profit-producing responsibilities. Ludmerer (2) stated that we need to slow down the pace of clinical care so that physicians have time to teach and learners have time to learn. We cannot replace the physician-teacher with a computer; every student requires a mentor who instills in the student the morality required for the practice of medicine, as well as how to deal with clinical uncertainty, a major part of the practice of medicine.
While the introduction of cost-effectiveness by managed care was long overdue, the introduction of efficient use of time by managed care was terribly overdone, and the prime victim was the doctor-patient relationship. No matter how skilled the doctor, mistakes occur when patients are seen and treated in haste. Patient satisfaction depends heavily on good communication, which is impossible without a good doctor-patient relationship. Cost constraints introduced by managed care were necessary and good— to a point. If cost constraints are overdone, they will squeeze out quality and professionalism.
Academic medicine is a public trust and resource, which is why society must support and protect it. The important social functions of academic health centers are separate from their clinical practice—in essence, clinical practice should be an adjunct function of the academic health center, not its major function and certainly not its prime mission. Society depends on academic health centers for the education of future generations of physicians, for research on disease and discovery of new knowledge, and for the care of the indigent and uninsured (2). These are revenue-draining, not income-generating, functions. These latter functions must be established as cost centers separate from the clinical function and must be financially supported by society.
To obtain public support, academic health centers must demonstrate that their programs are serving the needs of the public with budgets that have cost constraints and in addition show their commitment to society’s needs such as preventive medicine, the monitoring of quality of care, and public health. With these functions, society is in partnership with the academic health center and has the right to oversee and monitor progress.
Schein (6) suggested an interesting parable. He suggests that the three elements in the typical culture of any organization are the executors, the engineers, and the operators. In the academic health center, the administrators are the executors who focus on financial survival and try to minimize costs, the engineers are the teachers and researchers who design new concepts and teach students how to use them, and the operators are the clinicians who treat illness. The increase in the importance of the operator’s functions has created turmoil with the engineers.
Once education, research, and care of indigent patients are separated from the clinical aspects of academic health centers, society has to decide how they should be funded. We should assume that managed care will not voluntarily support these functions. Whatever form of health insurance finally evolves, we must have attached to it a social supplement to cover education, support of research, and health care for the residual uninsured. This would involve a major change in our current philosophy, one that would be opposed by insurance companies and part of organized medicine. It would require support from the tax base, but, on the basis of other countries’ experience, the basic plan should not cost more than the 14% of the gross national product we now spend for health care. If universal health care is not in our immediate future, then support of education and research must come from a federal trust fund established from tax revenues or tax on health insurance premiums.
As Burrow (7) pointed out, we can expect great things from academic medicine during the next 25 years. This may include specific therapy for cancer and heart disease, vaccines for acquired immunodeficiency syndrome and retroviral diseases, treatment of autoimmune diseases, and elucidation of the human genome and the ability to eliminate particular diseases. These potential accomplishments certainly merit support from a social contract with society. As Ludmerer (2) stated, "For the general public, there is one overarching message: Academic health centers are fragile institutions that need aggressive nurturing, sustained protection, and the unwavering support of those with vision, power, and means."
REFERENCES
This article has been cited by other articles:
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  R. B. Gunderman, K. A. Buckwalter, and J. M. Farber Seeking an Academic Department Chairperson Am. J. Roentgenol., October 1, 2003; 181(4): 951 - 954. [Full Text] [PDF]
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 M. D. Cohen and R. B. Gunderman Academic Radiology: Sustaining the Mission Radiology, July 1, 2002; 224(1): 1 - 4. [Full Text]
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