Correspondence

Social Missions of Academic Health Centers

N Engl J Med 1998; 338:1232-1233April 23, 1998

Article

To the Editor:

Blumenthal et al. (Nov. 20 issue)1 present a picture of academic health centers that is difficult to reconcile with the centers' current activities. Many of these centers have taken aggressive steps to purchase and assimilate medical practices, and some have gone into the insurance business. In short, the centers have not used their resources to reduce their high costs to patients but instead have attempted to acquire a large fraction of the patients in their various areas.

Ralph G. Wieland, M.D.
13221 Ravenna, Chardon, OH 44024

1 References

1. 1

   Blumenthal D, Campbell EG, Weissman JS. The social missions of academic health centers. N Engl J Med 1997;337:1550-1553
   Full Text | Web of Science | Medline

To the Editor:

Blumenthal and colleagues may yet breathe new life into the academic health center. As they suggest, any lasting change will require accountability. However, the institutional accountability detailed in their paper is only part of the story. Accountability will devolve to individuals as well, because that may be the only reliable means of promoting both fiscal and professional discipline. Once academic health centers were thought to be the repositories of both knowledge and professional values, and the “threadbare gentility” of the professors enhanced their image as the teachers of the servants of the ill.1 However, the hierarchical tenure system has created an expectation of lifetime employment and has engendered an attitude of entitlement that now offends the paying public. Only accountability can restore the tarnished image to its former luster. In addition to the examples mentioned by Blumenthal et al., accountability means that the unbridled training of physicians as a source of staffing can no longer justify a higher cost of care; personal ministration should replace surrogate practice through house staff; the scramble for personal grants for salary support should be replaced by coordinated departmental research projects; equal weight should be given to clinical, teaching, and research contributions 2; and salaries should reflect the real market value of the services rendered. All this will require deft leadership from deans and department chairs to maintain the quality and morale of the faculty while trimming overblown faculty ranks, stimulating productivity, and maintaining revenues for unique and valued services.3

Michael Radetsky, M.D., C.M.
Lovelace Health System, Albuquerque, NM 87108

3 References

1. 1

   Petersdorf RG. Academic medicine: no longer threadbare or genteel. N Engl J Med 1981;304:841-843
   Full Text | Web of Science | Medline

2. 2

   Alpert JS, Coles R. Careers in academic medicine: triple threat or double fake. Arch Intern Med 1988;148:1906-1907
   CrossRef | Web of Science | Medline

3. 3

   Brent RL. The changing role and responsibilities of chairmen in clinical academic departments: the transition from autocracy. Pediatrics 1992;90:50-57
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The letters by Wieland and Radetsky offer two very different although not necessarily contrasting views of academic health centers. Wieland makes the case that such centers are taking aggressive actions to corner large shares of the local health care market. We do not disagree with this but consider it an inevitable reaction to changes in local markets. The key question is how market forces can be tempered to protect the missions of academic health centers. In our article we argued that the goal of public policy should be to enable academic health centers to compete in the provision of private goods and services on a level playing field with other health care providers, while protecting the centers' social and academic missions. Although the creation of a national trust fund would facilitate and rationalize that endeavor, until that happens academic health centers will be left to their own devices. There is abundant evidence that many academic health centers are moving to protect the flow of patients that enables them to teach and do research, and to protect the flow of dollars that enables them to cross-subsidize these and other socially valued activities. These activities can involve using the centers' market position to advantage. The question that we prefer to pose is whether those market activities interfere with the performance of the centers' traditional academic missions.

Radetsky raises fundamental questions about the manner in which medical schools encourage their faculties to be most productive. We share his concern about the ability of traditional faculty policies to allow academic health centers to be effective and accountable in a changing environment. Here again, changes are already occurring. According to a recent survey, medical schools are beginning to institute post-tenure reviews and other faculty reforms.1

David Blumenthal, M.D., M.P.P.
Eric G. Campbell, Ph.D.
Joel S. Weissman, Ph.D.
Massachusetts General Hospital, Boston, MA 02114-2698

1 References

1. 1

   Jones RF. Faculty appointment and tenure policies in medical schools: a 1997 status report. Acad Med 1998;73:212-219
   CrossRef | Web of Science | Medline