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 Table of Contents  
EDITORIAL
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 85-92

What's new in academic International medicine? The evolving terrain of American academic medicine


Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA

Date of Submission05-Jun-2019
Date of Decision26-Jun-2019
Date of Acceptance11-Jul-2019
Date of Web Publication29-Aug-2019

Correspondence Address:
Dr. Anish Bhardwaj
Department of Neurology, University of Texas Medical Branch, Galveston, Texas
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_25_19

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How to cite this article:
Bhardwaj A. What's new in academic International medicine? The evolving terrain of American academic medicine. Int J Acad Med 2019;5:85-92

How to cite this URL:
Bhardwaj A. What's new in academic International medicine? The evolving terrain of American academic medicine. Int J Acad Med [serial online] 2019 [cited 2019 Sep 23];5:85-92. Available from: http://www.ijam-web.org/text.asp?2019/5/2/85/265678



Academic Medicine in the United States has been deeply rooted in fulfilling its “tripartite mission” of excelling in domains of clinical service, education and education and training, research and scholarship. Rapid changes in healthcare economics and resulting constriction of revenue streams, easy and rapid access to burgeoning data, generational and environmental influences calls for re-evaluating the metrics for successes in fulfilling the mission(s) of academic medicine. This recalibration is critical for continued excellence in teaching, innovation and discovery and ensuring that U.S. remains the vanguard in all domains of academic medicine in the world and ensuring success for future generations.


  Historical Perspective Top


For 200 years, American academic medicine has been deeply rooted in the traditions of instruction, mentorship, apprenticeship, and “paying it forward” to future generations. Based on the published data and my direct experience in academic medicine over the past three decades, this descriptive, literature-based treatise highlights the past and present state of American academic medicine and underscores future direction and challenges for the coming generations.

The history of modern European academic medicine is well documented in the records of teacher–student and mentor–mentee relationships dating as far back as the 18th century.[1] These include such influential figures as, in the United Kingdom, Edward Jenner, William Lister, James Parkinson, and Charles Bell; in Germany, Franz Joseph Gall, Carl Wernicke, and Alois Alzheimer; and, in France, Jean Martin Charcot and his mentees Sigmund Freud, Joseph Babinski, Pierre Marie, and Georges Gilles De La Tourette.[1] Americans who crossed the Atlantic for further education via the European tradition of medical apprenticeship include such luminaries as S. Weir Mitchell, William H. Welch, William Osler, William S. Halstead, and Alfred Blalock.[1]

In the U.S., the practice of medicine started as a “family affair,” with fathers handing down wisdom and practice to their sons, and until the late 18th century was labeled “domestic medicine.”[2] In 1765, the University of Pennsylvania ushered in the era of medical scientific inquiry and formal medical school teaching and training in the U.S. resulting from the efforts of John Morgan and William Shippen (both graduates of the University of Edinburgh). Shortly thereafter, other medical schools were established as Kings College (later metamorphosed into Columbia University) in 1768 and Harvard University in 1783. In the 19th century, groups of physicians began founding small affordable medical colleges that were largely unregulated in tuition or educational standards, which led to abler students pursuing training in the medical sciences in Europe (Great Britain, France, Germany, and Austria) and returning to the U.S. to transform the teaching and practice of medicine.[1]

Harvard University's graded medical school curriculum was introduced in the 1870s by President Charles Elliot; this was soon followed by a graduate education curriculum in research introduced at the Johns Hopkins University in 1893. With the close integration of the Johns Hopkins Hospital and its medical school, the residency training system was born.[1] Over the past century, a number of regulatory bodies such as the American Medical Association, founded in 1847, and the Association of American Medical Colleges (AAMC), established in 1876, have taken on a major role in the accreditation of undergraduate medical education through the Liaison Committee on Medical Education (LCME).[1] The number of LCME-accredited U.S. medical schools has burgeoned to 154 at present. American academic medical institutions today offer a continuum of undergraduate medical education (typically 4 years postbaccalaureate), Accreditation Council for Graduate Medical Education (ACGME) – accredited 3–6 years of residency training, and 1–3 years of postdoctoral subspecialty fellowship training before a medical doctor can join the academic faculty of a university.


  Health-Care Economics and Revenue Streams in American Academic Medicine Top


Health-care costs in the U.S. have escalated exponentially over the past several decades and are approaching 20% of gross national product, far more than any other country.[3],[4],[5] Per capita health-care spending in the U.S. is more than twice the average of other developed Organisation for Economic Co-operation and Development countries, and health-care spending has grown much faster than the rest of the economy for the past several decades.[6] This exponential growth in health-care cost has widespread ramifications, putting enormous pressure on consumers (i.e., patients and their families), health-care providers, government, medical schools, and the U.S. economy. Already high and increasing administrative costs (estimated at 20%–30% of all U.S. health-care costs) are also a major contributor.[7] Further compounding the matter are diminishing reimbursements by third-party payers (i.e., Medicare, Medicaid, and commercial payers).[8]

Revenue streams for academic medical institutions include clinical service, research grants (e.g., federal, foundations, and contracts), philanthropic support (i.e., gifts and endowments), tuition fees, and institutional and state appropriation [Figure 1] and [Figure 2]. Of these, clinical revenue is the fastest-growing, largest, and most flexible revenue source in the budget of Academic Medical Centers (AMCs) and represents the major portion of cross-subsidy for the institution's overall missions and programs. However, for most institutions, the contribution margin from clinical revenue is razor-thin. Research revenue stems largely from the National Institutes of Health (NIH) that has had periods of both high and low funding growth.[9] This extramural funding source flattened after the 1999–2003 doubling era (NIH budget of $27.2 billion), making grant awards far more competitive. Since FY 2003, NIH funding has increased more gradually in nominal dollars. Over a 3-year period (FY 2016 through FY 2019), there have been increases in NIH funding increases of >5% each year. The largest increase in NIH funding increase ($3.0 billion; +8.7%) was from FY 2017 to FY 2018, making this the largest single-year nominal dollar increase since FY 2003.[9] Both the current federal deficit and political divisions continue to cloud the future of the NIH budget. The NIH salary cap at ~$190K requires institutional cost-sharing for faculty with salaries above this threshold. Furthermore, there are issues related to indirect cost (facilities and administration) recoveries such as developing and maintaining research programs (e.g., protected time for faculty, unfunded and start-up funding for research, bridge funding, institutional cost-sharing, and supporting research core facilities). State appropriation and tuition support the core educational mission of medical schools and their basic administrative and infrastructure costs and are typically the primary source for department-based budget allocation. State budget deficits have led to reduced state support to AMCs supported by public and state universities over the past decade (presentation by Lilly Marks, Vice President for Health Affairs, University of Colorado at AAMC Executive Development Seminar for Deans, 2019). Therefore, this revenue stream is now inadequate as a cross-subsidy for education and teaching missions or help circumvent gaps in funding for research. There are limitations in mitigating these cuts to the educational mission via generation of additional tuition revenue because of restraints on increasing tuition and student debt load and due to the relatively small medical school class size. Faculty are under increasing pressure to cover salaries via research funding and clinical activities. Consequently, the affordability of administrative and other nonrevenue generating activities (e.g., teaching) is becoming increasingly challenging via cross-subsidy from clinical revenues. Lilly Marks comments on the overarching guiding principle and framework of American AMCs: “No money, no mission; no margin, no mission; no margin, no marginal mission; but the margin is not the mission.”
Figure 1: Revenue by source for medical schools with full accreditation, FY 1977 through FY 2017. Source: LCME I-A Annual Financial Questionnaire © Association of American Medical Colleges 2018. Reproduced with permission

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Figure 2: Fully-accredited medical school revenue by source 139 medical schools, FY 2017. Source: LCME Part I-A Annual Financial Questionnaire © Association of American Medical Colleges 2018. Reproduced with permission

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  Governance of Medical School and Health Systems Top


The governance of medical schools across the U.S. is highly varied, underscoring the adage, “If you've seen one medical school, you've just seen one medical school.” Relationships and partnerships between medical schools and their health system(s) are also very heterogeneous. The present data suggest that few U.S. medical schools have their own hospitals and that most are affiliated with nonprofit health-care systems. While the governance structure may differ, each medical school has an executive dean responsible for faculty and for undergraduate, graduate, and postgraduate residency and fellowship medical education and training. A faculty group practice may be a collaborative undertaking between the health system (i.e., “clinical enterprise”) and the medical school. Funds flow methodology is also highly variable with contractual agreements between health systems and medical school used largely for faculty recruitment and their salary support, as well as for program development. The dean of the medical school typically reports to the provost or directly to the president of the university, who in turn reports to the institutional board. Many departmental chairs have a dual reporting relationship to the dean and to a senior leader within the hospital or health system. Because clinical enterprise is the largest revenue generator, health systems are the most powerful entities in this complex architecture. While there are no published data to indicate which structure is optimal for academic medical institutions, anecdotal observation suggests that things work best when the same leader subserves the function of chief executive officer of the health system and dean of a medical school. Theoretically, the reason postulated is that this framework minimizes the conflict, specifically pertaining to funds flow that invariably mars the relationship between these subentities.


  Tripartite Academic Mission Top


Akin to a “three-legged stool,” the intertwined missions of academic medicine include (1) excellence in clinical care; (2) education (i.e., undergraduate, graduate, and postgraduate teaching and training); and (3) research and scholarship [Figure 3]. In keeping with the traditions of apprenticeship in academic medicine, implicit in the tripartite mission is continuous learning, discovery, innovation, and mentoring the next generation of clinicians, scientists, scholars, educators, and investigators. More recently, other missions of academic medicine are being incorporated into the traditional paradigm – “community involvement and integration” and mentoring (although most consider this to be an integral part of the tripartite mission).
Figure 3: The missions of academic medicine

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  Appointments, Promotion, and Tenure Top


Traditionally and historically, clinicians and basic science researchers were expected to achieve excellence in the domains of clinical practice, research, and teaching with the goal of rising through the academic ranks along the tenure track (i.e., instructor, assistant, associate, and professor). This expectation persists today in most American academic medical institutions. Furthermore, to obtain successful promotion and award of tenure, specified achievements (e.g., regional, national, or international reputation via presentations and invited talks; original peer-reviewed publications; and an extramural funding record) are evaluated by the departmental and institutional committees for appointment, promotion, and tenure (APT) over a defined time period through a rigorous peer-reviewed process. Tenure denotes “a status of continuing appointment as a member of the faculty of the academic institution and reflects professional integrity as well as educational and intellectual qualities that make the individual a desirable permanent member of the faculty.”[10] The award of tenure is based on continuing scholarship as well as value and service to the university. While many academic medical institutions in U.S. are doing away with tenure due to its downstream effects (e.g., financial liability for an extended period of time, diminished productivity, and the difficulty of dismissal) despite a periodic and mandatory peer-review process for posttenure review, some institutions continue to adhere to the tradition of tenure. However, many other institutions have implemented multiple tracks (non-tenure track; clinical, research, and educator tracks) to emphasize excellence in only one primary academic mission for prototypic clinicians, researchers, or educators. This paradigm shift is becoming increasingly common because of emphasis on revenue-generating activities, predominantly clinical productivity, as well as resource constraints including both monetary support and protected time for research and teaching. The corollary of such change has been a marked reduction in clinician–scientist as a vitally important subgroup to the point that some characterize this prototype as a “dying breed.”[11] Similarly, the conventional prototypic “triple threat” (with excellence in all three academic missions) is in grave danger of becoming extinct. Appointments as “adjunct” faculty or those on the “clinical track” are typically courtesy (i.e., without salary), time-limited appointments.


  Changing Role of Departmental Chairs and Division Chiefs Top


As a symptom of the changes in health care coupled with shrinking revenue streams, over the past few decades, the role of departmental chairs, division chiefs, and other leaders in academic departments has evolved. The traditional role defined as a “triple threat” for clinical departmental chairs or division director constituting a strong clinical–educator–researcher has gradually transformed into a “quadruple threat” with the added necessity of being a strong administrator and manager. This has been partly due to diminishing resources and having to account for the business aspects of the departmental enterprise. The prototypic M.D. or M.D./Ph.D. scholar has evolved to include management and leadership experience with additional qualifications of Master of Business Administration (MBA) or Master of Health Administration (MHA). Most departments have a designated administrator who, in many cases, functions in partnership with the departmental chair as a “dyad” across academic institutions, with variable effectiveness.[12] Today, the role of the chair can be characterized as a “middle management administrative position” and largely serves as an interface between, faculty, house staff, administrative staff, and the dean's office and higher institutional leadership.[13] The peer review of a departmental chair may vary in terms of academic productivity of the department (e.g., extramural funded research and publications), clinical service (i.e., patient volume, quality, and outcomes), faculty recruitment and retention, and the departmental “bottom line” (i.e., contribution margin and meeting budgetary targets).[13] Because of this paradigm shift in departmental leadership, the younger generation of physicians is eschewing the “triple threat” prototype for business degrees and executive programs (MHA or MBA) to meet new challenges in this changing era of academic medicine.[12]


  Trends and Metrics in Academic Medicine Top


The unfolding economic realities of U.S. health care are having a profound effect on academic medicine. Stress on increasing efficiency in the delivery of health care has led to a focus on managed care and incorporating the practice of the “supply chain” concept of the manufacturing and service industries. The key ingredients that nurture excellence, namely discovery, teaching, and time, have eroded and continue to be compromised.[14] The data demonstrate that academic careers in teaching and discovery have taken a downturn over the past few decades. For example, trends over the past 30 years indicate that fewer physicians are now involved in teaching, research, or administration,[14] with a diminishing number of teachers and mentors per practicing graduate from U.S. medical schools.[15] Investment in the growth rate of biomedical research funding has decreased to 0.8% since 2004.[16] The number of Nobel Laureates in physiology and medicine at U.S. institutions at the time of award has steadily decreased over the past two decades from a high of 80% to 45%.[14],[17]


  Challenges and Future Directions Top


What does “academic medicine” mean in 2019? It is abundantly clear that academic medicine has evolved and is rapidly changing due to numerous factors, namely financial constraints and shrinking revenue streams to meet the tripartite academic mission, generational evolution including lifestyle expectations, burnout,[18] technological advances in a rapidly evolving information age, and scientific advances in genomics and proteomics. While these changes are inevitable and perhaps reflect a natural evolutionary process, American academic medicine is at a greater risk of losing its position as leader in discovery and in educating and training the next generation of clinicians, researchers, educators, and leaders in academic medicine. This danger of developing mediocrity suggests a quote from Yogi Berra: “If you don't know where you are going, you might wind up someplace else.” It is high time to take account of the state of American academic medicine – where we've come from, where we are, and where we hope to be in the not-too-distant future.

As a start, the governance of medical schools and collaborations with AMCs should be simplified, so that institutional leaders and key stakeholders can implement a shared, transparent vision. Departments should reflect the entire spectrum of clinicians, clinician–scientist, educators, and basic scientists and develop interdisciplinary matrix relationships (as opposed to a siloes) to enhance translational research of clinical significance.[19] Departments and programmatic focus on global health, urban health, and leadership development will be critical in the future. Departmental chairs and administrative institutional leaders must focus on working closely as “dyads” to create a vision for the future, building effective teams and cultivating working relationships with key institutional stakeholders, implementing rigorous development and mentoring programs, and cultivating diversity.[12],[20],[21]

While the number of medical schools in the U.S. continues to rise, the “bottleneck” remains the ACGME-accredited residency training programs that are supported and funded by the Center for Medicare and Medicaid.[20] In the past, high cost of medical education in the U.S. has had serious downstream effects such as choices made by medical graduates for residency and fellowship training in high-paying subspecialties (e.g., dermatology, orthopedics, and radiology). However, recent data suggest that medical school graduates are making subspecialty career choices based on “fit with personality, interests, and skills;” “content of specialty;” and “role model influence.”[22] Irrespective of the underlying cause(s), the most dire consequence is a paucity of primary care physicians (family medicine, internists, etc.), particularly in rural areas. While projections have been hitherto less than accurate,[21] the AAMC has projected a shortfall of between 21,100 and 55,200 primary care physicians.[23] Many physicians were and are forced to pursue careers in private practice instead of academic medicine to pay off debts accumulated during their medical education and training. It will be critical to continue to invest in tuition subsidies, scholarships, and other medical school debt-forgiveness programs for medical school training to lighten the burden on physicians as they join the workforce.

The two major drivers of discovery and innovation are time and resources.[14] It is likely that further consolidation and mergers of health-care systems will increasingly occur. Although clinical service is the major revenue source of the three academic missions, this revenue stream is shrinking. “Fee-for-service” models and volume-based reimbursements by third-party payers is shifting toward capitation models with a focus on “value-based,” low-cost, high-quality care (i.e., safe, effective, patient-centered, timely, efficient, and equitable).[4],[21] Some have suggested that delivery of clinical care should be comparable to other service industries and have proposed patient experience (cf. “customer satisfaction”) as a key metric for health systems and individual health-care providers. A paradigm shift from centralized care (i.e., the single-site, “hub and spoke” model) to a more decentralized, multisite model of clinical care is becoming likely as health-care organizations recalibrate to meet market challenges and rapidly changing economic realities.[21] While the incorporation of community physicians has added much needed extra sites for undergraduate, graduate, and postgraduate training, the “hybrid model” presents challenges in maintaining the tripartite academic mission. A further shift from inpatient services to population health, interdisciplinary team care, and ambulatory care is also highly likely in the form of telehealth and other web-based systems for referrals and consultation for enhanced patient convenience. Academic medical institutions must face the great likelihood of physician and nurse shortages and invest in physician extenders (i.e., physician assistants, nurse practitioners, and nurse anesthetists) to provide team-based longitudinal patient care. They must also embrace diversity (e.g., gender, race, socioeconomic status, sexual orientation, and alternate viewpoints) in their workforce and leadership. Generational issues including lifestyle considerations are also taking on new importance in academic medicine. Faculty and house staff orientation and on-boarding, burnout, and resilience [18] must be addressed at the institutional level on a continuing basis to improve retention and diminish attrition and early retirement rates among health-care providers.

American academic institutions must invest in research and teaching in a disciplined manner with strict milestones for success and metrics for return on investment. Marginal mission areas and programs have to be eliminated thoughtfully or prioritized. Developing a physician–scientist “pipeline” is critical and will involve carefully selecting potential candidates during medical school admission, reserving a set number of positions for such candidates, developing a research track within the medical school curriculum, developing strong mentoring programs, and expanding loan repayment programs to offset medical school debt.[11] Protected time for research should be provided to clinicians who aspire to pursue careers as clinician–scientist and become independent investigators in their fields of specialty with bridge funding set aside for investigators who have a gap in research funding support.

As with clinical care for patients, it will be increasingly important to focus on creating interdisciplinary research teams for translational research (”bench to bedside” and vice versa) underscoring population health management, quality improvement, cost-effectiveness, identification of biomarkers and linking them to clinical phenotypes for early diagnosis and treatment, and enhancing computational and analytic capacity with large databases. With constricted federal funding, philanthropic support must be sought for research, teaching, and other non-revenue-generating activities for career development of faculty and trainees. Educational methods are also evolving quickly in this rapidly transforming informational age from face-to-face classroom didactic lectures to web-based learning, use of simulation, and more decentralized community-based training sites.

Finally, departmental and APT committees must recalibrate the metrics and criteria for promotion through the faculty ranks along various tracks to ensure excellence in the tripartite mission with a view to maintaining local, regional, national, and international reputation [Table 1]. Award of tenure as well as periodic mandatory posttenure review must be conducted with strict criteria regarding continued productivity, scholarship, citizenship, and service to the academic community. Ultimately, tenure and monetary compensation should be uncoupled, in that tenure should not imply a salary guarantee.
Table 1: Criterion for academic promotion and tenure

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  Conclusions Top


Historically, academic medicine in the U.S. has long been rooted in fulfilling a “tripartite mission” of excelling in the domains of clinical service, education and mentorship, and research and scholarship. Rapid changes in health-care economics and the resulting constriction of revenue streams, easy and rapid access to burgeoning data, and generational and environmental influences call for reevaluating the metrics for success in fulfilling that mission. Going forward, reevaluation and recalibration is crucial for the continued excellence of American health-care provision, teaching, innovation, and discovery and to ensure that the U.S. retains its vanguard position in all domains of academic medicine. Continual reassessment of a disciplined approach toward investing resources will also be crucial to developing the next generation of clinician–educator–researchers. The words of Abraham Lincoln, “The best way to predict your future is to create it,” hold very true for the future of academic medicine in the U.S.

Financial support and sponsorship

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Conflicts of interest

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Preparation of this article was conducted with search engines - Pubmed, Medline, Google with appropriate citations in the text.



 
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