Scholarship in the medical faculty from the university perspective: retaining academic values.

Academic medicine and research universities have enjoyed a close relationship that has strengthened both, spawning an era of discovery and scholarship in medicine that has earned the U.S. academic medical enterprise a high level of public trust and a deserved leadership position in the world. However, changes in the financing of medical care and in the organization of health care delivery have dramatically affected the medical school-university partnership. The growing emphasis on delivery of clinical services and the concomitant decrease in time for tenured and clinician-educator faculty to teach and do scholarly work jeopardizes both the potential for continued discovery and the education of the next generation of medical scholars. The background of the medical school-university relationship and the factors leading to the development of clinician-educator faculty tracks are reviewed, and recent trends that impact faculty scholarship are discussed. Both tenure-track and clinician-educator medical faculty, as members of the broader university community, should expect from their university colleagues a continued demand for scholarship and educational activity that reflects the underlying philosophy of the parent university. As a corollary, the university, through its medical school, must provide these faculty the time and the financial support necessary to fulfill their academic mission. The size of the clinician-educator faculty should be determined by the academic needs of the medical school rather than by the service demands of its associated health care delivery system. To accomplish this, academic medical centers will have to develop cadres of associated or clinical faculty whose primary focus is on the practice of medicine.     

Viewpoint: infusing professionalism into a school of medicine: perspectives from the dean.

In 2000, leaders at Indiana University School of Medicine (IUSM) consciously set out to incorporate professionalism into the culture of the school. The dean of IUSM offers his personal perspective of the state of professionalism at his institution before the culture change, explaining the inspiration for the leadership's efforts toward pursuing a culture of professionalism. The author describes specific actions taken at IUSM to foster professionalism, including crafting a Core Values and Guiding Principles document that explicitly stated the institution's ideals and that was circulated to and eventually approved in 2001 by every member of the IUSM faculty, graduate trainees, and student body; explicitly incorporating professionalism into faculty recruiting and student admissions processes; integrating professionalism into the IUSM curriculum; and employing a Relationship-Centered Care Initiative, which encourages members of the IUSM community to acknowledge and reflect on their personal experiences as caregivers, to cultivate an appreciation for what is best about medicine. To underscore the importance of the culture change, IUSM leadership have been involved in every step of the process and have committed to rewarding professional behavior among faculty members. The author encourages other institutions to strive for similar culture change to promote professionalism across medicine.     

The effects of a changing environment on relationships between medical schools and their parent universities.

Medical schools differ from other university graduate schools in that community settings, hospitals, and ambulatory care facilities are required for medical education, and most of these settings are either owned by or closely affiliated with the university. Thus, the extraordinary changes in recent years in the organization, delivery, and financing of health care have required the attention not only of the leadership of academic medical centers (i.e., medical schools and their owned or closely affiliated teaching hospitals) but also of the administrators and boards of their parent universities. Many university-wide structures and policies that previously served the medical school well in accomplishing these missions may now be viewed as inflexible by the faculty and administration of the school. Conversely, the historically distant governance and administrative oversight of the medical school has become a concern for some at the university, given the huge budgets of the school, its faculty practice, and its affiliated hospital(s). From information derived mainly from annual visits to 14 medical schools from 1996 through June 2000, the authors review the issues between medical schools and their parent universities and the strategies being used to resolve them. These strategies include changes in the governance, organization, and management of the medical school, such as unified authority for health affairs, reengineered administrative systems, and increased autonomy in decision making. The authors conclude that these strategies appear to be working on behalf of not only the medical school but, in some instances, the university at large. They also comment on possible negative implications of the greater separation of the medical school from its parent university.     

Organizational models for medical school-clinical enterprise relationships.

Changes in the organization, financing, and delivery of health care services have prompted medical school leaders to search for new organizational models for linking medical schools, faculty practice groups, affiliated hospitals, and insurers-models that better meet the contemporary challenges of governance and decision making in academic medicine. However, medical school leaders have relatively little information about the range of organizational models that could be adopted, the extent to which particular organizational models are actually used, the conditions under which different organizational models are appropriate, and the ramifications of different organizational models for the academic mission. In this article, the authors offer a typology of eight organizational models that medical school leaders might use to understand and manage their relationships with physicians, hospitals, and other components of clinical delivery systems needed to support and fulfill the academic mission. In addition to illustrating the models with specific examples from the field, the authors speculate about their prevalence, the conditions that favor one over another, and the benefits and drawbacks of each for medical schools. To conclude, they discuss how medical school and clinical enterprise leaders could use the organizational typology to help them develop strategy and manage relationships with each other and their other partners.     

Perspective: the potential of student organizations for developing leadership: one school's experience

Leadership development is vital to the future of medicine. Some leadership development may take place through the formal curriculum of the medical school, yet extracurricular activities, such as student government and affiliated student organizations, can provide additional, highly valuable leadership development opportunities. These organizations and their missions can serve as catalysts for students to work with one another, with the faculty and administration of the medical school, with the community, and with local, regional, and national organizations. The authors have organized this discussion of the leadership development potential of student organizations around six important principles of leadership: ownership, experience, efficacy, sense of community, service learning, and peer-to-peer mentoring. They provide practical examples of these leadership principles from one institution. They do not presume that the school is unique, but they do believe their practical examples help to illuminate the potential of extracurricular programs for enhancing the leadership capabilities of future physicians. In addition, the authors use their examples to demonstrate how the medical school, its surrounding community, and the profession of medicine can benefit from promoting leadership through student organizations.     

Crushing the commercial spirit in academic medicine: a crusade that failed.

The struggle between academic values and the practice opportunities in clinical medicine has continued throughout the present century. The reformers who prevailed in bringing clinical teaching into the university as a full-time occupation were persuaded that only university ideals--academic rigor, high professionalism, and full-time service in teaching and research--could create the kind of environment in which clinical science and effective clinical teaching could flourish. Their victory was never complete, and much of America's clinical establishment resisted the change, arguing that it was not commercial gain but concerns over teaching medicine in a narrowly academic enclave that motivated them. For the first two thirds of the century, the commercial spirit in academic medicine, while never completely crushed, gave way to an academic ethos that honored academic recognition and research honors over making money. Events of the past 30 years have reawakened the commercial spirit with a vengeance. In the years since Medicare, managed care, and HMOs have become prominent, faculty practice has become a principal means of maintaining teaching hospitals, high professional salaries, and medical teaching. In the present crisis, the author believes, only an unprecedented, all-out effort on the part of medical faculties and their allies to separate out medical education from other health care concerns and secure strong support from government offers any long-range hope for success.     

Clinical faculty tracks and academic success at the University of California Medical Schools.

PURPOSE: To describe the five faculty series for medical school faculty in the University of California (UC) system, their criteria for advancement, associated challenges, and the different ways they are used by each school. METHOD: During 2001-02, the associate dean for academic affairs at each UC medical school was interviewed for information on the number of faculty in each academic series, the role of each series, and problematic issues associated with them. The averaged merit and promotion results for each series for 1999-2002 at the University of California, Davis, School of Medicine, were examined. RESULTS: The two clinical faculty series showed the most variability among the UC campuses for number of faculty, and strategy for appointment and advancement. The percentage of faculty in the Clinical X series varied from 8% to 39% at the five campuses. All campuses agreed that faculty in the Clinical X series must participate in applied or translational clinical investigation or educational investigation, and disseminate their work. All campuses required that the Ladder-Rank and In-Residence faculty devote the majority of their time to hypothesis-driven research. At University of California, Davis, the two clinical series had the highest approval rates for merits and promotion actions. The Ladder-Rank series had the highest denial rate for merits and promotion. CONCLUSIONS: Clinical series in the UC system are used differently at the five medical schools. Appointing junior faculty in series with minimal expectations as a "safe starting place" is favored for building long-term faculty. Faculty in all series tend to do well in the academic review process, indicating that these series define distinct expectations. Clinical faculty's accomplishments are increasingly understood, valued, and rewarded.     

The primary care specialties working together: a model of success in an academic environment.

In today's environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year "doctoring" curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCI's generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.     

Clinical academies: innovative school-health services partnerships to deliver clinical education.

During the past five years (2001-2006), the University of Bristol Medical School has developed and implemented a new model for delivering clinical education: the clinical academy. The principal features of the model are (1) having both in-Bristol and out-of-Bristol campuses for clinical education, (2) innovative partnerships with local health care providers, (3) local leadership of educational delivery, and (4) the recruitment and training of new cadres of clinical teachers.The seven clinical academies consist of two academies based in traditional acute-care teaching hospitals in the city of Bristol and five academies in the surrounding counties. The same Bristol curriculum is delivered in every clinical academy by locally recruited hospital specialists and family physicians. Each academy is led by an academy medical dean, who has local responsibility for program delivery, quality assurance, academic and personal support for students, and finances on behalf of the university.Medical students rotate between clinical academies every half academic year, alternately based in and outside of Bristol. They learn clinical medicine and develop clinical competence as apprentice members of a local multiprofessional learning community. The medical school now has enough high-quality clinical placements to accommodate increasing numbers of medical students whilst keeping a "human-scale" educational environment.Clinical academies are thus the key components of a decentralized system of curriculum delivery; they differ in concept and purpose from the new academies of medical educators in the United States that offer a centralized focus for the educational mission.     

PhD faculty in clinical departments of U.S. medical schools, 1981-1999: their widening presence and roles in research.

PURPOSE: To analyze the growth, research activities, and academic status of PhD faculty in U. S. medical school clinical departments between 1981 and 1999. METHOD: Full-time U.S. medical school faculty who had PhDs and appointments in clinical departments in 1981 and 1999 and junior PhD faculty who became assistant professors between 1981 and 1990 were selected from the Faculty Roster System of the Association of American Medical Colleges. Their research activities and academic statuses were compared with those of MD or MD/PhD faculty in clinical departments or PhD faculty in basic science departments in the same years. RESULTS: The number of PhD faculty in clinical departments now exceeds the number of PhD faculty in basic science departments. PhD faculty in clinical departments come from diverse research backgrounds, contribute substantially to the research intensity of their institutions, and are more likely than their counterparts in basic science departments to become involved in research involving human participants or human tissues. PhD faculty in clinical departments are less likely than their counterparts in basic science departments, but are as likely as physicians in clinical departments, to be rewarded with academic promotion. They are less likely than their physician colleagues to be promoted in research-intensive departments such as departments of medicine and at top 20 research-intensive schools. CONCLUSIONS: The burgeoning career opportunities for PhD faculty in clinical departments should be reflected in the course work, mentorship, and potential thesis topics of PhD training programs. In lieu of tenure, research-intensive medical schools should develop alternative career tracks providing somewhat greater job stability for these faculty.     

Academic ranks and medical schools of underrepresented minority faculty in family medicine departments.

PURPOSE: To examine academic rankings and educational backgrounds of underrepresented minority (URM) family medicine faculty and compare their academic ranks with national trends. The authors also determined the extent to which international and historically black educational institutions contributed URM faculty to family medicine. METHOD: In 1999 questionnaires were sent to 129 family medicine departments asking for academic ranks and educational institutions attended by their URM faculty. Comparisons were made between URM faculty's academic ranks and all family medicine faculty, medical school minority faculty, and medical school faculty. RESULTS: A total of 80% of URM faculty were assistant professors or instructors, and 4.4% were professors. URM family medicine faculty had significantly lower rankings compared with medical school minority faculty and all family medicine faculty. URM family medicine faculty at historically black medical schools were more likely to have received their degrees from historically black undergraduate institutions and medical schools than were URM family medicine faculty at non-historically-black medical schools. CONCLUSIONS: URM family medicine faculty appear to experience a double disadvantage: being minority and working for family medicine departments. Their academic ranks remain far below those of both minority medical school faculty and family medicine faculty, a discouraging finding considering the current shortage of URM faculty in family medicine departments. Historically black medical schools cannot address the shortage alone, so non-historically-black medical schools need to both recruit URM faculty and follow up with appropriate mentoring of those faculty.     

The end of mandatory retirement and its implications for academic medicine.

The prohibition against age-based mandatory retirement, codified in amendments to the Age Discrimination in Employment Act (ADEA) in 1986, remains a concern in the academic medical community. A seven-year exemption covering tenured faculty expires at the end of 1993. The author reviews the legislative history of the ADEA and explores in detail the planning and management issues--and the available projections of likely faculty behavior in the future--concerning the banning of age-based mandatory retirement of higher education faculty, with special reference to the academic medical community. Although the major studies concerning the probable course of events after the seven-year exemption expires indicate that there will not be a cataclysmic effect on institutions of higher education, it is still not certain how tenured faculty will behave and how that will affect medical schools. The author cautions that the management acumen of institutional leaders will be taxed, and that medical school deans should realize this and begin the transition into the new era by improving systems for faculty evaluation and development, clarifying the financial guarantees of tenure, implementing space utilization reviews, and developing programs to make retirement attractive.     

Faculty practice plans: the organization and characteristics of academic medical practice

The contemporary academic medical center is a complex organization providing medical and other professional health education, biomedical and behavioral research, and a comprehensive range of patient care services. This paper presents data from the Association of American Medical Colleges' 1989 survey of 125 member faculty practice plans. The survey data showed that 62% of the 74 responding plans were units or associations within the medical school corporate structure. Plans were organized along a broad continuum from the autonomous, departmental model with decentralized governance and management to the group model with centralized governance and management. The growth of managed care, increased competition, and a greater reliance by the medical school on clinical practice income as a financing source are causing the practice plan to expand beyond billing of professional fees. The survey data showed that 75% of the practice plans operated satellite centers, and 61% planned to build new ambulatory care facilities in order to expand and improve services to patients. The practice plans also have adapted to changes in third-party reimbursement and are establishing mechanisms to negotiate managed care contracts involving multiple clinical departments to increase referrals and maintain patient shares; 86% of the plans participate in at least one managed-care organization. The role of the practice plan will continue to evolve in response to the needs of the academic medical center for a cooperative and supportive environment in which to conduct its traditional missions of teaching, research, and patient care.     

Academic medicine: what does an outsider have to offer?

One of the many problems of academic medicine is its detachment from actual health problems of the population. Family medicine has a potential of bridging this gap. The paper describes the positive experience from introducing family medicine as a new academic discipline to the medical school in Slovenia. Its introduction was of benefit to family medicine, which has received recognition and has experienced a rapid academic growth. Medical academic establishment has benefited by being exposed to new ideas in research and education. The key to success was the fact that the academic world accepted a newcomer to its midst and that the newcomer managed to integrate its principles into the rules of the academic environment. The next step in this process is to apply some of the positive experiences of the family medicine department to the curriculum reform of the entire faculty.     

Research centers and institutes in U.S. medical schools: a descriptive analysis.

Research centers and institutes are a common mechanism to organize and facilitate biomedical research at medical schools and universities. The authors report the results of a study on the size, scope, and range of activities of 604 research centers and institutes at research-intensive U.S. medical schools and their parent universities. Centers and institutes with primary missions of patient care, education, or outreach were not included. The findings indicate that, in addition to research, centers and institutes are involved in a range of activities, including education, service, and technology transfer. The centers and institutes the authors studied were more interdisciplinary than those included in previous studies on this topic. Most research centers and institutes did not have authority comparable to academic departments. Only 22% of centers directly appointed faculty members, and most center directors reported to a medical school dean or a department chair. A small group of centers and institutes ("power centers"), however, reported to a university president or provost, and may have considerable power and influence in academic decision making and resource allocation. Two main types of centers and institutes emerge from this research. The first type, which includes the vast of majority of centers, is modest in its scope and marginal in its influence. The second type--with greater amounts of funding, larger staffs, and direct access to institutional decisionmakers--may have a more significant role in the organization and governance of the medical school and university and in the ways that researchers interact within and across academic divisions.     

Faculty ownership of medical facilities: inappropriate conflict or an opportunity that benefits physicians and patients?

As a result of a confluence of issues, including faculty compensation in an academic health center (AHC), increasing awareness of conflict-of-interest issues, growing interest by faculty in entrepreneurial activities, and the creation of numerous new facilities and buildings associated with the AHC, the Indiana University School of Medicine (IUSM) in Indianapolis addressed the question of whether its faculty or even faculty groups could invest in any of these new entities, either as individuals or as groups. The dean of IUSM appointed a subcommittee of the school's standing Conflict of Interest Committee that included distinct groups of stakeholders and those without any fiduciary interests. As a result of meetings of this subcommittee, a new policy was set forth in a Points to Consider document to meet the emerging needs of the school to deal with such issues. The authors present the policy and the deliberations leading up to it as an example of how to address the issue of faculty ownership of medical facilities.     

Overcoming a perfect storm: an academic cardiology section's story of survival.

Increasingly, academic institutions are grappling with financial pressures that threaten the academic mission. The author presents an actual case history in which a section of cardiology in an academic health center was confronted with huge projected deficits that had to be eliminated within the fiscal year. The section used eight principles to shift from deficit to profitability (i.e., having revenue exceed costs). These principles included confronting the brutal facts, managing costs and revenue cycles, setting expectations for faculty, and quality improvement. The section accomplished deficit reduction through reducing faculty salaries (nearly $2 million) and nonfaculty salaries ($1.3 million) and reducing operational costs while maintaining revenues by increasing individual faculty productivity and reducing accounts receivable. In the face of these reductions, clinical revenues were maintained, but research revenue and productivity fell (but research is being fostered now that clinical services are profitable again). These principles can be used to stabilize the financial position of clinical practices in academic settings that are facing financial challenges.     

Lessons learned from the introduction of personalized genotyping into a medical school curriculum

PurposeThere is an expanding gap between the availability of direct-to-consumer whole genome testing and physician knowledge regarding interpretation of test results. Advances in the genomic literacy of health care providers will be necessary for genomics to exert its potential to affect clinical practice. However, implementation of a major shift in medical education to include genomics is not easily done. The purpose of this educational report is to describe efforts to incorporate knowledge of personalized medicine into a medical school curriculum.MethodsIn this report, we describe the experiences, both good and bad, of a multidisciplinary faculty group that examined ways to improve genomic education at Tufts University School of Medicine during a 16-month period.ResultsThe results of the faculty's deliberation process resulted in the use of anonymous, rather than student genomes, to teach material on genomic medicine.ConclusionIncreased medical school education regarding genomic analysis and personalized medicine is a necessity, both to be able to translate the advances made by the Human Genome Project into improvements in human health and to begin to think of diseases as disruptions in specific pathways. Our experiences illustrate that adding this material to a medical school curriculum is a complex process that deserves careful thought and broad discussion within the academic community.     

The impact of the changing health care environment on the health and well-being of faculty at four medical schools.

PURPOSE: Increased pressure for clinical and research productivity and decreased control over the work environment have been reported to have adverse impacts on academic faculty in limited studies. The authors examined whether work-related stressors in academic medicine negatively affected the physical and mental health, as well as life and job satisfaction, of academic medical school faculty. METHOD: A 136-item self-administered anonymous questionnaire modified from a small 1984 study was distributed to 3,519 academic faculty at four U.S. medical schools following institutional review board approval at each school. Validated scales measuring depression, anxiety, work strain, and job and life satisfaction; a checklist of common physical and mental health symptoms; and questions about the impact of institutional financial stability, colleague attrition, and other work-related perceptions were used. Responses were analyzed by sex, academic rank, age, marital status, faculty discipline, and medical school. RESULTS: Responses were received from 1,951 full-time academic physicians and basic science faculty, a 54.3% response rate. Twenty percent of faculty, almost equal by sex, had significant levels of depressive symptoms, with higher levels in younger faculty. Perception of financial instability was associated with greater levels of work strain, depression, and anxiety. Significant numbers of faculty acknowledged that work-related strain negatively affected their mental health and job satisfaction, but not life satisfaction or physical health. Specialties were differentially affected. CONCLUSIONS: High levels of depression, anxiety, and job dissatisfaction-especially in younger faculty-raise concerns about the well-being of academic faculty and its impact on trainees and patient care. Increased awareness of these stressors should guide faculty support and development programs to ensure productive, stable faculty.