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Academic Medicine's Culture Facing 'Seismic' Change

The patient-safety movement and the demand for evidence-based medicine are mandating that academic medical centers shed their traditions of reigning by "eminence" or reputation rather than by the knowledge they add.

Darrell Kirch, M.D.: "What we are realizing now is that health care is a team sport, and very high levels of autonomy [among physicians] can be counterproductive." Credit: Mark Moran

Academic medicine needs to reassert itself as a social and public good commanding public and governmental support.

That's what psychiatrist Darrell Kirch, M.D., president of the Association of American Medical Colleges (AAMC), told psychiatric educators at last month's meeting of the American Association of Directors of Psychiatric Residency Training in San Juan, Puerto Rico.

"What we do is uniquely at the convergence of three of our most important public goods—education, research, and health care," Kirch said. "Throughout our history we said that higher education, discovery, and health care are public and social goods worthy of our public commitment, that we will put our tax dollars and resources toward those goods.

"But over the last two decades we have moved into a stage where we are saying, 'Let the market and private sector take care of it.' Should we be surprised now that even at public institutions tuition is through the roof? That the cost of attendance at medical school is now documented to be driving disadvantaged students away from careers in medicine? That we have 46 million people uninsured?"

Align Revenue and Missions

Kirch said among the greatest challenges for academic medical centers is alignment of revenue streams with the missions of education, research, and clinical care. While research grant dollars are typically restricted, and clinical care often produces a margin, it is the educational mission that rarely has a designated funding source.

The result is cross-subsidization. "This is our biggest enemy in academic medicine," Kirch said. "Nobody has any idea the way the dollars have gone [from one source to another mission], and no one believes it makes any sense because it all goes into the cauldron and gets mixed up."

He said a "funds flow analysis" can at least provide institutions with some sense of where its money is. In the absence of that knowledge, he said, faculty and others at the institution are left with "myth, suspicion, and unhappiness."

Even in the rare institution in which there are revenues to support the educational mission, funds frequently get diverted. That was the case, he said, at the Medical College of Georgia, where he held several leadership positions from 1994 to 2000. There, state appropriations and student tuition were supporting what Kirch called a massive burden of charity care. "Student tuition was underwriting charity care in the clinic," he said.

The patient-safety movement and demand for evidence-based medicine are mandating that academic medical centers shed the traditions of reigning by "eminence," or reputation, rather than by evidence.

"How do we know we are good?" Kirch asked. "Because our billboards say we are? Because we have 'professor' in front of our name? We have had a kind of self-satisfaction, some would say a smugness, that hasn't challenged us to look at our systems."

Kirch said that medicine would never be able to undergo the same standardization as the airline or other industries that are typically held up as models of safety and quality control.

"But we still have a long way to go in terms of our willingness to climb out of our complacency and pay attention to what other high-reliability, high-risk industries are telling us," he said.

Apprenticeship Model Gives Way

In other ways, Kirch said, academic medicine is not what it used to be and will be different in the future. Many long-standing aspects of academic medicine— from broad cultural mores within medical education to day-to-day strategies for teaching and learning—are undergoing sweeping change.

For example, he said, the "apprenticeship" model of learning, under which he and others of his generation were trained, is giving way to a new model of reciprocal education (sometimes referred to as "all learn, all teach," in which residents learn from their peers as well as from faculty). And the culture of autonomy and individual achievement that has long characterized medicine is giving way—slowly—to a culture of teamwork and common ownership, a transformation that is likely to run counter to the highly independent nature of many American physicians.

"The culture of academic medicine is changing in seismic ways," he said. "For any of us of a certain age, medicine when we entered it was an individual sport. The emphasis was on your own personal accomplishment, and medical school was about training you up to higher levels of independence.

"What we are realizing now is that health care is a team sport, and very high levels of autonomy can be counterproductive," he said.

More immediately, important day-to-day changes are occurring in the way medical schools educate, pursue research, and do business. Among the changes he out-lined were the movement toward assessment of core competencies, attention to the "informal curriculum," and incorporation of technology in teaching and learning.

About the core-competencies requirements—which some training directors have viewed with ambivalence at best or derision at worst—Kirch was optimistic, saying that they represented a reaffirmation of academic medicine's responsibility to produce good doctors.

"I would argue that when I was in training in the 70s, we were so focused on the acquisition of medical knowledge that we were in danger of losing sight of what it meant to be a good doctor in all its dimensions," he said. "So the core competencies are a reaffirmation of that."

And Kirch also stressed the need for educators to attend to the "informal curriculum"—the nontraditional venues encountered by the student or resident in which values and knowledge are likely to be transmitted.

He cited an October 26, 2006, article in the New England Journal of Medicine by David Stern, M.D., and Maxine Papadakis, M.D., in which the authors stated that "the conceptof 'teaching' must include not only lectures in the classroom,small-group discussions, exercises in the laboratory, and care for patients in clinic, but also conversations held in the hallway,jokes told in the cafeteria, and stories exchanged about a 'great case' on our way to the parking lot."

In that vein, Kirch recalled the revered chief resident at his medical school who, when informed that Kirch was entering a psychiatry residency, said "what a waste."

"Think of the message conveyed in those three words," Kirch said. "One misalignment in the informal curriculum can undo a year of your teaching in the formal curriculum."

He added that the Liaison Committee on Medical Education, which accredits medical colleges, was in the process of developing standards for informal curricula.

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