The vision of things to be done may come a long time before the way of doing them becomes clear, but woe to him who distrusts the vision.
The fact that dramatic changes are taking place in academic medicine hardly needs to be restated here (2). It has become very difficult to avoid a topic that has preoccupied virtually every conference planner and journal editor for the past several years. All the hew and cry could easily lead one to conclude that the best to be expected for academic medicine is serious injury under the hooves of the onrushing horde that is stampeding across the health care landscape. The more common prediction is that, without some form of special protection, academic medicine's wounds might well be terminal (3,4).
In an attempt to do something to brace themselves, the leaders of most academic institutions have turned to some form of strategic planning and a critical reassessment of the traditional structure and function of their educational, research, and clinical service programs (5—10). There is a growing awareness of the need for all programs to demonstrate their effectiveness, efficiency, and relevance to institutional priorities (11,12).
If academic departments of psychiatry are going to survive in the new health care era, they must also be part of this strategic process and demonstrate their relevance (13,14). It is our basic premise that departments of psychiatry will be regarded as valuable to the extent that they help to fulfill the crucial requirements of academic medicine. If they are able to be helpful, they will not only survive, but they might even thrive. However, if academic departments are not helpful, they will likely be relegated to secondary status in the new health care era.
If our assessment is correct, the crucial issues, and the goals of this article, are to identify the specific requirements of academic medicine and to suggest the manner in which departments of psychiatry might help to fulfill them. We begin this article by outlining six major requirements of academic medicine in the new health care era. Within the discussion of each requirement, we present specific strategies that academic departments might pursue to help fulfill them. We then present and discuss selected implications of these strategies for psychiatry department chairs, psychiatric faculty, and the professional organizations that serve them.
To respond adequately to the forces at work in the new health care era, we believe that academic medicine must fulfill the following six basic requirements. We do not mean to imply that these requirements are all that will be necessary to ensure that academic medicine survives. There are most certainly other crucial issues that either are not apparent to us at this time or that will arise in the future. The six requirements we describe next are merely those that currently seem most pertinent to us. There is some overlap among several of these requirements, and we have divided them to facilitate discussion. They are not presented in any particular order of priority. We believe they are all crucial to the future of academic medicine.
Requirement 1: Organizations That Are Effective, Efficient, and Responsible
All of higher education is under increasing scrutiny by a public that is demanding more accountability and better management of scarce resources (15). While the nation's 125 medical schools have experienced significant public support and tremendous growth in revenues over the last several decades, they too are facing tough questions about the effectiveness and efficiency of their educational, research, and clinical service programs (16—18). As academic medicine pleads for some type of special protection that will make it competitive in a more market-based health care system (19), we can only expect these questions to increase. To maintain credibility, academic medicine must be able to demonstrate with hard evidence that its programs are not only effective, but also efficient, consistent with existing laws and regulations, and relevant to the needs of the citizens who support them. This has obvious implications for administrative, strategic planning, and financial-management systems used by academic medical centers, as well as for the expertise required by deans, department chairs, and other academic leaders (2,11,12).
To help meet this requirement, departments of psychiatry should 1) initiate strategic planning processes to delineate departmental mission, vision, operating principles, and objectives that are compatible with those of the entire academic system; 2) develop educational, research, and service programs of demonstrated effectiveness that are consistent with community needs; 3) maintain effective budgeting, cost accounting, financial management, and adherence to billing requirements; 4) emphasize program quality assurance, utilization review, and patient satisfaction; and 5) adopt a spirit of flexibility and cooperation as well as a willingness to modify existing programs to respond to new requirements and opportunities.
Requirement 2: Quality Educational Programs of Appropriate Type and Size
In recent years, discussions of medical work force size and characteristics have assumed center stage in a debate that has been at times strident and acrimonious (20,21). In general, there seems to be a consensus of opinion that the United States has too many physicians, too many specialists, too few generalists, major problems with geographic and sociocultural maldistribution of the physician work force, and significant deficiencies in the training of physicians to practice in modern service-delivery systems (22,23). Academic medicine is under pressure to demonstrate that its trainees are being prepared in appropriate numbers and types and with the knowledge, skills, and attitudes required to adequately serve the public in the new health care era (9,24). These forces mandate that academic medicine design its educational programs in a manner that is consistent not only with its own needs but also with local, state, and national work force requirements. These forces also dictate that priority be placed on the quality rather than the quantity of graduates, careful consideration be given to the educational needs of primary care trainees, that multidisciplinary training experiences be developed, and training be expanded into alternative sites available in new service-delivery systems.
To help meet this requirement, departments of psychiatry should 1) "right size" training programs based on local, state, and national needs and collaborate with training programs in other institutions; 2) emphasize the quality rather than the quantity of programs and trainees; 3) focus on the educational needs of medical students and primary care residents; 4) develop educational programs in nontraditional sites available in new health care systems (e.g., health maintenance organizations [HMOs]); and 5) implement multidisciplinary training experiences with other medical and mental health disciplines.
Requirement 3: Linkage to Health Care Networks
Over the past 15 years, the most available source of new revenue for academic medicine has been through the expansion of clinical services (4). By 1995, total income from professional services of clinical faculty had risen to about 50% of medical school revenues.
The dependency of academic medicine on income from clinical services poses a major dilemma because those funds are jeopardized in the managed care era (6). Of course, this problem becomes even more acute with the threatened reduction of government support for academic medicine (19). These factors have sent academic leaders scrambling for strategies that might help ensure the survival of their clinical services (2). One of the most common approaches has been the participation of academic programs in health care networks that develop integrated systems capable of providing a full range of specific services and levels of care (12). Through innovative marketing, aggressive contracting, decentralization of services, referral of patients within the network, increased efficiency, and economies of scale, these networks hope to be able to compete for patients with other integrated systems in the medical marketplace (7). In the modern health care era, it is clear that a high premium will be placed on those strategies that are able to expand network services into new areas and to bring additional funded patients into the system.
To help meet this requirement, departments of psychiatry should 1) develop specific services that increase the value and competitiveness of the overall academic system to potential customers (e.g., employee-assistance programs, substance abuse services, and subspecialty clinics); 2) demonstrate effectiveness and efficiency of programs (e.g., adherence to practice guidelines, quality assurance and utilization review, practitioner credentialing, and patient satisfaction); 3) implement systems that facilitate linkages (e.g., cost accounting, financial management, and management information systems); 4) secure referrals to the academic system from departmental contacts (e.g., departments of mental health, juvenile justice, and corrections); and 5) reinforce relationships between voluntary clinical faculty and the academic system.
Requirement 4: Primary Care Capacity and Services
In the managed care era, primary care has become a key element of the foundation upon which most modern health care networks are built, because control over primary care also exerts significant influence over subspecialty and hospital referrals (6). These facts have encouraged the leaders of academic medicine to adopt aggressive strategies to expand their own primary care capacity and services, form linkages with primary care groups in the community, or both (7,12). A common theme throughout all strategies is their significant cost to the academic system, not just in revenue but also in the time and energy commitment required of academic leaders to implement them (2). Because of the financial risks involved, academic medicine must take steps to ensure that its primary care services are efficient and that it obtains the maximal primary care capacity possible for its investment (11,12). Any reasonable strategies for increasing primary care services or capacity within existing resources are likely to be warmly received by academic leaders.
To help meet this requirement, departments of psychiatry should 1) place mental health professionals in primary care departments for direct service to patients as well as consultation and education to primary care clinicians; 2) readily accept referrals from primary care departments; 3) provide basic primary care services by psychiatrists to psychiatric patients; 4) refer psychiatric patients with more complicated problems to primary care departments; 5) develop demand-management programs in primary care departments (e.g., employee assistance, prevention, and patient education programs).
Requirement 5: Restructured Systems for Research
Perhaps academic medicine's most striking success over the past half century has been its contribution to our nation's preeminent position in medical research (4). These efforts have been funded through a combination of federal, state, and private resources, as well as from revenues generated by clinical services. Threats exist to the integrity of each of these traditional sources of funding in the new era (2), and it appears unlikely that academic medicine will be able to maintain current levels of research effort without a serious reconsideration of the structure and function of existing programs (10,12). This might very well lead to a reorganization of departmental structures to promote efficiency and to be more consistent with multidisciplinary research requirements (2,3). It almost certainly will entail much closer collaboration between academic medicine and private industry as well as a willingness to focus on issues pertaining to health service delivery in more nontraditional systems of care (6,12).
To help meet this requirement, departments of psychiatry should 1) develop multidisciplinary medical and mental health research collaborations; 2) focus on health services research relevant to the mental health and medical care systems; 3) establish research linkages with private industry (e.g., pharmaceutical companies); 4) initiate research projects in nontraditional systems of care (e.g., HMOs); and 5) expand research linkages with state and federal institutions (e.g., departments of mental health, juvenile justice, substance abuse, developmental disabilities, corrections, and the Veterans' Administration).
Requirement 6: Effective Leadership
Ensuring that academic medicine continues to play a meaningful role in the new health care era will require leadership with talent and courage. Academic systems must be organized more like businesses with streamlined operations and effective methods for financial analysis, cost allocation, and the careful assessment of potential markets for educational, research, and service products (16,17). New models of academic organizations may be required, as well as modification in the roles and responsibilities of deans, department chairs, faculty, and administrators (11). These changes may well mandate an evolution in the basic culture of academic medicine, as priority is placed on the documentation of performance in market terms rather than more traditional academic measures (2). To manage these difficult transitions, academic leaders must be ready, willing, and able to develop and implement effective strategic planning processes that identify the major elements of a program's mission, set a realistic yet challenging vision for the future, clarify basic operating principles that will govern the academic enterprise, and outline specific objectives that capitalize on the unique capabilities of faculty and staff as well as local market conditions (25). These complex tasks will require that medical leaders possess not only stellar academic credentials, but also the special administrative knowledge and skills required to analyze and manage increasingly complicated health care systems.
To help meet this requirement, departments of psychiatry should 1) implement innovative departmental administrative processes (e.g., strategic planning, budgeting and financial management, billing compliance, and assessment of faculty productivity); 2) reinforce leadership education and development for faculty; 3) support faculty assumption of leadership positions in the academic system; 4) encourage faculty participation in academic committees and programs; and 5) maintain the active involvement of the department chair in the management and leadership of the academic system.
We believe that our recommended strategies have important implications for psychiatry department chairs and faculty (T1) as well as for the professional organizations that serve them (T2). Space and knowledge limitations prevent us from listing all conceivable implications of our suggested strategies. Instead, we again outline in T1 and T2 those that seem most pertinent to us at this time.
T1 presents a recommended guide for chairs and faculty interested in helping to create an effective psychiatry department capable of assuming a leadership position in its academic medical system. The guide is proactive and positive rather than passive and negativistic. This type of approach is important. All of us in academic medicine have to change, and psychiatry chairs and faculty that spend their time bemoaning the past are less likely to face current challenges and to be appreciated by academic leaders, many of whom have been chosen because they support the changes that have been made in the system.
T1 emphasizes the importance of administrative matters and fiscal responsibility at all levels of departmental work. It specifically makes recommendations concerning the development and implementation of important research and teaching programs. This point cannot be overemphasized. Psychiatry departments will seldom be big earners in new health care systems. Their currency in the medical school will more likely be reflected in the quality of their efforts in research and teaching. New research and teaching opportunities will exist in the future (e.g., in primary care and alternative service delivery systems), but dedication and investment will be necessary by chairs and faculty to take advantage of these opportunities and to demonstrate the value of psychiatry to the academic medical system.
T1 also emphasizes collaboration within the academic center and with community partners. It particularly advises psychiatry chairs and faculty to do their part to help primary care initiatives work both from an educational and fiscal point of view. Table 1 concludes with an emphasis on quality. An academic medical system must continually emphasize quality in all of its programs. Without programs of special quality, an academic medical system has very little reason to exist.
T2 presents an overview of the responsibilities we believe that professional organizations should have to academic psychiatry in the new health care era. Professional organizations have crucial roles to play in ensuring the future survival of academic psychiatry, and their leaders should take immediate action to discharge these responsibilities. T2 emphasizes the roles of professional organizations in developing training programs for psychiatric administrators and faculty in important areas of academic life: 1) advocating for patients, practitioners, and the academic centers that will produce the next generation of psychiatrists; and 2) advancing the prestige of psychiatry by participating in the development of professional standards, the enforcement of ethical guidelines, and the collaboration with allied professional medical organizations.
Ensuring the survival of academic psychiatry in the new health care era will be a difficult challenge. We believe it will also be achievable if the attention of our profession is focused over the next few years on the specific requirements facing all of academic medicine and if psychiatry departments implement effective strategies to help fulfill those requirements. This will only be possible if psychiatric chairs, faculty, and our professional organizations take specific steps now to prepare themselves to meet this challenge. If done judiciously, we believe our profession will not only survive but will also thrive in the 21st century. For as Thomas Woodlock noted, "In all human activities … times of stress and difficulty are seasons of opportunity when the seeds of progress are sown" (26).