The degree of turmoil existing in academic health centers (AHCs) has been a matter of extensive discussion and debate over the last decade (1, 2). This commentary offers the perspective of the author, who has served as a medical school dean and academic health system chief executive over the last 12 years. Although representing an individual perspective, an attempt is made to rely on known data regarding the structure and function of AHCs as well as principles for organizational change.
Within the AHC community, individual faculty members express views ranging from longing for times that seemed "easier" to feeling that they are in the midst of a full-blown crisis. When asked to identify the cause of this sense of turmoil, more often than not, financial instability is cited as the key driver. There is no doubt that some challenging fiscal forces are at work (3). In the aftermath of managed care and legislative efforts to create balanced budgets, revenues from both private and public payers for healthcare services have been significantly restricted. The effect on teaching hospitals and practice plans has been profound. Another factor is that direct public appropriations to medical schools have had their growth slowed or in some cases have been significantly decreased. In addition, as the "hard landing" following a 5-year doubling of the budget for the National Institutes of Health has occurred, competition for research funding has become even more intense. Finally, with concern mounting regarding medical student debt, increased scrutiny has been placed on tuition levels (4).
The forces described above certainly have affected morale and contribute to a commonly expressed set of negative beliefs within the AHC community. These beliefs are not necessarily supported by the facts, but perception is in many ways reality. Several of these beliefs that are especially relevant to medical education are summarized as follows:
Belief 1: We Have Grown in All Respects Except in Our Commitment to Teaching
Indeed, the post World War II era has been marked by remarkable growth in medical schools and their affiliated clinical enterprises (5). Data from the Association of American Medical Colleges (AAMC) show that from 1960 to 2000 (a period in which the U.S. population increased by 56% and the number of U.S. medical students grew by 124%), the number of full time basic science faculty members in U.S. medical schools increased more than threefold. During this same period, the number of full time clinical faculty members grew more than 10-fold. The reality is that the number of "potential" teachers per student on the full time faculty has grown dramatically. While the faculty size has ballooned, concerns frequently expressed by teachers regarding insufficient "academic" time indicate that the actual availability of these faculty members to teach has not necessarily grown in parallel.
Belief 2: We Are Being Paid Less To Do More
The AAMC conducts an annual survey on faculty salaries in medical schools (6). Detailed data are produced regarding salaries by discipline, rank, and region. A review of the trend for salary data does lend credence to the belief that compensation is not keeping pace with work demands. When examined in the aggregate, after a period of strong salary growth very early in the 1990s, for more than a decade medical school faculty salaries have managed to grow only at a rate roughly comparable to general inflation. This has occurred at a time when the emphasis on income generation certainly has pushed faculty productivity in areas such as clinical billing. Thus, the reality in this case is that faculty members are doing more, but pay adjusted for inflation is essentially static.
Belief 3: Our Funding Sources Are Drying Up, and There Is No Revenue Source for Teaching
In the introductory paragraphs, reference was made to the revenue constraints faced by medical schools, including falling fees for clinical care, weakening appropriations, and pressure to contain tuition. However, the claim that there is no revenue source of any kind for teaching certainly would be disputed by at least two groups—the students who have seen tuition grow at rates far beyond inflation (4) and the legislators who consider their appropriations to have a core educational purpose. If one accepts the premise that these are "educational" revenues which first and foremost are there to support teaching, it could be argued that many schools have more than enough funding to support their educational mission. In fact, when examining public medical schools with the highest state appropriations, the data indicate that there are cases in which there is a combined level of state appropriations and tuition of well over $200,000 per year per student (7). Not all schools receive significant state support, but those that do not tend to have the highest tuition levels, with annual tuition and fees now topping $40,000 per year at a number of institutions. The reality is that medical schools do receive significant revenues for the educational mission, and there are cases in which that amount of revenue significantly exceeds the estimated cost of medical student education. In many schools, however, the mode of allocating these funds is unclear to the faculty.
Belief 4: The Incentive Structure for Faculty Is Skewed Toward Clinical and Research Productivity
In recent years there has been increasing attention in AHCs to developing financial incentive systems to reward faculty for individual productivity in support of core missions. For faculty physicians, these systems generally focus on relative value units (RVUs) for clinical activity that are easily monitored through billing and collection systems. Faculty researchers have a very visible productivity measure in terms of sponsored grant and contract funding. In general, however, institutions have not developed comparable metrics for teaching contributions. The net result is that faculty members perceive an imbalance in the reward system, with a bias against teaching productivity.
Belief 5: To the Degree That There Are Resources, They Are Being Taken Away
There is very little clarity to the manner in which funds in the AHC flow through the institution (8). While revenue streams may be well demarcated as they enter the system, they then are reallocated in a manner that typically makes it unclear whether the "mission assignment" of the revenues is matched when the funds are distributed to support various efforts at the level of individual faculty members. As a result of this ambiguity in funds flow, faculty members suspect that others are being supported at their expense. In the absence of transparency, there often is little trust that the system of fiscal support is fair.
Beliefs such as those described above are widely held by both faculty members and administrators in the AHC today. As noted, some of these beliefs are supported by fact, and others are misperceptions resulting from ambiguities in administrative and financial systems. The net result is a situation in which the education mission, rather than being at the center of institutional effort, increasingly is viewed as being marginalized. Nevertheless, this does create an opportunity to "rebalance" the system in a manner that returns education to the center of attention. To do so, however, will require assertive action on a number of fronts. There are several steps that would help restore a measure of educational balance to our institutions.
Step 1: Stop Longing for a Fondly-Remembered Past That Probably Never Occurred
Academic institutions, while intended to be sources of new ideas and innovation, are themselves typically very resistant to organizational change. In particular, medical school faculty members are prone to idealize earlier decades in which growth was rapid and funding seemed plentiful. It is important for the AHC to move away from hoping that past conditions can be restored and instead turn its full attention to transforming itself, all the while reaffirming its core values (9). The additional steps that follow can serve as critical success factors facilitating that transformation.
Step 2: Create Transparency by "Opening the Books" In Order To Achieve a Shared Understanding of Funds Flow for All Missions
Given the scale of the AHC, with total annual budgets in many cases exceeding $1 billion, it is amazing how little organizational financial information is known by key leaders such as department Chairs and educational program directors. The corporate world has learned that "open book management," the widespread sharing of financial performance data within an organization, can be an effective tool for improving employee productivity and commitment. In contrast, the AHC historically has been dominated by tightly held fiscal data and a culture of "secret deals" involving the distribution of resources. The net result is that mistrust yields internally competitive, rather than collaborative, behavior.
In terms of education, there is a strong need for administrators and faculty members to understand how specific educational revenues (e.g., tuition and state appropriations) actually are allocated in support of teaching effort. Doing so would better align the faculty and administration and prevent the misperception that teaching is a purely voluntary (i.e., optional), uncompensated activity.
Step 3: Develop an Explicit Structure of Rewards and Recognition for Educational Efforts
Once the flow of funds is understood on an institutional and departmental level, there then is an opportunity to focus on creating incentives for the teaching done by individual faculty members. To do so, however, requires that there be agreement regarding the metrics by which educational contributions are measured. For example, in addition to counting direct contact hours for teaching, there must be a consensus on what constitutes a reasonable amount of preparation time for lectures and small group sessions. Supported by such metrics, a department Chair then is in a position to assess effort and more fairly allocate financial support for individual faculty members who teach students and residents (10).
Another important form of reward is embodied in the promotion and tenure process. Many institutions now are utilizing some form of educational "portfolio" or "dossier" to ensure that teaching efforts are documented in a consistent manner for evaluation by promotion and tenure committees (11). While the creation of special promotion and tenure "tracks" for educators is a step forward, their efficacy is limited unless committees have a means for applying criteria objectively. The educator’s portfolio can be a key tool to assist the process. Lastly, there are other forms of recognition that can be very meaningful to faculty members. Many institutions have created an "academy" or "society" to recognize their most skilled and dedicated educators, and in some cases these appointments have become among the most highly valued by faculty members.
Step 4: Create Models for Improving the Efficiency of Teaching
Educational activities cannot be immune to the push for increased productivity and more efficient use of limited resources, including faculty time. The successful AHC of the future will seize opportunities to use technology, such as computer-based simulation, and new assessment techniques, such as standardized patients, in order to leverage the efforts of faculty members and improve educational outcomes. In this process, one issue that must be confronted is to what degree the curriculum can rely upon facilitated small group teaching. While this format is very useful in problem based learning, it is also very labor intensive from a faculty resources perspective. Thus, using lectures and small groups wisely as an educational approach will be increasingly important. Overall, it will be vital to conduct rigorous research on the effectiveness of new teaching models.
Step 5: Move From an Emphasis on Individual Professional Achievement To a Culture of Shared Accountability, Collaboration, and Participative Leadership
All these steps require a level of group process and collective commitment historically not seen in academic settings. Quite simply, they call for a culture change of major proportions (12). In the past, academic careers were built by focusing on individual effort. The complexity of today’s challenges calls for collaboration and shared effort. Teamwork in all missions, including teaching, will be the key to high performance and better outcomes (13). In turn, the most successful leaders will be those who can inculcate this kind of collective culture (14). In such a culture, it should be possible to "rebalance" the missions of the AHC in a manner that moves education from the margins back to the center.
Insofar as the steps outlined above are critical to future success in the AHC, it can be argued that faculty members in psychiatry are well positioned to play key roles in the process. For example, the emphasis in education for both medical students and residents is shifting decisively to developing and assessing "core competencies" (15). While medical knowledge remains a key core competency, several of the other competencies are elements for which psychiatrists are especially well positioned to be valued teachers. Teaching and assessing the competencies of "professionalism," "communication," and "interpersonal relationships" seem squarely suited to the skill sets of psychiatry faculty members.
Similarly, if the leadership task in AHCs is moving away from presiding over a collection of rugged individualists toward building group process and a collaborative culture, psychiatrists again should be well positioned to serve as leaders. For example, a key educational task in the future will be teaching physicians to work effectively in teams (16). Mental health services have long relied on interdisciplinary professional teams in the care setting, with psychiatrists working collaboratively with nursing, social work, and others to use scarce resources to deliver effective care. These models now are being called for across the full range of medical and surgical care.
The question is not whether AHCs need to transform themselves to meet their organizational challenges; the question is when and how will they do so. In that transformation is an opportunity to rebalance our missions, returning education to its proper place as a core activity. As a discipline, psychiatry should recognize this opportunity, rather than viewing it as a crisis, and assume a leadership role. The result will be good for both our institutions and our discipline.
This article was presented at the President’s Education Summit, April 29—May 1, 2005, Arlington, Va.