Joseph E. Kerschner, MD
WMJ. 2019;117(5):229-230.
Academic medical centers (AMC)—medical centers and affiliated hospitals and clinics that provide care for the majority of complex medical conditions and have a medical school as a central component of their missions—are at the crux of changes in the US health system. Concurrently, they allocate resources and support for important biomedical research and train the physician workforce. AMCs face increasing complexity and expense in conducting biomedical research and providing excellent medical education, as well as challenges from many directions for reimbursement of clinical services. There are no simple solutions to these headwinds; however, the ability to continue to create new knowledge to improve health and provide an outstanding medical education system depend on the development of novel ideas for these anchor institutions/organizations to thrive.
The Medical College of Wisconsin (MCW) and its predecessor institutions have been committed to creating new knowledge through biomedical research, training the physician workforce, and improving the health of Wisconsin patients and communities since 1893. As part of our 125th anniversary celebration, MCW convened a group of US medical school deans to discuss these important issues in a panel format entitled Leaders of Academic Medicine: Challenges and Solutions.
The panel included Peter Buckley, MD, Virginia Commonwealth University School of Medicine; E. Albert Reece, MD, PhD, MBA, University of Maryland School of Medicine; Paul Rothman, MD, Johns Hopkins School of Medicine; Robert Simari, MD, University of Kansas School of Medicine; and Selwyn Vickers, MD, University of Alabama School of Medicine, with me serving as moderator. These outstanding leaders discussed a number of themes that are summarized below.
Medical Education
The discussion of medical education focused on the subthemes of student debt, graduate medical education, and the place of basic science in the medical school curriculum. The question of increasing medical student debt burden prompted a conversation about the primary concern of debt affecting students’ choices of specialties—exacerbating shortages and maldistribution in areas such as primary care and psychiatry. The panelists suggested potential solutions to reduce student debt burdens to a reasonable level (which would not influence career decisions), including an accelerated curriculum, philanthropic and state government support, and helping students take advantage of existing loan forgiveness programs.
In discussing the effects of increased medical student enrollment on difficulties for medical students in matching into residency programs, it was noted that increasing the student base was a national strategy for addressing the projected physician shortage. Graduate medical education positions, however, have not kept pace because most of them are funded through the Medicare budget, and there has not been a substantive increase in funding for positions since 1997. Solutions were noted in the support of the Veterans Administration for increased residency program growth, as well as state support—such as in Wisconsin where the legislature has provided support to MCW to develop primary care and mental health residencies.
Responding to the question around the importance of research exposure in the medical student curriculum, it was expressed that it is critical to blend science and clinical curricula while balancing essential skills with the availability of vast amounts of information that students and physicians can access on demand via technology. Further, it was noted that the science of medicine is critical to the profession’s future in the emerging age of artificial intelligence, precision medicine, and bioinformatics, and that an emphasis on scientific knowledge and discovery would ensure that physicians being trained today would have the tools to synthesize the discoveries of tomorrow and remain clinically at the forefront of medical care for many decades.
Balance of Research and Clinical Missions
The central question on this topic was how to properly invest in the mission of discovery while concurrently balancing the other missions from the resources provided by clinical revenues. Several respondents discussed the need to continue expanding clinical operations and to create new efficiencies to safeguard the academic missions. Others discussed the need to better tell the story of discovery and how this research is a major source of progress to reduce the long-term costs of clinical care. The examples illustrating this idea were called “definitive technologies”—and included treatments such as immunizations, antibiotics, and anesthetics that dramatically reduce disease burdens, improve health outcomes, and lower the cost of treating certain conditions. Innovations are particularly needed in common, costly, and/or chronic conditions to reduce health care spending.
Community Engagement
The importance of medical schools and academic health systems as “anchor institutions” for communities was addressed, with an emphasis on how these institutions view the important mission of community engagement. Several respondents mentioned that their institutions historically had been good about telling people what is beneficial for their health, whereas now these institutions are focusing more on listening to better understand and engage in communities’ priorities. The importance of the economic advancement of communities and the emphasis on health disparities also were discussed. Panelists shared various programs and strategies, including commitments to train and hire local residents from distressed areas while also spending more money to buy goods and services from local vendors to boost employment and its associated health benefits. Respondents felt it was important that academic medical centers contribute their strengths as economic engines and through their scientific expertise, without confusing missions and taking on roles best filled by social service agencies and other partners.
Workforce Equity
In discussing needed solutions to gender inequities in academic medicine, the panelists noted success in the earliest career phases—as women are now admitted as medical students in equal numbers to men. Many institutions also have equity at the assistant professor level, although it declines as faculty progress to associate and full professor. The respondents agreed upon the importance of intentional leadership at the highest levels, systemically reviewing reviewing and ensuring equity in pay, and in supporting institutional programs that advance women’s leadership as a local supplement to nationally focused programs.
Wellness
The panelists shared that addressing wellness, reducing burnout, and resiliency are major initiatives in their respective institutions as well as across US medical schools—for faculty, students, and staff alike. In some cases, these efforts are spearheaded by a Chief Wellness Officer. All agreed that more needs to be done to reduce stress, especially on health care providers.
The above is a sample of the invigorating discussion that occurred on topics critical for medicine throughout Wisconsin and beyond. I welcome readers to view the entire panel conversation here.