Those Were The Days

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Getting ready to leave the Medical College of Wisconsin and move to Children’s Hospital of Wisconsin has made me a bit nostalgic.  I recalled recently when I was interviewing for my first job after fellowship, I was asked by my soon-to-be boss how I would design the ideal academic position.  I described what was the predominant model at academic children’s hospitals for my specialty of emergency medicine: approximately 60% clinical time, with the rest devoted to scholarly activity (education and research).  To my chagrin, he replied that model was becoming extinct.  People would have to choose to be 80-90% clinical or 80-90% academic (and get the external funding to support that).  I ended up in the 80% academic track.

Here it is 20 years later, and in many places, including ours, that is still the model.  But Brian Strom was correct.  The death of that model occurred earlier in Philadelphia and some other places than here, and perhaps in adult medicine ahead of pediatrics, but the trends are clear.  For a long time we have heard that the “triple threat” (i.e., the superhero physician who is clinician, educator, and researcher all rolled into one) was no longer possible because only those with a singular focus on research could compete successfully for extramural funding.  But many academic physicians do research that is internally funded with excess clinical revenue. The idea that the margin generated by spending 60% of one’s time in clinical work can support the other 40% is simply no longer tenable.

This was underscored by a set of articles about the future of academic health centers that appeared recently in JAMA and NEJM.  The articles talk about a variety of challenges and potential responses.  But a common theme is the unsustainability of cross-subsidization of the academic missions by the margin generated by clinical activity.  That margin is being eroded by downward pressure on reimbursements, at the same time alternative sources of funding for research and education are drying up.  The relative size of the clinical and academic activities is going to have to change.

For children’s hospitals, especially, where the paradigm of the triple threat has tended to hang on, we will have to rethink what it means to be an academic physician.  Rather than every faculty member participating in all activities, we will need to specialize.  The majority of faculty will be excellent clinicians who may do some bedside teaching, and provide access to patient material for clinical and translational researchers, but who will not themselves be expected to generate traditional “scholarly products” such as peer-reviewed articles, abstracts, book chapters, etc.  Their efforts, however, will generate sufficient margin to allow a smaller cadre of colleagues to engage in research and core educational activities.

This would represent a significant cultural change for us, leading to some serious soul-searching.  How do we continue to provide adequate intellectual stimulation to people who are “only” clinicians?  Would the pay scale be similar for clinicians and academics?   How do we ensure that prestige and career advancement are equally available to those doing the clinical work, when the traditional path to promotion and success has been via grant funding and publication?  What is it exactly that makes someplace an “academic health center?”

Fortunately, we are not the first to face these questions.  An article about the experience of Brigham and Women’s Hospital, for example, provides some encouragement.  But I wonder if someone who trained at the Brigham 20 years ago would recognize the place anymore.  Nostalgia may be fun, but we can’t reminisce our way forward.

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