Ratings of patients’ experience with hospital care now comprise
approximately 25 percent of the Centers for Medicare & Medicaid
Services’ (CMS) value-based purchasing payment. Improving the patient
experience is a goal that academic physicians, trainees, and everyone else
who comes into contact with patients could achieve immediately if we
applied sufficient effort.
There are four key take-home messages from our chapter. The first is not
original to our research, but goes to the reality that faculty in academic
health centers tend to be “eminence-based” as opposed to “evidencebased.”
Clearly, we need to find ways to ensure that faculty rely more
regularly on evidence versus personal experience alone. Many senior
faculty in academic health centers are highly respected for their research.
But too often that means that they provide care based on just their
experience. Having done things one way for a long time, they may
not necessarily know all of the data on how best to manage patients. We
have learned the hard way that this just isn’t good enough.
Given the nature of medicine today, team-based research and practice is
tremendously important. The second key message is that the data show
that faculty are not yet as effective as they need to be in working in teams.
That is not surprising. Many of today’s senior faculty entered the practice
of medicine at a time when autonomy was a defining characteristic.
Even now, the National Institutes of Health typically grants money to a
principal investigator (although it is moving toward team-based research).
Teamwork is not a given, and learning how to practice in teams is going
to require active training. Further, metrics need to be developed that
demonstrate the value of team-based care.
Third, the idea of the one-day-a-week clinician just does not work
anymore. It used to be that we could offer researchers who wanted to see
patients the opportunity to do so once a week. Today, however, unless that
person has truly phenomenal talents—and there are such exceptions—
medicine is so complicated that the traditional one-day-a-week clinician
simply cannot meet the standards that outstanding practice centers are
held to in terms of availability, efficiency, and effectiveness. That strongly
suggests that if one is going to be a full-time researcher, one probably
needs to concentrate on that role and probably shouldn’t practice.
Fourth, we need to think more carefully and thoroughly about rewarding
teaching. We need to find better ways to recognize and reward those who
can and do teach effectively. The great teacher almost never becomes a
bad teacher. One way to look at tenure is that it is a “bet” on the future
contributions of a faculty member. Perhaps for the great teacher, tenure
should be awarded on the basis of teaching excellence.
There are two potentially disruptive ideas in our chapter. One is that
some academic health centers might consider a path in which the AHC
hospital is “quaternary” and cares only for patients with conditions
requiring research, referring patients with more common conditions to
other network partners. We may have to stop competing for the normal
procedures that make money; it is a waste of time for academic faculty.
The real value of the academic health center comes from advancing the
state of medicine, not competing for appendectomies. Teaching should
be done in all parts of the network. If we are to realize the full value of
academic medicine, academic health centers need to be paid differently.
We outline some options for payment in our chapter.
The second potentially disruptive idea concerns research in the academic
health center. We know that research in clinical departments was
bolstered in the early days of Medicare when ample money was available.
But those funds are no longer available. Consequently, we can no longer
rely on the principle of clinical cross-subsidization for either research
or teaching. Today, both teaching and research need to be paid for on
their own. One suggestion of ours is to house basic research—i.e., not
involving the patient directly—in basic science departments that might
be part of university-wide research enterprises and part of the university’s
basic science budget. The university could decide how much it wants to
subsidize basic research, and the rest could be supported by grants and
indirect costs. The rare faculty members who can take their own bench
research to the bedside could receive appointments such as “University
Recognizing that academic health centers will continue to play a vital
role in medical education, research, and clinical care, we offer a range
of further ideas in such areas as leadership, mission, continuous learning
and improvement, and transparency and patient engagement. One of our
observations in writing this chapter was that there are surprisingly few
data that demonstrate the superiority of academic health centers in the
care of patients. That gap provides an opportunity, however, for academic
health centers and health services researchers in academic health settings
to, in essence, prove how good they are.
Carolyn M. Clancy, MD
Interim Under Secretary
U.S. Department of
Arthur Garson, Jr., MD, MPH
Director, Health Policy Institute
Texas Medical Center