The perilous state of academic medicine

The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives

INTRODUCTION

Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies.

METHODS

Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017-18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories.

RESULTS

Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher-order themes emerged related to aligning missions, including (a) shared vision and strategies, (b) alignment of strategy with community needs, (c) tension of economic drivers, (d) coproduction of knowledge, and (e) unifying set of concepts spanning all missions. Second, strategies for each mission were identified, including education (new competencies, instructional methods, recruitment), research (shifting agenda, developing partnerships, operations), and clinical operations (delivery models, focus on patient factors/needs, value-based care, well-being). Lastly, strategies for integrating each dyadic mission pair, including research-education, clinical operations education, and research-clinical operations, were identified.

CONCLUSIONS

Academic health centers are at a crossroads in regard to identity and alignment across the tripartite missions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.

Professing clinical medicine in an evolving health care network

For at least the past several decades, medicine has been embroiled in a crisis concerning the nature of its professionalism. The fundamental questions that drive this ongoing crisis are primarily three. First, what is the nature of medical professionalism? Second, who are medical professionals? Third, what does medicine or these professionals profess or promise? In this paper, the professionalism crisis vis-à-vis these questions is examined and analyzed chiefly in terms of both Francis Peabody's and Edmund Pellegrino's writings. Based on their writings, I introduce a conceptual framework for professionalism to address the crisis. In addition, I contend that to address the professionalism crisis adequately, medicine's position within an evolving health care network must also be considered. To that end, I first discuss the genesis of the crisis in terms of the Flexner Report and especially Peabody's response to it. Next, I explore how the crisis intensified during the twentieth century, particularly in terms of medicine's ultimate scientification and eventual commercialization, and how Pellegrino reacted to this. I then propose a health care professionalism cycle and a care-competence cycle to provide a conceptual framework for addressing the crisis. I conclude that medicine's position is no longer as the center of health care but rather as another node within a wider evolving health care network. And the resolution of medicine's professionalism crisis depends on medicine's positioning and defining itself in terms of the professionalism for each of the other professions within the health care network.

A Comparison of Defense and Plaintiff Expert Witnesses in Orthopaedic Surgery Malpractice Litigation

BACKGROUND

According to the American Academy of Orthopaedic Surgeons (AAOS) Standards of Professionalism, the responsible testimony of expert witnesses in orthopaedic surgery malpractice lawsuits is important to the public interest. However, these expert witnesses are recruited and compensated without established standards, and their testimony can potentially sway court opinion, with substantial consequences. The objective of this study was to characterize defense and plaintiff expert orthopaedic surgeon witnesses in orthopaedic surgery malpractice litigation.

METHODS

Utilizing the WestlawNext legal database, defense and plaintiff expert witnesses involved in orthopaedic surgery malpractice lawsuits from 2013 to 2017 were identified. Each witness's subspecialty, mean years of experience, involvement in academic or private practice, fellowship training, and scholarly impact, as measured by the Hirsch index (h-index), were determined through a query of professional profiles, the Scopus database, and a PubMed search. Statistical comparisons were made for each parameter among defense and plaintiff expert witnesses.

RESULTS

Between 2013 and 2017, 306 expert medical witnesses for orthopaedic cases were identified; 174 (56.9%) testified on behalf of the plaintiff, and 132 (43.1%) testified on behalf of the defense. Orthopaedic surgeons who identified themselves as general orthopaedists comprised the largest share of expert witnesses on both the plaintiff (n = 61) and defense (n = 25) sides. The plaintiff witnesses averaged 36 years of experience versus 31 years for the defense witnesses (p < 0.001); 26% of the plaintiff witnesses held an academic position versus 43% of the defense witnesses (p = 0.013). Defense witnesses exhibited a higher proportion of fellowship training in comparison to plaintiff expert witnesses (80.5% versus 64.5%, respectively, p = 0.003). The h-index for the plaintiff group was 6.6 versus 9.1 for the defense group (p = 0.04). Two witnesses testified for both the plaintiff and defense sides.

CONCLUSIONS

Defense expert witnesses held higher rates of academic appointments and exhibited greater scholarly impact than their plaintiff counterparts, with both sides averaging >30 years of experience. These data collectively show that there are differences in characteristics between plaintiff and defense witnesses. Additional study is needed to illuminate the etiology of these differences.

The role of academic health centres in improving health equity: a systematic review

Purpose Academic health centres (AHCs) are organisations that pursue a "tripartite" mission to deliver high-quality care to patients, undertake clinical and laboratory research, and train future health professionals. The last decade has seen a global spread of AHC models and a growing interest in the role of AHCs in addressing health system equity. The purpose of this paper is to synthesise and critically appraise the evidence on the role of AHCs in improving health equity. Design/methodology/approach Peer-reviewed and grey literature published in English between 2000 and 2016 were searched. Articles that identified AHCs as the primary unit of analysis and that also addressed health equity concepts in relation to the AHC's activity or role were included. Findings In total, 103 publications met the inclusion criteria of which 80 per cent were expert opinion. Eight descriptive themes were identified through which health equity concepts in relation to AHCs were characterised, described and operationalised: population health, addressing health disparities, social determinants of health, community engagement, global health, health system reform, value-based and accountable financing models, and role clarification/recalibration. There was consensus that AHCs can and should address health disparities, but there is a lack of empirical evidence to show that AHCs have a capacity to contribute to health equity goals or are demonstrating this contribution. Originality/value This review highlights the relevance of health equity concepts in discussions about the role and missions of AHCs. Future research should improve the quality of the evidence base by empirically examining health equity strategies and interventions of AHCs in multiple countries and contexts.

Reasons for faculty departures from an academic medical center: a survey and comparison across faculty lines

BACKGROUND

Faculty departure can present significant intellectual costs to an institution. The authors sought to identify the reasons for clinical and non-clinical faculty departures at one academic medical center (AMC).

METHOD

In May and June 2010, the authors surveyed 137 faculty members who left a west coast School of Medicine (SOM) between 1999 and 2009. In May and June 2015, the same survey was sent to 40 faculty members who left the SOM between 2010-2014, for a total sample size of 177 former faculty members. The survey probed work history and experience, reasons for departure, and satisfaction at the SOM versus their current workplace. Statistical analyses included Pearson's chi-square test of independence and independent sample t-tests to understand quantitative differences between clinical and non-clinical respondents, as well as coding of qualitative open-ended responses.

RESULTS

Eighty-eight faculty members responded (50%), including three who had since returned to the SOM. Overall, professional and advancement opportunities, salary concerns, and personal/family reasons were the three most cited factors for leaving. The average length of time at this SOM was shorter for faculty in clinical roles, who expressed lower workplace satisfaction and were more likely to perceive incongruence and inaccuracy in institutional expectations for their success than those in non-clinical roles. Clinical faculty respondents noted difficulty in balancing competing demands and navigating institutional expectations for advancement as reasons for leaving.

CONCLUSIONS

AMCs may not be meeting faculty needs, especially those in clinical roles who balance multiple missions as clinicians, researchers, and educators. Institutions should address the challenges these faculty face in order to best recruit, retain, and advance faculty.

Expert witness testimony in ophthalmology malpractice litigation

PURPOSE

To examine the relative qualifications of expert witnesses testifying on behalf of plaintiffs vs defendants in ophthalmology malpractice litigation.

DESIGN

Correlational and descriptive study; analysis of expert witness and physician demographic data available on several databases.

METHODS

The Westlaw legal database was searched for ophthalmologist expert witness testimony from January 2006 to June 2014. Physician demographic data were used as the main outcome measures, including length of experience, scholarly impact (as measured by the h-index), practice setting, and fellowship training status and were obtained from state medical licensing board sites and online medical facility and practice sites. H-indices were obtained from the Scopus database.

RESULTS

Defendant and plaintiff expert witnesses had comparable mean years of experience (32.9 and 35.7, respectively) (P = .12) and scholarly impact (h-index = 8.6 and 8.3, respectively) (P = .42). Cases tended to resolve on the side of the expert witness with the higher h-index (P = .04). Significantly higher proportions of defendant witnesses were in academic practice (P < .05) and underwent fellowship training (P < .001).

CONCLUSION

Ophthalmologist expert witnesses testifying for both plaintiffs and defendants had over 30 years of experience and high scholarly impact. Practitioners testifying on behalf of plaintiffs were statistically less likely to work in an academic setting and have subspecialty training. Scholarly impact of expert witnesses appeared to affect trial outcomes. Surgical societies should stringently police for appropriate expert witness testimony given by both plaintiff and defense experts in malpractice litigation.

Comparison of plaintiff and defendant expert witness qualification in malpractice litigation in neurological surgery

Object

Expert witnesses provide a valuable societal service, interpreting complex pieces of evidence that may be misunderstood by nonmedical laypersons. The role of medical expert witness testimony and the potential professional repercussions, however, have been controversial in the medical community. The objective of the present analysis was to characterize the expertise of neurological surgeons testifying as expert witnesses in malpractice litigation.

Methods

Malpractice litigation involving expert testimony from neurological surgeons was obtained using the WestlawNext legal database. Data pertaining to duration of a surgeon's practice, scholarly impact (as measured by the h index), practice setting, and the frequency with which a surgeon testifies were obtained for these expert witnesses from various online resources including the Scopus database, online medical facility and practice sites, and state medical licensing boards.

Results

Neurological surgeons testifying in 326 cases since 2008 averaged over 30 years of experience per person (34.5 years for plaintiff witnesses vs 33.2 for defense witnesses, p = 0.35). Defense witnesses had statistically higher scholarly impact than plaintiff witnesses (h index = 8.76 vs 5.46, p < 0.001). A greater proportion of defense witnesses were involved in academic practice (46.1% vs 24.4%, p < 0.001). Those testifying on behalf of plaintiffs were more likely to testify multiple times than those testifying on behalf of defendants (20.4% vs 12.6%).

Conclusions

Practitioners testifying for either side tend to be very experienced, while those testifying on behalf of defendants have significantly higher scholarly impact and are more likely to practice in an academic setting, potentially indicating a greater level of expertise. Experts for plaintiffs were more likely to testify multiple times. Surgical societies may need to clarify the necessary qualifications and ethical responsibilities of those who choose to testify.

Applying the Balanced Scorecard approach in teaching hospitals: a literature review and conceptual framework

Teaching hospitals (THs) simultaneously serve three different roles: offering medical treatment, teaching future doctors and promoting research. The international literature recognises such organisations as 'peaks of excellence' and highlights their economic function in the health system. In addition, the literature describes the urgent need to manage the complex dynamics and inefficiency issues that threaten the survival of teaching hospitals worldwide. In this context, traditional performance measurement systems that focus only on accounting and financial measures appear to be inadequate. Given that THs are highly specific and complex, a multidimensional system of performance measurement, such as the Balanced Scorecard (BSC), may be more appropriate because of the multitude of stakeholders, each of whom seek a specific type of accountability. The aim of the paper was twofold: (i) to review the literature on the BSC and its applications in teaching hospitals and (ii) to propose a scorecard framework that is suitable for assessing the performance of THs and serving as a guide for scholars and practitioners. In addition, this research will contribute to the ongoing debate on performance evaluation systems by suggesting a revised BSC framework and proposing specific performance indicators for THs.

Development and implementation of a comprehensive strategic plan for medical education at an academic medical center

Despite their vital contributions to the training of future physicians, many academic teaching hospitals have grown operationally and financially distinct from affiliated medical schools because of divergent missions, contributing to the erosion of clinical training. Some institutions have responded by building hybrid organizations; others by creating large health care networks with variable relationships with the affiliated medical school. In this case, the authors wished to establish the future educational mission of their medical center as a core element of the institution by creating data-driven recommendations for reorganization, programs, and financing. They conducted a self-study of all constituents, the results of which confirmed the importance of education at their institution but also revealed the insufficiency of incentives for teaching. They underwent an external review by a committee of prominent educators, and they involved administrators at the hospital and the medical school. Together, these inputs composed an informed assessment of medical education at their teaching hospital, from which they developed and actualized an institution-wide strategic plan for education. Over the course of three years, they centralized the administrative structure for education, implemented programs that cross departments and reinforce the UME-GME continuum, and created transparency in the financing of medical education. The plan was purposefully aligned with the clinical and research strategic plans by supporting patient safety in programs and the professional development of faculty. The application of a rigorous strategic planning process to medical education at an academic teaching hospital can focus the mission, invigorate faculty, and lead to innovative programs.

Teaching by residents

This paper stresses the importance to students and residents of committed and competent teaching by residents who nationwide provide 20% to 70% of the clinical teaching for medical students. The obstacles to teaching effectiveness by residents are the lack of: (1) sufficient role modeling by faculty; (2) time (and money); (3) knowledge of the principles of adult learning and teaching techniques; (4) service-specific learning objectives; (5) recognition of teaching efforts; and (6) resident interest in teaching. Overcoming these obstacles will require increased faculty commitment to teaching, compensation for structured educational activities, more effective use of potential teaching moments, teaching workshops for residents, development of service-specific educational objectives, and recognition of exemplary teaching by residents and faculty.

Conflict of interest or ideological divide: the need for ongoing collaboration between physicians and industry

Continued collaboration between the health profession and industry is essential for future innovation and for fighting disease and illness well into the 21st century. Evidence that suggests conflicts of interest have a negative effect on patient care or the total cost of health care is lacking. Many arguments put forth to address this issue include strictly limiting or severing ties with industry. Research takes place in university, government, and pharmaceutical laboratories, but only industry translates research into drug therapy. While both parties have a shared goal of optimizing health outcomes, industry critics conveniently invoke 'conflict of interest' to express their opinion about the need to more strictly regulate physician/industry interactions. Retreat from industry by academic institutions and working in isolation are simply not strategic options and other points of view must be expressed to help avoid the 'triumph of emotion over fact'.

The future of hospital economic health

OBJECTIVE

To evaluate factors which may influence the economic future of academic medical centers (AMCs).

DATA SOURCE AND SELECTION

A literature search was performed to identify publications which reviewed the areas of revenue sources for AMCs, costs and expenses incurred by these institutions, and mechanisms for optimizing institutional economic stability.

DATA EXTRACTION AND SYNTHESIS

Data were reviewed and evaluated in two primary contexts: hospital revenues and organizational and administrative factors influencing hospital economic health.

CONCLUSIONS

Increasing economic stress will require AMCs to make efforts both to increase revenue through a variety of mechanisms and to minimize expenses without compromising their mission or impairing worker morale.

The role of government in health care: a societal issue

The history of the role of government in health care is briefly reviewed and more fully discussed in the United States since the establishment of Medicare 40 years ago. Data and other evidence of the unintended consequences of this historic event are presented, identifying thorny and onerous issues that government has created, showing failed attempts at band-aid solutions, and suggesting that our present health care system is in disarray and cannot be rectified by the "incrementalism" approach. The establishment of a high-level commission jointly endorsed by the President of the United States and Congress is recommended to consider and analyze scrupulously all the components of our health care complex and provide a "roadmap" toward achieving a universal health care system that is culturally acceptable, affordable, and of optimal quality while avoiding its administration and total control by an ultimately rigid and unwieldy governmental or insurance-industry bureaucracy.

Cost accounting in radiology: new directions and importance for policy

OBJECTIVE

The purpose of this article is to promote insight into radiology costs through improvements in assessing patient-level cost data. Accurate patient costing is a prerequisite for establishing a proper payment system-one where the price paid for a service approximates the cost of delivering that service. In the absence of an accurate payment scheme, margins can vary significantly from one patient to the next.

CONCLUSION

The resulting financial incentives skew the radiology marketplace away from the provision of efficient and appropriate care toward the selection of patients whose costs are low relative to reimbursements.

Reinventing the academic health center

Academic health centers have faced well-documented internal and external challenges over the last decade, putting pressure on organizational leaders to develop new strategies to improve performance while simultaneously addressing employee morale, patient satisfaction, educational outcomes, and research growth. In the aftermath of a failed merger, new leaders of The Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center encountered a climate of readiness for a transformational change. In a case study of this process, nine critical success factors are described that contributed to significant performance improvement: performing a campus-wide cultural assessment and acting decisively on the results; making values explicit and active in everyday decisions; aligning corporate structure and governance to unify the academic enterprise and health system; aligning the next tier of administrative structure and function; fostering collaboration and accountability-the creation of unified campus teams; articulating a succinct, highly focused, and compelling vision and strategic plan; using the tools of mission-based management to realign resources; focusing leadership recruitment on organizational fit; and "growing your own" through broad-based leadership development. Outcomes assessment data for academic, research, and clinical performance showed significant gains between 2000 and 2004. Organizational transformation as a result of the nine factors is possible in other institutional settings and can facilitate a focus on crucial quality initiatives.

Critical care medicine as a distinct product line with substantial financial profitability: The role of business planning

OBJECTIVE

As academic health centers face increasing financial pressures, they have adopted a more businesslike approach to planning, particularly for discrete "product" or clinical service lines. Since critical care typically has been viewed as a service provided by a hospital, and not a product line, business plans have not historically been developed to expand and promote critical care. The major focus when examining the finances of critical care has been cost reduction, not business development. We hypothesized that a critical care business plan can be developed and analyzed like other more typical product lines and that such a critical care product line can be profitable for an institution.

DESIGN

In-depth analysis of critical care including business planning for critical care services.

SETTING

Regional academic health center in southern New Jersey.

SUBJECTS

None.

INTERVENTIONS

As part of an overall business planning process directed by the Board of Trustees, the critical care product line was identified by isolating revenue, expenses, and profitability associated with critical care patients.

MEASUREMENTS AND MAIN RESULTS

We were able to identify the major sources ("value chain") of critical care patients: the emergency room, patients who are admitted for other problems but spend time in a critical care unit, and patients transferred to our intensive care units from other hospitals. The greatest opportunity to expand the product line comes from increasing the referrals from other hospitals. A methodology was developed to identify the revenue and expenses associated with critical care, based on the analysis of past experience. With this model, we were able to demonstrate a positive contribution margin of dollar 7 million per year related to patients transferred to the institution primarily for critical care services. This can be seen as the profit related to the product line segment of critical care. There was an additional positive contribution margin of dollar 5.8 million attributed to the critical care portion of the hospital stay of patients admitted primarily through other product lines or the emergency room. This can be seen as the profit related to the "hospital service" segment of critical care. This represented a total contribution margin of dollar 12.8 million, approximately 24% of the institution's entire contribution margin. This information was subsequently used to develop strategic plans to promote this product line.

CONCLUSIONS

We were able to define the critical care product line, and we were able to demonstrate profitability through an analysis of revenue and expenses related to critical care services. Our experience suggests that the concept of critical care as a product line, in addition to a hospital service, may lead to a useful analysis of this new discipline. This plan provided a rational foundation for development of the operating and capital budgets for the health system.

Contextual tensions of the clinical environment and their influence on teaching and learning

BACKGROUND

Academic medical centres face major challenges, and finding creative, effective strategies to support patient care and teaching are critical for survival. At the centre of these challenges is clinical teaching.

AIM

To characterise how context influences clinical teaching.

METHODS

Multiple embedded case-study design analysed 3 internal medicine in-patient teams. Direct observations, interviews and documents were data sources. Triangulated data, audit trails and member checks enhanced trustworthiness.

RESULTS

Three tensions influenced clinical teaching: 1, patient census; 2, time sensitivity of the context; and 3, the multiple and conflicting commitments of participants. Patient census exhibited the greatest influence and was the catalyst for teaching, learning, and the allocation of total time. Time functioned as an important element influencing the pace of action, reflective and interpretative cognitive processes of the team, time available for action, and the general fatigue of the team. Conflicts among the multiple roles of ward team members disrupted individual and team teaching and learning.

CONCLUSION

Clinical teaching is an open system influenced by multiple forces. Learning, teaching and patient care were very closely coupled, and learning knowledge and using knowledge were parts of the same process within the clinical context.

The manpower crisis in academic radiology: don’t kill the milk cow for meat

There is a manpower crisis in academic radiology departments. These departments cannot sustain their academic missions from clinical revenues alone. Salaries can' t be competitive with private practice, and the recruitment and retention of faculty members are compromised. The education of medical students, residents, and fellows and the clinical and basic research that sustains the specialty suffers. There is no simple remedy; academic departments need philanthropy from industry and private practice, more support from the government and the schools of medicine, and more efficient clinical practices. The future of our specialty is truly at stake. Academic departments are responsible for the great majority of training and technical innovation in the specialty. If academic departments cannot sustain their academic missions, the specialty of diagnostic radiology will certainly suffer.

The Balanced Budget Act of 1997 and the financial health of teaching hospitals

BACKGROUND

We wanted to evaluate the most recent, complete data related to the specific effects of the Balanced Budget Act of 1997 relative to the overall financial health of teaching hospitals. We also define cost report variables and calculations necessary for continued impact monitoring.

METHODS

We undertook a descriptive analysis of hospital cost report variables for 1996, 1998, and 1999, using simple calculations of total, Medicare, prospective payment system, graduate medical education (GME), and bad debt margins, as well as the proportion with negative total operating margins.

RESULTS

Nearly 35% of teaching hospitals had negative operating margins in 1999. Teaching hospital total margins fell by nearly 50% between 1996 and 1999, while Medicare margins remained relatively stable. GME margins have fallen by nearly 24%, however, even as reported education costs have risen by nearly 12%. Medicare + Choice GME payments were less than 10% of those projected.

CONCLUSIONS

Teaching hospitals realized deep cuts in profitability between 1996 and 1999; however, these cuts were not entirely attributable to the Balanced Budget Act of 1997. Medicare payments remain an important financial cushion for teaching hospitals, more than one third of which operated in the red. The role of Medicare in supporting GME has been substantially reduced and needs special attention in the overall debate. Medicare + Choice support of the medical education enterprise is 90% less than baseline projections and should be thoroughly investigated. The Medicare Payment Advisory Commission, which has a critical role in evaluating the effects of Medicare policy changes, should be more transparent in its methods.

Managed care or managed inequality? A call for critiques of market-based medicine

This review article critiques the growing dominance of market-based medicine in the United States against the background of existing problems with quality of care, rising costs, devaluation of doctor-patient relationships, and, especially, persistent inequalities of access and outcomes. It summarizes the present state of health care delivery by focusing on the concurrent trends of growth in managed care, expanding profits, increasing proportion of those uninsured, and widening racial, ethnic, and class disparities in access to care. Allowing market forces to dictate the shape of health care delivery in this country ensures that inequalities will continue to grow and modern medicine will become increasingly adept at managing inequality rather than managing (providing) care. The article challenges anthropology to become more involved in critiquing these developments and suggests how anthropologists can expand on and contextualize debates surrounding the market's role in medicine, here and abroad.

Indicators of early research productivity among primary care fellows

OBJECTIVE

Little is known about the impact of fellowship training in primary care on subsequent research productivity. Our goal was to identify characteristics of research fellows and their training associated with subsequent publications and research funding.

DESIGN

Mail survey in 1998.

SETTING AND PARTICIPANTS

1988-1997 graduates of 25 National Research Service Award primary care research fellowships in the United States.

OUTCOME MEASURES

1) Publishing 1 or more papers per year since the beginning of fellowship, or 2) serving as principal investigator (PI) on a federal or non-federal grant.

RESULTS

One hundred forty-six of two hundred fifteen program graduates (68%) completed the survey. The median age was 38 years, and 51% were male. Thirty-two percent had published 1 or more papers per year, and 44% were PIs. Male gender (odds ratio [OR], 3.6; 95% confidence interval [95% CI], 1.4 to 9.2), self-reported allocation of 40% or more of fellowship time to research (OR, 4.4; 95% CI, 1.8 to 11.2), and having an influential mentor during fellowship (OR, 5.0; 95% CI, 1.5 to 17.2) were independently associated with publishing 1 or more papers per year. Fellows with funding as a PI were also more likely to have an influential mentor (OR, 3.0; 95% CI, 1.3 to 7.2).

CONCLUSION

Primary care fellows who had influential mentors were more productive in research early after fellowship. Awareness of the indicators of early research success can inform the policies of agencies that fund research training and the curricula of training programs themselves.

The political, legal, and financial issues that plastic surgery is facing and how to develop a plan to cope

Our specialty has been a creative wonder and an outright blessing to mankind. We have honed the arts of soft-tissue reconstruction to a level never thought possible just 100 years ago. We have found solutions to wound problems long after others have given up. We have restored the destroyed features of people ravaged by disease, life circumstances, and the acts of war. We have treated the deformed child, the patient with cancer, and reversed the signs of age. But as Thomas Sowell states in his article in 1994 in Forbes Magazine on the 100th anniversary of the birth of Fredrich Hayek, the author of The Road to Serfdom, the rule of law, which Hayek saw as crucial to the economy and to the survival of freedom, is nowhere in greater danger than in the supreme court of the United States. Sowell warned of the process going on that would bring socialism to our health care delivery system. He goes on to assert that it will be paid for by "loss of freedom to make our own decisions about medical care that are literally questions of life and death. The key to the future of medicine is now in our hands. This key will open the door to every doctor's dream of having the technologies that will allow physicians to diagnose and treat all the physical ills of the human race. Or the key, on the other hand, could open the exit door through which the best and brightest will leave medicine, feeling that they no longer can take on the legal and the financial risks to themselves and their families. The road to freedom from the controlling factors noted will require a change in culture. Knowing these facts will allow the plastic surgeon in practice to accept these factors and work with them to provide better care for their patients.

Professionalism and justice: ethical management guidelines for leaders of academic medical centers

Academic health centers (AHCs) exist for the sake of pursuit of excellence in their missions of patient care, teaching, and research. Survival should be a means to these goals and not an end unto itself. Because of the fiscal crisis in health care, leaders of AHCs face the possible diminution or even extinction of their centers. When preventing such a fate becomes the governing concern of these leaders, power concentrates in their hands and can be used to force cooperation among competing faculty members and groups for the sake of mutual survival. The ethical concepts of professionalism and justice can be used to create a vital, practical, alternative vision for the leadership of AHCs, in which their missions once again become central to their organizational culture. Creating a morally sustainable organizational culture of professionalism and justice should rely not on forced cooperation, but on voluntary cooperation of all stakeholders in the pursuit of a common goal-professional excellence in patient care, teaching, and research-with survival understood to be a means to this goal. To achieve this alternative vision, the authors propose five management guidelines. For example, all faculty should be made accountable not only for maximizing the good of the organization's professionalism but also for fostering financial viability.

Global health assistance: a new perspective

Health care priorities for many emerging economies have undergone a dramatic transition in the recent past because of the rise in chronic illness, increased longevity, and lessened infant mortality. Two additional major societal forces, democratization and the information revolution, will alter the nature of global health assistance. Because of democratization, governments will feel increasing pressure to provide adequate health care. Because of the information revolution, all practitioners will know what is available. The convergence of these three forces will create an enormous financial burden for emerging economies. Adapting to these new realities will be the challenge to donor organizations. What is likely to emerge as a critical health care problem around the world is the need to balance priorities between acute care and prevention or modification of chronic disease. These efforts will be directed at different populations, one manifestly ill and one potentially so, and each will need to be recognized politically as having valid claims on governmental resources. External support will need to include demonstration within the recipient communities that data collection permits an accurate identification of disease burden, that risk factor modification ameliorates the impact of disease, that continuity of care is essential to long term outcomes, and that therapy of developed disease can be rationally carried out utilizing evidence based medicine to insure efficiency and appropriateness.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection

We again review four areas of interest to office-based pediatricians: office laboratory procedures, office economics, parenting and patient education, and urinary tract infections. Sean Elliott provides an update on the Clinical Laboratories Improvement Amendments (CLIA) and their impact of office practice. Eve Shapiro reviews office economics, focusing on measuring quality of care, use of performance data, costs of new technologies, and the impact of managed care on the medical marketplace. John Walter offers an update on parenting and parent education, with approaches to counseling families about overuse of antibiotics, teen pregnancy, hyperactivity, violence, and asthma. Richard Wahl reviews the recent research on urinary tract infection, with special attention paid to office diagnosis and management, longitudinal studies of children with urinary tract infections, and the controversy surrounding the American Academy of Pediatrics Task Force on Circumcision report.