THE FACULTY 2000
PROJECT This Undertaking is Initiated and Organized by the Steering Committee of the Medical Faculty Senate and the Faculty – 2000 Steering Committee, and is Directed by the Leadership of the Medical Faculty Senate.
James C. Saunders, Ph.D. Chair, Faculty – 2000 Project TABLE OF CONTENTS Section Page |
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Beginning in late 1997, the
Steering Committee of the Medical Faculty Senate
began extensive discussions which have resulted in
the Faculty – 2000 Project. A recurring theme
emerged among committee members; namely the ability
or lack thereof among the junior faculty in the
Clinician Educator Track to fulfill the academic
requirements for promotion. There were other
criteria, of course, but the emphasis was on
scholarship as it should be for an institution
characterized by academic excellence like the
University of Pennsylvania. At the same time, the concept of
"protected time", time dedicated to the pursuit of
the scholarly output required for promotion, was
undergoing significant revision. Protected time is
a rather paradoxical term because the School does
not have the financial resources to protect
anyone’s time! The entire faculty in the
Medical School must earn income (either from
clinical activity or from grants) to support their
salary. In more flush times, when surplus resources
were available in departments, allocations could be
made to some faculty to carve out time "protected"
for scholarly activity. There never was, nor has
there ever been, a sufficient institutional
resource to guarantee time for scholarly or
educational activity to all Clinician Educator
faculty. At the same time that promotion
standards were at high levels, alarming decreases
in health care reimbursement rates, fueled, in
part, by the Balanced Budget Act of 1997, were
beginning to impact on our clinical faculty. Also,
the expanded University of Pennsylvania Health
System and its network of hospitals and doctors
were working well as a source of referrals. The
increased referral base and our superb reputation
for health care delivery created a substantial
increase in the patient load at HUP. A high promotion standard,
falling reimbursement rates (with the resulting
need to work more hours in clinical activities to
maintain income), and a burgeoning patient load,
increased the stress on all of our faculty, but
particularly among the junior faculty. The
interplay of these factors is very complex, and
this crude attempt to capture the flavor of the
problem touches only the surface, and likely misses
many points. Nevertheless, the net result was that
time for scholarly and educational activity was
diminishing for many of the Clinician Educators,
and this was placing their promotions in
jeopardy. In spite of these factors, it
was difficult for the Medical Faculty Senate in
1997 and 1998 to identify any hard evidence that
junior faculty were in trouble. There appeared to
be a substantial jump in the number of "advisory"
letters being sent out by the Committee on
Appointments and Promotions (COAP) after the
initial three- or six-year review of many Clinician
Educators. Moreover, it was impossible to gain an
idea of how many Assistant Professor appointments
were not being renewed at the three- and six-year
review intervals because they would not make the
promotion hurdle. Nevertheless, there appeared to
be a process of attrition occurring, the result of
which was that only the strongest candidates were
coming before the COAP. Yet anecdotal evidence was
mounting for a substantial "bubble" of junior
faculty moving through the system with an
ever-decreasing likelihood of meeting promotion
requirements. Our junior Tenure Track faculty,
whether M.D./Ph.D. or Ph.D. appointments, were not
immune to the changes occurring in medicine either.
The bar for their promotion was already set high.
However, the complexity of modern biomedical
research was taking its toll. Increasing
competition for federal support, and the
requirement for producing stellar scholarship, in
sufficient quantity, with an identifiable impact,
meant that otherwise talented investigators were
facing severe problems in generating adequate
credentials within the five-year probationary
period prior to their promotion review. These concerns were not
exclusive to the junior faculty. Mid-level faculty
were also encountering difficulty in achieving
sufficient scholarly credentials for promotion to
full professor because of the demands for clinical
service. Lurking behind all of these matters were
the "quality of life" issues. The more cynical
members of the faculty noted that if they could
just move their families into HUP quarters, things
would be better! Finally, to all this must be
added the perception that the corporatization of
the Health System was extending the concepts of
management into academic lives. The issues of
academic freedom were being quietly
raised. In fairness, the story was not
all "doom and gloom." Throughout the late nineties,
the magnitude of new construction and renovation
throughout the School and System was spectacular,
and the expansion of the Health System was
successfully moving forward. Faculty largely felt
that the management of the School was in good
hands. Moreover, the national recognition of Penn
as a Center of Excellence in the delivery of health
care and the unprecedented rise in research
support, left faculty with the sense of pride that
they were part of one of the world’s best
academic Medical Centers. Nevertheless, when the focus
returned to faculty issues, strong sentiment
emerged in the Medical Faculty Senate Steering
Committee that it was time for the faculty to stand
up and have a voice in determining its future. The
Steering Committee came to the conclusion that an
examination of the faculty, in terms of its roles,
missions, structure and organization, was needed to
determine who we are and what we ought to look like
to best achieve the academic mission. In addition,
faculty should take on the job of identifying
strategies and tactics that would assure the
survival of their academic character. It was not
clear, at first, how this could be accomplished,
because, in large measure, faculty are ill-equipped
to undertake such a venture. As these issues emerged in
Steering Committee discussions, they also appeared
as growing themes in the monthly meetings between
the Medical Faculty Senate Leadership and the Dean,
and a plan slowly emerged. Obviously, a
self-directed review by the faculty of themselves
could not be undertaken without the concurrence of
the Dean and the Department Chairs. A project of
this magnitude required careful and extensive
deliberations and planning. The Medical Faculty
Senate leadership was particularly sensitive to the
need to be constructive, not confrontational, when
presenting the plan to the Dean, Senior
Administration and Department Chairs, and to
emphasize the benefits of such an undertaking.
After all, it was argued, our faculty and
administration had developed a nationally
recognized health system, had instituted the
medical curriculum for the next century, and had
achieved spectacular success in gaining research
grant support. The faculty were obligated to
examine themselves in order to assure the continued
delivery of outstanding health service, while at
the same time advancing the scholarly and
educational traditions of a "world class" Medical
School and University. This theme resonated within
our administration, within the Department Chairs,
the Office of the President and Provost, within the
Trustees, and within the University Faculty Senate.
Faculty – 2000 Project was
launched. The leadership of the Medical
Faculty Senate can not assure our faculty
colleagues that this effort will cure anything. We
have provided the foundations for success, and the
Dean has agreed to accept the recommendations and
apply them to the normal review process used by the
School of Medicine. If the Working Groups undertake
their inquiries with honesty and wisdom, and
produce recommendations that are both practical and
beneficial, we may, indeed, be able to guarantee
the quality of our academic character into the
future. As a faculty we must undertake this Project
and do it well, for what other choice do we have?
If we do not find our own "voice" and identify our
own vision for the future, there are plenty of
others ready to speak and identify it for
us. The Organization Chart on Page 8
illustrates the overall plan of the Faculty - 2000
Project. This plan was formulated by the leadership
of the Medical Faculty Senate (Drs. Guerry,
Hansen-Flaschen, Herrmann, and Saunders) over an
18-month period, and was refined considerably by
the Faculty - 2000 Steering Committee. This
committee, assembled in September of 1998,
consisted of individuals with considerable
experience in the School of Medicine. The Committee
developed the Mission Statement on the following
page, and served to identify the themes of the
Working Groups, as well as the issues they might
discuss. The initial Charges to the Working Groups
were formulated by the Steering Committee. The work
of the Committee is currently finished, but it will
reconvene to consider the plans for the Faculty
Retreat, and when the process is finished, to
structure the final form of the recommendations
transmitted to the School of Medicine. The roles of
the Department Chairs and the Dean's Symposium are
outlined below. The original proposal of eight
Working Groups was pared down to a more manageable
number of four. Each Working Group has two
co-Chairs. The use of co-Chairs was to provide
continuity in leadership of the meetings. In
addition, it allowed us the opportunity to appoint
individuals with different perspectives, which
helped assure that a healthy range of opinions
would be represented. A call for participation in the
Working Groups to the faculty netted 174 replies.
This was an astounding expression of interest.
Membership in each of the Working Groups was chosen
to accommodate as diverse a spectrum of the School
as possible. The Working Groups have between 20 and
28 members, and constitute a total of 97 faculty.
Add to this the members of the Medical Faculty
Senate Steering Committee and the Faculty - 2000
Steering Committee (31) who have worked on this
project, and an additional 42 volunteers to the
Clinician Educator Track Faculty Working Group, who
were not able to be used. These latter faculty
members could not be accommodated on that Group,
but will be used as "sounding boards" as the
deliberations about the Clinician Educators
progress. Thus, about 173 faculty in the School of
Medicine will, in different forms, be engaged in
the Faculty - 2000 Project. This is a remarkable
14% of the School. The four Working Groups are
described in detail below in the Charges developed
for each by the Faculty - 2000 Steering Committee.
The issues for discussion are not exhaustive, but
designed to provide the Working Groups with some
direction. Hopefully, other issues will emerge
during the inquiry and from the faculty at large.
Each Group has been assigned an Administrative
Assistant. These individuals and their roles are
also described within. These support staff will
contribute significantly to the success of each
Working Group by freeing the co-Chairs to formulate
agenda, organize thoughts, and lead the
discussions. The task of each Working Group
is to identify a set of recommendations at the end
of their inquiry. These recommendations should
represent the strategies and tactics identified by
faculty to assure their continued academic success.
These recommendations may impact School and
University policy, or they may impact University
policies as specified in the Handbook. At this
stage, the faculty needs to identify the ideas that
best assure the success of faculty in fulfilling
their diverse missions and roles. The only
guideline in this process is that the scholarly and
educational excellence of our School and its
faculty be preserved and enhanced, and that this
must be achieved within the context of limited
financial resources. This is a tall order, but we
all have to struggle with it. The recommendations from the
Working Groups will be presented at a School-wide
Retreat to be held in February, 2000. The plans for
the retreat are not yet in place. The Retreat will
give the entire faculty an opportunity to comment
on the recommendations and to raise additional
issues or concerns. The recommendations from the
Working Groups, and the discussions at the Retreat,
will be integrated by the Faculty - 2000 Steering
Committee into a final report, which will be
presented to the Dean. The report will pass through
the normal review process for such documents in the
School of Medicine. We will see what happens then.
What is becoming increasingly clear is that the
magnitude of involvement by faculty in the School
with this Project means that it can not be
summarily rejected. Faculty - 2000 Steering
Committee Purpose: Identify Working Group
Topics Dean's Faculty 2000
Symposium Purpose: Bring to Penn 3-4
Nationally Recognized Speakers to Discuss
Global Issuesof Medical School Faculty
Structure Standing Comm. of
Chairs Purpose:To Provide Consultation to
the Purpose: Working Groups Need
to: --- Establish Background Material on
Topic --- Identify Issues of Concern to
Faculty --- Make Specific Recommendations
in School Wide Retreat in
Winter of 2000 Purpose: Publicly Present Working
Group Position Papers School –
Wide Discussion of Recommendations The Faculty – 2000 Steering
Committee drafted the Faculty – 2000 Mission
Statement in January of 1999. The final content
areas of the Working Groups were yet to be
determined at that time. The themes of the Working
Groups as they evolved are somewhat different from
the expression below in that the Associated
Faculty, other than the Research Track Faculty, are
considered only within the context of other issues.
The specific wording of the Statement was not
changed to reflect this difference, but
nevertheless continues to capture the spirit of the
Project. Profound changes in the delivery
of health care during the last decade are
contributing to equally profound changes in the
scholarly, educational and service missions of
Academic Health Systems throughout the Nation. The
University of Pennsylvania Health System has been
remarkably successful in adapting to these changes
and is recognized as one of the leaders in the
Nation in this regard. Nevertheless, these changes
have created extraordinary challenges for its
faculty, academic physicians and non-physician
scientists alike. Perhaps the clearest effect of
the altered environment is the difficulty faced by
junior faculty in meeting the increased demands for
clinical service and extramural funding, while at
the same time maintaining scholarly and educational
productivity. It is thus timely and
important to undertake a review of the role of
faculty within the Health System. This undertaking
is initiated and organized by the Steering
Committee of the Faculty Senate of the School of
Medicine and is known as FACULTY-2000. The goal of this review is to
develop a faculty-based vision for delivering new
knowledge and outstanding health care. This goal is
realized by having faculty explore and identify
strategies and tactics that enable them to achieve
their research and educational missions within the
context of an Academic Health System that requires
outstanding service and management skills in an
environment of constrained financial resources. The
focus of the inquiry will be the mission,
structure, organization and size of the Standing
Faculty (Tenure and Clinician-Educator tracks). Its
scope will include the Associated Faculty (Health
System Physicians and Research track) and the
interactions between Standing and Associated
Faculty and the Clinical Associates in the Health
System. The methodologies that emerge for advancing
faculty missions must work within the framework of
our current faculty tracks and resources. The
inquiry is open to new ideas from all quarters of
the Health System and University, and will engage a
large portion of the School’s faculty over the
next year. The recommendations that emerge will
undergo the normal review processes within the
School of Medicine. V. THE ROLE
OF DEPARTMENT HEADS IN THE FACULTY – 2000
PROJECT Early in the Faculty - 2000
planning stages, it was recognized that interaction
with the Department Chairs in the School of
Medicine would be essential to the success of the
project. The Chairs were approached with the idea
that anything that could enhance the scholarly and
educational activities of their faculty would
facilitate their departmental missions. In
addition, it was noted that they had a vested
interest in the success of the project because
they, too, were faculty members of the School of
Medicine. The viability of the academic character
of the faculty was as much in their interest as it
was in the interest of the rest of the
faculty. The original plan was to see if
a separate Working Group of Department Chairs could
be formed. This Group would consider the same sort
of issues faced by the other Working Groups, but
would examine them from the unique perspective of
the Department Chairs. It was hoped that they might
identify issues confronting faculty that might
otherwise be missed. Moreover, we wanted the
Department Chairs to act as consultants, so that
preliminary ideas emerging from the Working Groups
could be presented to them for comment. By actively
engaging the Department Chairs in the Faculty -
2000 Project, we were conveying to them the
important role they had to play in this
process. In retrospect, this plan was a
bit ambitious. Nevertheless, the Department Chairs
have agreed to participate in the Project by acting
as consultants to the various Working Groups. This
is important because there may be matters that
emerge in the Working Group discussions that could
be fruitfully commented upon by the Department
Chairs. Their preliminary thoughts on various
issues might facilitate the Working Group
discussion considerably. In addition, the
Department Chairs have endorsed the Faculty - 2000
Project, and have contributed a series of
"Operational Principles" which were deemed to be
consistent with the purpose and spirit of the
Project by the Faculty – 2000 Steering
Committee and the Medical Faculty Senate
leadership. The memorandum from Richard
Tannen, M. D. outlining the Operational Principles
follows: E-mail Message From Richard
Tannen, M. D. Dated: March 4, 1999 Jim, The Steering Committee of the
School of Medicine met on March 2, 1999 and
approved the following "Operational Principles for
Faculty 2000". As you will recall, this group was
asked to serve as the Chair group to provide input
into the process. The following were the
recommendations they came up with, which I believe
are consistent with the spirit and direction which
the process has been taking. Please let me know if you
have any questions/concerns about the
above. Dick Early in the planning
stage, it was acknowledged that it would be
beneficial for our Working Groups to consult with
senior leadership from peer institutions who are
grappling with similar problems. The Dean’s active
participation is critical to this endeavor. In
addition to his positions as a senior administrator
and tenured faculty member, he is a highly
respected leader in the national Medical School
scene. Additionally, this process would gain
exposure to the University, and create a forum in
which Penn’s faculty, through an exchange of
ideas, were actively addressing those vexing
faculty-related issues currently plaguing Schools
of Medicine across the country. The Dean accepted
this role, and the planning of the Symposium was
set in motion. It was decided that four
individuals from "sister" institutions (private
medical schools with a composition and size similar
to our own) would be invited to participate in the
Symposium. The guests would be invited for a
day-and-a-half visit, comprised of three major
events. On November 4th, a working
dinner will be held in the Faculty Lounge of the
new Biomedical Research Building II/III. An
overview of the Faculty – 2000 Project will be
provided, followed by presentations by Chairs of
the Working Groups describing the issues they are
deliberating and their progress to date. The Symposium will take place on
November 5th in the large lecture
theater of the Biomedical Research Building II/III,
and will be open to the entire Medical School
faculty and interested administrators in the
Medical School and Health System. Dean Kelley will
moderate. Each of the guest speakers are asked to
make a 40 – minute presentation followed by
ample time for questions. The presentations will
address how our sister institutions are dealing
with the same problems we are facing here at Penn.
From the point of view of the Faculty – 2000
Project, we are primarily interested in comparing
our approach to faculty problems with those taken
by other schools. After the Symposium, there will
be a boxed lunch in the Faculty Lounge for the
guest speakers, the members of the Working Groups,
Medical Faculty Senate Steering Committee and the
Faculty – 2000 Steering Committee. The day
will conclude with a Panel Discussion consisting of
our guest speakers and the Chairs of the Working
Groups. The Chair of the Faculty – 2000
Project will moderate the discussion. Members of
the four Working Groups are invited to this event,
and will be encouraged to participate in the
discussion. In this format, it is hoped that
details will be revealed of how faculty in other
institutions are coping with the issues the Project
is addressing. The Panel Discussion will end around
4:00 PM. The invited speakers are
identified below followed by a detailed schedule of
the planned events. INVITED GUEST
SPEAKERS: EUGENE D. BRAUNWALD,
M. D. Vice President for
Academic Programs, LYNN A. CORNELIUS,
M.D. Associate Dean for
Faculty Affairs, EDWARD D. MILLER,
M.D. Dean, Johns Hopkins
School of Medicine, HERBERT PARDES, M.D.
Vice President for
Health Sciences Thursday, November
4th 4:00 P. M. Arrival of Guests:
Eugene D. Braunwald, At airport and/or
30th Street Train Station, the guests
will be picked-upby our driver, and transported to
the Four Seasons Hotel where they will be staying
overnight. 5:45 PM Transport from hotel to
the University of Pennsylvania. 6:00 P. M. Cocktails in Faculty
Lounge, 14th Floor, Biomedical
Research Building II/III. 6:45 P. M. Dinner in Faculty
Lounge, 14th Floor, Biomedical
Research Building
II/III. The dinner is
attended by our four guest speakers, the
leadership of the Medical and University
Faculty Senates, the Dean, and Senior Vice
Dean of the School of Medicine,
the co-Chairs of the Faculty - 2000
Working Groups, and the Administrative
Assistants to the Faculty – 2000
Project. 7:45 P. M. An overview of the
Faculty – 2000 Project together with
Presentations by each Working Group (Each
to be 10 minutes in length). 8:30 P. M. Open discussion for
approximately 20 minutes as well as
"charge" to speakers for next day’s
presentations. Finish At approximately 9:00
P. M. to 9:15 P. M., guests are returned
to the Four Seasons Hotel. Friday, November
5th 7:45 A.M. Guests checkout of
hotel and are picked-up at hotel for
transportation to the
University. 8:00 A.M. Continental Breakfast
in Lobby of Biomedical Research Building
II/III 8:30 A.M. Dean’s Faculty
– 2000 Symposium. Open to all School
of Medicine Faculty - Auditorium, Ground
Floor, Biomedical Research Building
II/III 8:30 – 8:35
A.M. Introductory
Remarks, James C. Saunders,
Ph.D.,Chair,Faculty – 2000
Project Moderator: William N. Kelley, CEO,
University of PennsylvaniaHealth
System 8:35 – 9:15
A.M. Eugene D. Braunwald, M.
D., Harvard University 9:15 – 9:25
A.M. Questions 9:25 – 10:05
A.M. Lynn A. Cornelius, M.
D., Washington University 10:05 – 10:15
A.M. Questions 10:15 – 10:55
A.M. Edward D. Miller, M.
D., Johns Hopkins University 10:55 – 11:05
A.M. Questions 11:05 – 11:45 A.M.
Herbert Pardes, M. D.,
Columbia University 11:45 – 11:55 A.M.
Questions 12:00 – 1:15 P.M.
Boxed Lunch in Lounge,
14th Floor Biomedical Research
Building II/III for Guest Speakers,
members ofFaculty – 2000 Steering
Committee, Members of all
Working Groups, and
Medical Faculty Senate
Leadership, and Medical
Faculty Steering Committee 1:30 – 2:45
P.M. Panel Discussion led by
Guest Speakers and Co-Chairs of theFaculty
– 2000 Working Groups in Auditorium,
Biomedical Research Building II/III .
Members of all Working Groups and the
Faculty – 2000 Steering Committee are
invited toattend and participate in
discussion. 4:00 P.M. End of Symposium.
Guests are transported to their places of
departure. Clause, Bonnie T.
clauseb@mail.med.upenn.edu Mulhern, Victoria
vmulhern@mail.med.upenn.edu Napier, Dana
djnapier@mail.med.upenn.edu Zinser, Janet
janetz@mail.med.upenn.edu The Administrative Assistants
provide support for each of the Working Groups.
These four individuals occupy positions of
considerable importance within the School of
Medicine and the Health System. They have
well-developed networks which will prove invaluable
in the process of seeking information needed for
the deliberations of the Working Groups. The
Administrative Assistants also provide important
organizational support for the Co-Chairs in the
preparation for meetings and the identification of
agendas. At each meeting they will take minutes,
which in their "raw" form will be distributed via
E-mail to all members of the Working Group. From
these minutes, an "Executive Summary" will be
prepared in which the main points of the discussion
are succinctly organized in bullet format.
Sufficient detail will be provided so that the
flavor of the discussion and the direction of the
debate are clearly evident. When the Chairs of the
respective Working Groups have reviewed this
summary, it will be sent to the entire faculty as
an E-mail bulletin. Comments and suggestions will
be invited from the faculty on these summaries. The
Assistants will also keep track of proposed
recommendations as they emerge, and will bring them
before the Co-Chairs when clarification or
additional details are needed. The Administrative
Assistants will initially prepare the draft of the
final report of the Working Group. They will
further oversee the preparation of the final
recommendations. The Medical School has
generously allocated a sufficient portion of these
individuals’ activity to serve in this
important and essential capacity for the Faculty
– 2000 Project. The leadership of the Medical
Faculty Senate is very grateful to the School and
the Dean for this support. Over a seven-month period, the
entire work of the Faculty – 2000 Steering
Committee was conducted by E-mail. This was truly
an electronic committee. Although the
Committee’s work might have been better
conducted in another format, it, nevertheless, was
a success. A number of lessons were learned, among
them that E-mail is a marvelous tool for generating
an open, unrestrained discussion, especially among
very busy people, who are difficult to get together
at any given time. The use of E-mail communication
will be employed with our Working Groups to
communicate minutes of the meetings to all members
so that those not in attendance can be kept
apprized of the progress. More importantly, an
Executive Summary of the meetings in a more
condensed form will be forwarded to the entire
faculty. At the end of every one of these
Summaries, a request for comments will be made. A
special Faculty – 2000 E-mail address has been
established so, with the click of a button, faculty
can reply to the specific Working Group Summary. In
this way, we hope to engage the entire faculty. The
leadership of the Medical Faculty Senate does not
care where the ideas come from, only that the best
ideas be generated. IX. CHARGE TO
THE CLINICIAN EDUCATOR TRACK AND FACULTY
WORKING GROUP The memorandum below lays out
the charge to the Clinician Educator Track and
Faculty Working Group as developed by the
Faculty-2000 Steering Committee in late March. It
sketches in broad terms how the Working Group might
proceed, identifies some of the central issues for
discussion, and the recommendations that should be
prepared at the end of the process. MEMORANDUM March 19, 1999 TO: FACULTY - 2000 Steering
Committee From: Jim Saunders Subject: Clinician Educator
Track and Faculty Working Group This memorandum outlines the
Charge to the Clinician Educator (CE) Track and
Faculty Working Group (WG). CLINICIAN
EDUCATOR WORKING GROUP MEMBERSHIP AS OF SEPTEMBER
1999 CO-CHAIRS: Hansen-Flaschen, John M.
D. jflash@mail.med.upenn.edu Department of Medicine, Tomaszewski, John M. D.
tomaszew@mail.med.upenn.edu ADMINISTRATIVE
ASSISTANT: Mulhern, Victoria
vmulhern@mail.med.upenn.edu MEMBERS: Ballard, Roberta M. D.
ballardr@email.chop.edu Brennan, Patrick J. M. D.
brennanp@mail.med.upenn.edu Bridges, Charles M. D.
cbridges@mail.med.upenn.edu Ende, Jack M. D.
ende@mail.med.upenn.edu Fisher, Judith M.D.
judithf@mail.med.upenn.edu Goldfarb, Stanley M. D.
sgoldfar@mail.med.upenn.edu Guerry, Dupont M. D.
guerry@mail.med.upenn.edu Hadley, Trevor Ph.D.
trevor@cmhpsr.upenn.edu Hirshfeld, John M. D.
hirshfel@mail.med.upenn.edu Kelley, Mark M. D.
kelleym@mail.med.upenn.edu Kochman, Michael M. D.
kochman@mail.med.upenn.edu Kolansky, Daniel M. D.
kolansky@mail.med.upenn.edu Liu, Grant M. D.
gliu@mail.med.upenn.edu Mastroianni, Luigi M. D.
lmastroianni@obgyn.med.upenn.edu McCarthy, David M. D.
davidmcc@mail.med.upenn.edu Mollman, Joan M. D.
jmollman@mail.med.upenn.edu Seltzer, Vivian Ph.D.
seltzer@caster.ssw.upenn.edu Spinner, Nancy Ph.D.
spinner@mail.med.upenn.edu Steinberg, David M. D.
drsteinb@mail.med.upenn.edu Szapary, Phillipe M. D.
szapary@mail.med.upenn.edu Szuba, Martin M. D.
mszuba@mail.med.upenn.edu Tino, Gregory M. D.
gregtino@mail.med.upenn.edu Volpe, Nicholas M. D.
nickvolp@mail.med.upenn.edu Weber, Randal M. D.
rsweber@mail.med.upenn.edu Weinstein, Gregory M. D.
gsw@mail.med.upenn.edu Zager, Eric M. D.
zager@mail.med.upenn.edu The memorandum below lays out
the charge to the Tenure Track and Faculty Working
Group as developed by the Faculty - 2000 Steering
Committee in late March. It sketches in broad terms
how the Working Group might proceed, identifies
some of the central issues for discussion, and the
recommendations that should be prepared at the end
of the process. MEMORANDUM March 20, 1999 To: Faculty - 2000 Steering
Committee From: Jim Saunders Subject: Charge to the Tenure
Track and Faculty Working Group The Charge to the Tenure Track
and Faculty Working Group (WG) should be structured
in the following way. TENURE
FACULTY WORKING GROUP MEMBERS AS OF SEPTEMBER,
1999 CO–CHAIRS: Sterling, Peter Ph.D.
peter@retina.anatomy.upenn.edu Rubin, Harvey M.D./Ph.D.
rubinh@mail.med.upenn.edu ADMINISTRATIVE
ASSISTANT: Zinser, Janet
janetz@mail.med.upenn.edu MEMBERS: Brayman, Kenneth M.D.
brayman@mail.med.upenn.edu Bucan, Maja Ph.D.
bucan@pobox.upenn.edu Costarino, Andrew M.D.
costarin@mail.med.upenn.edu Cox, Malcolm M.D.
mcox@mail.med.upenn.edu Detre, John M.D.
detre@mail.med.upenn.edu Dinges, David Ph.D.
dinges@mail.med.upenn.edu Douglas, Steven M.D.
douglas@email.chop.edu Feldman, Harold M.D./MSCE
hfeldman@cceb.med.upenn.edu Felix, Carolyn M.D.
felix@kermit.oncol.chop.edu Goldman, Yale M.D./Ph.D.
goldmany@mail.med.upenn.edu Guttentag, Susan M. D.
guttentag@email.chop.edu Hess, Marilyn Ph.D.
hess@pharm.med.upenn.edu Kimmel, Stephen M.D./M.S.
skimmel@cceb.med.upenn.edu Kleyman, Thomas M.D.
kleyman@mail.med.upenn.edu Kopf, Gregory Ph.D.
kopf@mail.med.upenn.edu Lee, Virginia Ph.D.
vmylee@mail.med.upenn.edu O’Rourke, Donald
M.D. orourked@mail.med.upenn.edu Salzberg, Brian Ph.D.
bmsalzbe@mail.med.upenn.edu Sehgal, Amita Ph.D.
amita@mail.med.upenn.edu Simmons, Rebecca M.D.
rsimmons@mail.med.upenn.edu Stevens, Rosemary Ph.D.
rstevens@sas.upenn.edu Wand, A. Joshua
Ph.D. wand@mail.med.upenn.edu Weissman, Drew M.D.
dreww@mail.med.upenn.edu XI.
WORKING GROUP ON ISSUES OF CONCERN TO FACULTY
WITH SPECIAL
OPPORTUNITIES The memorandum below lays out
the charge to the Working Group on Issues of
Concern to Faculty with Special Opportunities as
developed by the Faculty - 2000 Steering Committee
in late March. It sketches in broad terms how the
Working Group might proceed, identifies some of the
central issues for discussion, and the
recommendations that should be prepared at the end
of the process. MEMORANDUM March 21, 1999 To: Faculty - 2000 Steering
Committee From: Jim Saunders Subject: Charge to the Working
Group on Issues of Concern to Faculty with Special
Opportunities The Charge to this Working Group
(WG) should be structured in the following
way. SPECIAL
OPPORTUNITY WORKING GROUP MEMBERS AS OF SEPTEMBER
1999 CO-CHAIRS: Driscoll, Deborah M. D.
driscold@mail.med.upenn.edu Johnson, Jerry M.D.
jcjohnso@mail.med.upenn.edu ADMINSITRATIVE
ASSISTANT: Napier, Dana
djnapier@mail.med.upenn.edu MEMBERS: Abbuhl, Stephanie M. D.
abbuhl@mail.med.upenn.edu Battistini, Michelle M.
D. mbattistini@mail.obgyn.upenn.edu Bernhard, Eric Ph.D.
bernhard@mail.med.upenn.edu Catella-Lawson, Francesca
M.D. francesca@spirit.gcrc.upenn.edu Gaiser, Robert
gaiserr@mail.med.upenn.edu Greenberg, Joel Ph.D.
greenberg@cvrc.med.upenn.edu Jensen, Pamela Ph.D.
jensenp@mail.med.upenn.edu Kinosian, Bruce M.D.
brucek@mail.med.upenn.edu Leonard, Debra M.D./Ph.D.
debraleo@mail.med.upenn.edu Nicolson, Susan M.D.
nicolson@email.chop.edu Palevsky, Harold M.D.
palevsky@mail.med.upenn.edu Robinson, Michael Ph.D.
robinson@pharm.med.upenn.edu Silberg, Debra M.D./Ph.D.
silberg@mail.med.upenn.edu Spratt, Kelly Anne
DO,FACC kspratt@mail.med.upenn.edu Steinberg, Annie M.D.
drannie@mail.med.upenn.edu Vandenborne, Krista Ph.D.
kvandenb@mail.med.upenn.edu Weinstein, Susan Pae M.
D. weinstei.@oasis.rad.upenn.edu The memorandum below lays out
the charge to the Senior Faculty Working Group as
developed by the Faculty - 2000 Steering Committee
in late March. It sketches in broad terms how the
Working Group might proceed, identifies some of the
central issues for discussion, and the
recommendations that should be prepared at the end
of the process. MEMORANDUM March 21,
1999 To: Faculty - 2000 Steering
Committee From: Jim Saunders Subject: Charge to the Working
Group on Senior Faculty The Charge to the Working Group
(WG) on Senior Faculty should be structured in the
following way, and, on the whole, it is much
simpler than those for the other WGs. SENIOR
FACULTY WORKING GROUP MEMBERS AS OF SEPTEMBER,
1999 CO–CHAIRS: Goldfine, Howard Ph.D.
goldfinh@mail.med.upenn.edu MacGregor III, Rob Roy
M.D. macgregr@mail.med.upenn.edu ADMINISTRATIVE
ASSISTANT: Clause, Bonnie T.
clauseb@mail.med.upenn.edu MEMBERS: Berman, Peter M.D.
berman@email.chop.edu Blasco, Luis M.D.
lblasco@mail.obgyn.upenn.edu Chalian, Ara M.D.
chaliana@mail.med.upenn.edu Chin, Alvin M.D.
chinalvi@mail.med.upenn.edu Conahan, Thomas M.D.
tconahan@mail.med.upenn.edu Cope, Constantin M.D.
cope@oasis.rad.upenn.edu Davies, Helen Ph.D.
daviesh@mail.med.upenn.edu Downes, John M.D.
downes@email.chop.edu Edwards, McIver M.D.
mwedw@mail.med.upenn.edu Elder, David MB, ChB,
FRCPA elder@mail.med.upenn.edu Esterhai, John M.D.
esterhai@mail.med.upenn.edu Evans, Audrey M.D.
evansa@email.chop.edu Kozart, David M.D.
kozart@mail.med.upenn.edu Lindstrom, Jon Ph.D.
jslkk@mail.med.upenn.edu Nass, Margit Ph.D.
margitn@mail.med.upenn.edu Potsic, William M.D.
potsic@email.chop.edu Ramsden, Elsa Ed.D.
ramsden@mail.med.upenn.edu Solomon, David
M.D./Ph.D. dsolomon@mail.med.upenn.edu Steinberg, Marvin M.D.
marvin@mail.med.upenn.edu Stunkard, Albert M.D.
stunkard@mail.med.upenn.edu HOWARD C. HERRMANN, M.D.
(Cardiology) Chair: 1999 - 2000 DUPONT GUERRY, M. D.
(Hematology/Oncology) Chair: 1996 - 1997 JOHN HANSEN-FLASCHEN, M.D.
(Pulmonary/Critical Care) Chair: 1997 -
1998 JAMES C. SAUNDERS, Ph.D.
(Otorhinolaryngology) Chair: 1998 - 1999 ALAN WASSERSTEIN, M. D. (Renal
Division) Chair Elect: 2000 – 2001 XIV.
MEMBERS OF THE 1999 – 2000 MEDICAL
FACULTY SENATE
STEERING COMMITTEE Secretary: David A. Asch, M. D.
Medicine Secretary Elect: Joan M.
VonFeldt, M.D. Medicine Basic
Sciences: Roland G. Kallen, M.D./Ph.D.
Biochemistry/Biophysics Clinical
Sciences: Stephanie B. Abbuhl, M.D.
Emergency MedicineKevin D. Judy, M.D.
Neurosurgery At –
Large: Jonathan A. Epstein, M.D.
Medicine Chair: JAMES C. SAUNDERS, Ph.D.
(Otorhinolaryngology) ARTHUR K. ASBURY, M. D.
(Neurology) CAROL DEUTSCH, Ph.D.
(Physiology) DAVID E. ELDER, M. D.
(Pathology) JACK ENDE, M.D. (Medicine,
Presbyterian) DUPONT GUERRY, M. D.
(Hematology/Oncology) JOHN HANSEN-FLASCHEN, M.D.
(Pulmonary/Critical Care) HOWARD C. HERRMANN, M.D.
(Cardiology) FREDERICK S. KAPLAN, M. D.
(Orthopedic Surgery) THOMAS W. LANGFITT, M. D.
(Management) (Ex Officio) S. BRUCE MALKOWICZ, M. D.
(Urology) JOAN MOLLMAN, M.D.
(Neurology) VICTORIA MULHERN (Faculty
Affairs) PETER C. NOWELL, M. D.
(Pathology) ALAN C. ROSENQUIST, Ph.D.
(Neuroscience) VIVIAN C. SELTZER, Ph.D. (Human
Development and Behavior) ROSEMARY STEVENS, Ph.D. (History
and Sociology) |
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H E R E I S T H E V O I C E O F T H E F A C U L T Y |
This was scanned from Dr. Eisenberg’s original FAXed text, so there may be some mistakes. It is an entertaining article, quite insightful, yet remarkably germane to our Faculty - 2000 Project. Jim Saunders Leon Eisenberg, M.D. Presley Professor of Social Medicine And Professor of Psychiatry, Emeritus Harvard Medical School Department of Social Medicine Boston Revision: May 24, 1999 Presented at a Special Meeting of May 20-23, 1999
I have entitled this address "Where Is the Voice of the Faculty?" to convey my dismay at how the prerogatives once exercised by faculty have been almost entirely usurped by administrators with relatively little protest from faculties as Academic Health Centers (AHCs) try to cope with a competing "medical market place." I considered another title for this talk: "Who Is Minding the Store?" to convey my dismay at the wrong-headed decisions made by AHC administrators without participation by faculty, and, so far as I can tell, without much oversight by any other group. Boards of Trustees, supposed to function as fiduciaries for the public, seem to be asleep at the switch, responding only after the train wreck, as seems to have been the case in the Allegheny fiasco. With neither question do limply that a more central role for faculty would, in and of itself, have assured a better outcome. During the past fifty years, all of us, faculty, administrators and trustees alike, have fed the exponential increase in health care costs; in the process, we created a pot of funds irresistible to corporate entrepreneurs. In the era of cost-plus reimbursement, neither physicians, nor administrators, nor trustees spoke up for the public interest to exercise restraint on growth. The Willie Suttons of Wall Street saw money for the taking in health care; and take it they did. They were able to siphon off tens of billions of dollars. Our failure to seek common ground with our patients allowed investors and managers to take charge of the health care system. There is simply no way for us to defend patient care, teaching and research if we join the battle with the entrepreneurs on their turf and on their terms. Simply put, health as a social good cannot be allocated effectively by the invisible hand of the market Do I exaggerate? Last week, under the headline "Oxford Health Turnaround is Still a Work in Progress," the New York Times reported that Oxford, to quote the story, "has backed away from the brink of bankruptcy by shedding thousands of loss-making members and raising premiums"(Freudenheim 1999). For those who need a translation, "loss-making members" means sick people. Who were shed? Medicaid and Medicare enrollees, the poor and the elderly, the vulnerable citizens that community-rated insurance should shelter. Market Medicine Fifteen years ago, in a prophetic paper, John McKinlay, a sociologist, and John Stoeckle, an internist, wrote about the "proletarianization" of the American physician That is, as the doctor loses control of the means of production, he becomes a wage laborer subject to the control and incentives of the owner-managers of the commodified health system Admittedly, we are well-paid proletarians, but we have lost control of our working conditions. With growth in size of the ARC, organizational centralization has become more prominent; decision-making is ever further removed from the sites where physicians care for patients. Physician-executives become more like executives and less like physicians as they rise in the hierarchy. Tics between the medical school, the university and the AHC are becoming more tenuous as some schools sell off their teaching hospitals and other hospitals expand into service Systems. Hospital behemoths, too large to be governed efficiently in the first instance, "merge" - whatever merge means in one or another case - into even larger entities.
How simple the past now seems! If my memory does not betray me, I dimly recall that the Massachusetts General Hospital was governed by a General Director who was expected to review major policy decisions weekly with a General Executive Committee on which all service chiefs were represented, and with an Executive Committee of the Board with elected staff representatives. It was no love feast; there were fierce arguments; I lost a number of battles; but all voices were heard. How quaint that memory seems today!
Department chairs no longer control faculty appointments. When the CEOs of the hospital corporation buy up physician practices and community hospitals, the doctors whose practices are acquired automatically receive faculty appointments. Apart from their varying degrees of competence as clinicians, many chose the practice mode because they lacked interest in, and skill at, teaching. Providing nominal faculty appointments for them dilutes the meaning of such appointments. It adds to the unfairness of exacting teaching commitments from career teachers who carry the burden at personal cost. Decisions about salaries and benefits, once (more or less) the prerogative of the chair and executive committee of each department, now are made by the executives of the hospital physicians' organization, who represent the corporate interest in keeping the bottom line in the black rather than in achieving academic, clinical, or research goals. Some wag recently described a Department Chair as a person who gets the bad news from the CEO and passes it on to the faculty.
Faculty find themselves over-burdened and constantly busy at paper work. Morale at teaching hospitals is lower than I can recall during my 50 years in academic medicine at Penn, Hopkins and Harvard. Clinicians Complain that the satisfactions they sought in choosing academic careers are eroding. To my dismay, colleagues report that they are happy none of their children are going into medicine! My wife and I are happy that three of our children have done so. I am astonished by how many physicians in their 50's and early 60's are longing to retire from clinical medicine once financing permits. What a striking change! When I was on the General Executive Committee of the Massachusetts General Hospital in the early 1970s, the problem we faced at all too frequent intervals - was how to persuade superannuated colleagues, whose skills were failing, to give up active practice.
Demoralization is virtually universal, although each medical community has its own laments. At Harvard Medical School, the fission and fusion of its teaching hospitals into two mega-behemoths and several residual free-standing independents competing with each other, has destroyed excellent joint fellowship and service programs and has replaced collegial relationships with strife over, forgive the despicable phrase, "covered lives."
Clinicians complain that they can no longer offer their patients the time necessary to make them active participants in their own care. They no longer have the "luxury" of consulting with colleagues about the complexities and challenges of the clinical conundrums they face. Because they are expected to generate clinical income, the time they devote to teaching is regarded as a debit item by the Division Chief. Indeed, although medical schools give more lip service to the importance of teaching for promotion than they did a decade or two ago, the one unequivocal recognition of time spent teaching is a smaller check at the end of the pay period because clinical income has declined. Teaching hospitals are hemorrhaging cash; clinicians are being pressed to bring in more patient income. The messages are direct, not subtle: teach less; teaching is not remunerative; see more patients per clinical session; we have to remain competitive.
Just how widespread these concerns are among faculty and students evident from a study reported in the March 25th issue of The New England Journal. Simon and his colleagues (1999) surveyed a national sample of medical students (506), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S medical schools to determine their views of managed care. Expressed attitudes were uniformly negative. A sizeable majority rated fee-for-service medicine better than managed care in terms of patient access, ethics, doctor-patient relationship, continuity of care, chronic illness care, and care at the end-of-life. Faculty members and deans reported that managed care had reduced the time available for teaching and research and had reduced income.
Physician disparagement of the extent of access, continuity, and quality of care for patients with chronic illness in MCOs echoes the complaints of their patients. Medicare patients in MCOs disenroll at high rates once they become sick and find out that services are difficult to obtain, a phenomenon Morgan and his colleagues (1997) have labeled "The HMO Revolving Door - The Healthy Go in and the Sick Go Out."
Faculty have lost control but so has Academic Health Center management. To increase market share in dealing with insurers, academic medical centers went into a virtual frenzy of buying up medical practices. Sale prices included a lump sum up-front for practice size plus several years of salary guaranteed at about what the physicians had been earning. In just about every venue where that strategy has been adopted, the result has been a net loss of tens of thousands of dollars per doctor per year for the duration of such contracts. Why? For one thing, doctors who had been hustling in order to maintain their incomes in the face of the fee reductions from third party payers slowed down their pace once income was not at risk For another, loss of control over thc practice environment by the imposition of central management and billing alienated the practitioners and introduced new inefficiencies. How did so many smart medical executives buy the Brooklyn Bridge at the same time'? As best as it can be reconstructed, it was the result of advice from management consulting firms with no understanding of medical practice.
As I see it, "we" are becoming clones of "them" in trying to compete in a winner-take-all poker game where they control the cards. They screen out the sick and the poor; they abjure teaching and research; they buy political influence in Congress and State Houses; and they wrap themselves in the American flag as they trumpet the virtues of the market-place - that is, so long as they continue to be winners. If profits thin out, it's off to selling used cars again!
There is simply no way at all over the long run that an academic health science center can maintain excellence in clinical care, serve impecunious patients, teach students and residents, advance the science of medicine and compete for price with hospitals that do not teach or do research and are willing to provide care no better than they need to, so long as they can do so at a profit (36). What is the evidence for my claim?
Analysis of extramural grant awards reveals an inverse relationship between penetration of the "medical market" by managed care organizations and the likelihood that medical schools situated within those "market areas" compete successfully for NIH awards (37). Potential investigators in such schools have less "protected time" because they are obliged to carry greater patient care responsibilities (38). Competition in health care markets squeezes out funds AHCs have (in the past) earmarked to support research. It reduces the time practitioners give to charity care (Fletcher 1999). Institutional support for unsponsored research in the most competitive markets was less than half that in the least competitive markets. Costs at academic medical centers are about 44% higher than those for non-teaching hospitals because of teaching intensity (39). Without substantial subsidies from an all-payer fund, academic medical centers will be non-starters in a competitive medical market place.
Bill Danforth, Chairman of the Board of Washington University at St. Louis, has reminded us that universities are not business enterprises:
"Some in business foresee a work force with loose, and even temporary, ties to organizations. Universities spring from a different culture. Faculty are citizens of their institutions as well as employees, citizens who deserve loyalty of the institution even as the institution asks for theirs ..." "Whether universities adapt successfully to the present environment will. in my view, depend on whether individual faculty members correctly read the needs of the era and take personal responsibility for the success of their institutions. I can think of nothing more important or rewarding than to help preserve our research universities for the next generation so that they may continue to represent the highest aspirations of the American people."
Bill Danforth, you will have noted, emphasizes reciprocity: loyalty of institutions toward faculty and loyalty of faculty toward their institutions. Loyalty is in short supply today.
As the behavior of the Academic Health Center emulates that of the MCO, is the game worth the candle? There is an old story of a nudist traipsing through the streets of London. Espying him from a distance, a Bobby shouted Out: "Halt!" The nudist began to run. The Bobby pursued him as fast as he could but began to fall behind because of his heavy equipment. As he discarded his helmet, his billy club, his overcoat his speed increased. When all his clothes were off, he caught the miscreant. However, it was no longer clear who was upholding law and who was violating it. Are "we" on our way to such a victory?
The Incompatibility of the World of Medicine with the World of Business
In the first book of The Republic. Socrates avers that:
"Medicine does not consider the interests of medicine, but the interest of the body.. no physician, insofar as he is a physician, considers his own good in what he practices, but the good of his patient..."
Socrates knew that physicians needed (and wanted) to be compensated. The art of medicine, he noted, is accompanied by another art; "the art of pay." Sadly enough, all of us know physicians far more dedicated to the art of pay than to the art of medicine. But the fact that some are corruptible does not alter the ideal physicians should follow. Socrates added that medicine is "not the art of receiving pay (simply] because a man takes fees when he is engaged in healing."
Contrast that ideal with the pragmatics of the market place, as enunciated by the high priest of laissez~faire capitalism, University of Chicago Professor Milton Friedman (1). He proclaims that:
"Few trends could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much monev for their stockholders as possible." (boldface added) (p.133).
Pragmatism is replacing idealism in the Academic Health Center. What works, we are told, is what matters. Some colleagues see nothing wrong with a market economy in medical care. They have become as adept at referring to "covered lives," "consumers," and "providers" as my generation was at using the quaint terminology of "patients" and "doctors." Words matter; words embody values Consumers had best beware of sellers; patients must be able to trust doctors. Providers are adepts of the art of pay, physicians adepts of the art of medicine.
I make no bones about it. The Surgeon General of the United States should be urged to stamp every investor-owned managed care policy with the warning: "For-profit care is dangerous to your health." If that statement sounds like hyperbole, I remind you that Columbia-HCA, the largest for-profit hospital chain1 had to sack its CEO in response to a federal criminal investigation of its practices (28, 29). An FBI affidavit charges that Columbia/FICA defrauded Medicare of tens of millions of dollars through its home health operations (30). The corporation maintained two sets of books, one for its own accounting purposes and a second set to justify overcharges to the government. It pressured its doctors to invest in its hospitals so they would have a financial stake in referrals; it provided cash bonuses to its executives if they met financial targets (31,32).
The most recent scenario in the spreading saga of mismanagement and corruption is the bankruptcy of the Allegheny Health Systems (AHS) and its captive medical school, the grandly named "Allegheuy University of the Health Sciences." In the year before the collapse, Allegheny's top three officers received $ 1 million or more in annual salary. Nineteen of the 100 best paid health executives in the Philadelphia area worked for AHS, fourteen of them earning more than $500,000 each.
The CEO of AHS, S-S. Abdelhak, sent a memo to his top lieutenants "to remove up to $70,000,000 from Philadelphia area endowments to pay bills; they were to borrow from "various temporarily restricted endowments" and use the money "for cash needs." Just how much was taken illegally from endowment income is still being determined. Why were there no whistle blowers? Hospital executives, academic administrators and key faculty were paid so well they kept their mouths shut!
Where were the Trustees, the representatives of the public interest, while the executives who kept purchasing new hospitals enriched themselves with large salaries? The tale should give us all pause as our own institutions buy up hospitals and practices at a loss, add administrative layers and usurp faculty prerogatives. In fairness, the Allegheny trustees did pay some attention to what was happening. In the weeks before the system filed for bankruptcy, it quadrupled the value of liability insurance policies covering its Board of Directors and system officials (Goldstein 1998). Newspapers reported that loans from Mellon banks were repaid in the months before bankruptcy. It is, undoubtedly, a coincidence that several Mellon bankers are on the Allegheny Board.
The "Good Old Days" Were Not Good for Patients
This is not a nostalgic plea for the resurrection of fee-for service medicine. The "good old days" were not good old days at all for far too many patients. Alone among industrialized countries (42), the United States has tolerated and continues to tolerate large numbers of people who have no health insurance (currently estimated at 45 million) or who are underinsured (29 million) Eleven million of the uninsured are children (43). Those children are twice as likely to have no regular physician and are four times more likely to go without needed care than children with insurance (44). In Uwe Reinhardt's (45) trenchant words: "The United States ... openly countenance(s) the practice of rationing health care for millions of American children ... by the parents' willingness and ability to procure charity care in their role as health care beggars."
The way medical care had been provided under fee-for-service was skewed toward doing too much and too often by a reimbursement scheme which systematically undervalued cognitive services and disproportionately rewarded procedures. The cost of care rose at an insupportable rate. It had been just under 6% of the GDP in 1965; by 1997, total health care outlays had risen to about 14% of the GDP (52). The sky-rocket was fueled by fee-for-service reimbursement for physicians and cost-plus reimbursement for hospitals. Neither academics nor practitioners complained until the health system was so awash in money that entrepreneurs, looking for easy ways to enrich themselves, came upon the new source. Now, managers reign supreme; doctors have become workers in "care" factories. Plans grow richer - and doctors get bonuses for withholding care. Trust in doctors, a key ingredient in care, is being eroded.
The Impending Demise of For-Profit Managed Care Radical change is on its way. The for-profit fantasy of fat profits and low costs has burst. The large sums squeezed out of the system have proved to be one-time things based on cutting back excess bed capacity, reducing physician/patient ratios and controlling referrals and bed use. Profits have fallen; bankruptcies are on the increase; credit ratings are lower. Just one week ago, the Boston Globe reported (Pham 1999) that all of this state's major health insurers reported operating losses for the three months of this year; the largest, Harvard Pilgrim Health Care, posted a $22 million loss. All estimate premium increases of 5 to 10%, however, with no plans to pay their doctors more. Several large physicians groups, Apex in Portsmouth, Nil, and Partners in Boston have cancelled contracts with Tufts Health Plan.
The much-vaunted boast of MCOs as moderators of rising costs of health care has turned hollow. Spending reached one trillion dollars in 1997. Once again, it is growing faster than the rest of the economy; at present rates, it is projected by the Health Care Financing Administration to reach $2.1 trillion, or 16.6% of the UDP, by the year 2002 (59). At the same time, insurance coverage is eroding; the proportion of Americans without insurance increased from 14.2% in 1995, to 15.3% in 1996 and 16.1% in 1997; the number who are underinsured grows even faster (60). Surely, this is intolerable and change will follow. What is not self-evident is what will be left in its wake. The shape of the future will depend in part on whether we continue to emulate business tactics or join forces in a coalition to support the health of the public.
Having cited The Republlc, let me turn to The Laws; that is, with Plato's description of commodified care. Plato contrasts two categories of doctors, slave doctors and free doctors;
"Slaves -. are almost always treated by other slaves who either rush about on flying visits or wait to be consulted in their surgeries. This kind of doctor never gives any account of the particular illness of the individual slave, or is prepared to listen to one; he simply prescribes what he thinks best in the light of experience as if he had precise knowledge, and with the self-confidence of a dictator. Then he dashes off on his way to the next slave-patient, and so takes off his master's shoulders some of the work of attending the sick. The visits of the free doctor, by contrast, are mostly concerned with treating the illnesses of free men his method is to construct an empirical case history by consulting the invalid and his friends; in this way he himself learns something from the sick and at the same time he gives the individual patient all the instruction he can. He gives no prescription until he has somehow gained the invalid's consent; then, coaxing him into continued cooperation1 he tries to complete his restoration to health. Which of the two do you think makes a doctor a better healer, or a trainer more efficient?..."
Which of the two methods is it to be? Will doctors continue to be coerced to prescribe without listening to the sick and to dash off to the next patient at the behest of their masters or will they be able to learn from the sick, obtain their consent, offer instruction, and try to restore those who are ill back to health?
The passage sounds almost prescient but that is because we read ourselves into the language. Having employed overheated rhetoric, let me caution against it. We doctors are not slaves, even if we have lost some degrees of freedom we enjoyed a decade or two ago. We are not proletarians or, if you insist we are, we are remarkably well-paid proletarians.
But we are adrift. We allow ourselves to be buffeted from all sides because we have lost sight of what should be our primary goal: protecting the health of the public rather than protecting the rights or the income of the profession (except in so far as conditions of practice affect health care delivery).
Specialists and generalists continue to fight over income streams; both are manipulated by managers. Clinicians complain that medical school resources are spent on basic scientists; basic scientists lament their lower salaries and their dependence on securing research grants while medical schools expect them to teach but pay them little or nothing for doing it. Yet, all of us, specialists, generalists and basic scientists are committed in principle to medical education, an educational process which requires the best efforts of each of us in a cooperative rather than competitive mode.
By all means, Academic Health Centers should cut out waste and maximize efficiency. We have waited far too long to get on with that job. However, precisely because we teach and because we do research and because we emphasize excellence in clinical care, our costs will remain higher, we cannot compete for price with medical institutions that do none of the three. We have to become political activists to get that message to the general public. We have to make it clear to our elected representatives that medical education and research ought to be supported by a tax on the entire health care system. The more we focus on the health of the public and submerge our parochial interests, the more believable we will be.
Faculty must organize and demand participation in decision-making. Generalists and specialists, basic scientists and clinicians have to confront differences, recognize that all of us are in a common enterprise, and rally to the defense of academic values.
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