History has shaped academic medical centers (AMCs) to perform $3$ functions: patient care, research, and teaching. These $3$ missions are now fraught with problems because the attempt to combine them has led to such inefficiencies as duplication of activities and personnel, inpatient procedures that could and should have been out-patient procedures, and unwidely administrative bureaucracies.
One source of inefficiency derives from mixed lines of authority. Clinical chiefs and practitioners in AMCs are typically responsible to the hospital for practice issues but to the medical school for promotion, marketing, membership in a faculty practice plan, and educational accreditation. Community physicians with privileges at a university hospital add more complications. They have no official affiliation with the AMC’s medical school connected, but their cooperation with faculty members is essential for proper patient treatment. The fragmented accountability is heightened by the fact that $3$ different groups often vie for the loyalty of physicians who receive research. The medical school may wish to capitalize on the research for its educational value to students; the hospital may desire the state-of-the-art treatment methods resulting from the research; and the grant administrators may focus on the researchers’ humanitarian motives. Communication among these groups is rarely coordinated, and the physicians may serve whichever group promises the best perks and ignore the rest- which inevitable strains relationships.
Another source of inefficieny is the fact that physicians have obligations to many different groups : patients, students, faculty members, referring physicians, third-party payers, and staff members, all of whom have varied expectations. Satisfying the interests of one group may alienate others. Patient care provides a common example. For the benefit of medical students, physicians may order too many tests, prolong patient visits, or encourage experimental studies of a patient. If AMC faculty physicians were more aware of how much treatments of specific illness cost, and of how other institutions treat patient conditions, they would be better practitioners, and the educational and clinical care missions of AMCs would both be better server.
A bias toward specification adds yet more inefficiency.AMCs are viewed as institutions serving the gravest cases in need of the most advanced treatments. The high number of speciality residents and the presence of burn units, blood banks, and transplant centers validate this belief. Also present at AMCs, through less conspicuous, are facilities for ordinary primary care patients. In fact, many patients choose to visit an AMC fr primary care because they realize that any necessary follow-up can occur almost instantaneously. While AMCs have emphasized cutting-edge speciality medicine, their more routine medical services need development and enhancement
A final contribution to inefficieny is organizational complacency. Until recently, most academic medical centers drew the public merely by existing. The rising presence, however, of tertiary hospitals with patient care as their only goal has immersed AMCs in a very competitive market. It is only in the past several years that AMCs have started to recognize and develop strategies to address competition.
The author's attitude toward the inefficiencies at academic medical centers is one of
- Reluctant acquiescence
- Strident opposition.
- agonized indecision.
- reasoned criticism.