How is academic medicine perceived by community practitioners?
Geesh. It's not like they're going to be denied royalties by making their papers available on the internet. If anything, they would get wider recognition. Of course, their methods would also get wider scrutiny as well. Is that what they're afraid of?
Speaking from the perspective of an NIH-funded researcher, I have to ask: Did you ever consider that it's just plain laziness and dislike of yet another administrative hassle to contend with when it comes to grant paperwork that's accounting for the relatively low rate of participation? Think of how you react to just one more little Medicare paperwork requirement, only this time imagine that there's no penalty for ignoring it. (As you know, if you ignore the Medicare reporting, you don't get paid.)
Another factor is that this is a new rule. A lot of researchers don't know any details about it yet. I know I don't. (I suppose when my first manuscript since I got my new NIH grant goes out in the next few weeks I'll have to learn, though.)
Believe me, it almost certainly has nothing to do with "fear" of scrutiny of our scientific method, just human nature coupled with the rather poor job of explaining the rule by the NIH.
I would suggest that public access be taken a step further. Any article that gets press-released to the media should also be available to the public for scrutiny, rather than portrayed in all its glorious positive spin without scrutiny.
In any case, Medpundit's comment got me thinking a bit about how scientists, specifically, academic physicians, the ones who, like me, try to do both basic or translational research and take care of patients. I added the idea to my list of future topics and made a note to try to get to it in the next week or two. Then, while catching up on some medblogs last night, I saw a piece by Kevin, MD in which he dismissed an article describing how academic physicians are feeling stressed out and depressed because they are being pressured to see more patients and generate more clinical income, thus leaving less time for research and teaching with a sarcastic: "All I can say is - welcome to the real world."
Yes, I was annoyed. Dr. Kevin's coment revealed a misconception of what it is like to work in academic medical centers that is common among physicians in private practice, and I decided to take on this topic today rather than just leaving it in my idea list. If you're in academia for any length of time, you become aware that many private practitioners appear to have some sort of stereotypical picture of us academicians sitting in our "ivory towers" sipping lattes, thinking deep thoughts, reading journals, doing seemingly arcane experiments, and not having to deal with the reality or nitty-gritty of the "real world" of taking care of patients. Would that it were so! Although I happen to be very fortunate in having a position where my superiors are very committed to developing clinician-scientists and helping me to protect my research time, mine is an increasingly rare and precious situation in academic medicine. Indeed, I have news for Dr. Kevin: Medical academicians have been operating in the "real world" for at least a decade now. It began back in the 1980's, when HMOs and managed care rose to become the dominant means of paying for health care, and accelerated throughout the 1990's. Before then, it was quite possible for clinical departments to build up impressive surpluses from clinical revenue that they could devote to research because it was generally accepted that academic institutions were more expensive and less efficient because of their research and teaching missions, and insurers and the government were willing to pay extra. However, as the bottom line became more and more important, as insurers and third party payers ceased to differentiate between academic and nonacademic health care providers, the financial squeeze became more and more pronounced. Worse, because of our research and teaching missions, it is almost impossible for academic medical centers to operate as efficiently as private medical centers, putting them at a competitive disadvantage for managed care contracts, as I've been learning from the prolonged discussions of finances and contracts that dominate nearly every Department of Surgery faculty meeting at my institution. Add to that the responsibility as tertiary care centers to accept and care for the sickest (and therefore often less profitable) patients and the frequently high rate of uninsured patients cared for in university medical centers, and it becomes clear that the "ivory tower" of academic medicine is something that has all but faded into legend. (I suspect that, as with all such nostalgia, it was never really as good in academia as the misconception, but I'm too young to have direct experience with the "golden age" of academic medicine.)
Let's look at some of the findings of the study, as helpfully listed at Health Care Renewal (I've also downloaded the study itself):
- Academic physicians spent an average of 40.7% of their time in direct patient care (up from 23% in a 1984 survey).
- Academic physicians spent less time supervising residents and medical students (15.2%) than they did in 1984 (21%), and overall spent only a little over a quarter of their time overall in teaching and related activities.
- Academic physicians spent less time on research (14.7%) than they did in 1984 (29%).
- One fifth (20.5%) of faculty were clinically depressed as indicated by scores of 16 or greater on the CES-D scale.
- About 11% of faculty had moderate to severe anxiety.
- One quarter (25%) of faculty had salaries completely dependent on their "productivity." More than one-tenth (12.6%) of faculty were contemplating leaving their institution within the next few years. Only 18.5% of faculty thought their institutions were in good financial shape.
My friend ended up leaving the institution and becoming a division chief, where he is more clinician and an administrator and less a researcher than he used to be, although fortunately he still does some research (although he hasn't published since 2002). Another friend of mine is struggling with the uncertainty in his department that led to a long gap without a chairman and increasing clinical responsibility. I fear that he will lose his laboratory because, due to his patient care responsibilities, he simply doesn't have the time to keep it running.
So, am I just an ivory tower type whining because the ivory tower isn't so ivory any more? I'll let the reader be the judge. Although--thankfully!--this doesn't apply to me, given my situation, most private physicians are blissfully unaware that at many private universities (and even some state universities) academic faculty are expected to fund their salary and overhead (secretary, office and clinic rent, and nursing support) from their billings alone--just like them. Then, if these faculty have time left over, they're supposed to do research, publish, compete successfully for extramural funding, do high-quality teaching, and provide service to their institution in the form of committee work, while at the same time attending more and more to the same billing headaches that colleagues like Dr. Kevin have been dealing with in running their businesses. Another example comes to mind of a surgeon I knew from my residency days. He did 500-600 major cases a year and still ran a lab. In fact, he's the one who schooled me a bit on the financial realities of being an academic surgeon over ten years ago. It was a real eye-opener that made me seriously consider abandoning my plan to try to practice surgery and run a lab, and, contrary to what some believe, salary support from grants usually doesn't come close to making up the shortfall in billings due to devoting a chunk of time to research rather than caring for patients, except in the cases of superstar researchers with multiple R01 or larger grants.
So why should you (and even Dr. Kevin) be concerned? Like it or not, academic medical centers and medical schools are the incubators from which major breakthroughs emerge and the major source of new physicians. As the authors of the study, while recognizing the limitations of their study, put it:
If, however, our data prove generalizable, today's medical students are interacting with faculty who have less time to teach them, who are increasingly discontent with their jobs, and who, especially among younger faculty, are increasingly depressed. Can such faculty be the role models they want to be, provide a quality educational experience, and be productive, let alone convey the excitement and privilege of caring for patients? And if faculty have less time for research, how will they continue to address the pressing needs for new clinical knowledge, achieve promotions, and to enhance their institutions with their experience and wisdom?
From my perspective, the bottom line is that much of academic medicine is becoming more and more like private practice, leaving physicians increasingly having to deal with all of the headaches of the "real world" in addition to the already formidable task of pursuing science and clinical research and taking care of the sickest patients. One of the attractions of academic medicine was that it partially insulated physicians from the financial and business aspect of medicine. It was a different, but, I would argue, no less arduous career than private practice. If it becomes more arduous than it already was because of financial pressures, more and more young physicians will eschew careers in academia, to the detriment of medical research and the training of the next generation of physicians.