Wednesday, January 11, 2006

How is academic medicine perceived by community practitioners?

I sort of feel as though I was being picked on over the last couple of days, while I've been a bit preoccupied. No, not me personally, but academic physicians in general. Actually, it's a bit lonely being an academic physician with a laboratory and a practice blogging. I have yet to encounter another one, although there are plenty of doctors who blog, as any brief perusal of my right sidebar will show (except on Internet Explorer, on which the right sidebar frequently shifts left and below the center panel). Unfortunately, I've yet to find an academic surgeon blogger. It would be nice to have some company in the blogosphere. In any case, this weekend, Medpundit wrote about the poor rate of compliance among NIH-funded researchers with a request for voluntary submission of journal articles accepted for publication to peer-reviewed journals to PubMed Central to allow public access to them after a reasonable delay of up to 12 months, such that legislation is being proposed to require it as a condition of NIH funding, the penalty for failing to comply being loss of federal funding. Her take on the matter:
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?
My response:
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.
To her credit, Sydney posted my response prominently, and I also rather liked her other suggestion:
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.
Of course, I doubt that having a bunch of nonscientists perusing such papers would turn up methodological flaws any more effectively than happens in the present situation, but it couldn't hurt, and it might help. More important would be the effect that such open access might have on exposing the public to the actual methodology behind the science, particularly the qualifications and caveats about the results that are always included in such papers but only rarely mentioned in the press coverage of them.

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.
It's really striking to me that one out of five are clinically depressed, at least by this instrument. The cause of this discontent is clear to me, as I have seen it again and again in my colleagues and at least two of my friends in other institutions: decreasing funding to support basic research and teaching, resulting in pressure to see ever more patients. Near the end of my fellowship, one friend of mine, who happened to be junior faculty, despaired that he no longer had time to do any research because the administration kept demanding that he generate more clinical income. He was doing promising research on hereditary colon cancer, but found himself spending less and less time in his lab. This resulted in a trap that is very hard to get out of and ensnares all too many young academicians. To advance in academia, young faculty have to do quality research and generate independent external funding to support their research. Failure to do so will mean failure to be promoted. However, doing the sort of high quality research that results in publications in high profile journals and is credible enough to persuade study sections to award grants to support it in an increasingly dismal funding situation. Oh, and young faculty is also expected to teach residents, serve on committees, and a variety of other duties, never forgetting that they are competing for the same research dollars with Ph.D.'s with no patient care responsibility.

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?
Despite these problems, all is not bleak, fortunately. Academic medicine still exerts a strong attraction to those of us who love science and want to apply science to improving the treatment of patients, and, as the authors themselves note, scores measuring overall satisfaction with life in general have not decreased significantly--yet. No other profession allows this opportunity or provides the possibility of improving the treatments used by all physicians. And there are still situations that allow something close to the old model in which a large percentage of one's time is reserved for research and scholarly activities, as my own situation demonstrates. It's just that such situations are getting more and more difficult to find, allowing fewer and fewer academic physicians the time and freedom to pursue the research that will form the basis of future therapies. Indeed, universities are tacitly recognizing that the old model of clinician-scientist doing bench research, taking care of patients, and teaching, is no longer tenable, as the evolution of academic career tracks other than the traditional tenure track (for example, the clinician-educator track) that allow academic promotion without nearly as much research commitment or independent funding.

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.

8 example(s) of insolence returned:


At 1/11/2006 10:30 AM, Blogger Greg P said...

For perhaps understandable reasons, academic physicians like to characterize those in private practice, and private practicing physicians those in academia. Typically with the assessment that "You don't know what it's like, you other guys have it so easy." One of the former Department heads at the local U had a mantra about us private practice docs that "all you want to do is make money, you don't care about the patients." Not exactly offering a hand of friendship.

The problem is, we're all getting the squeeze, and neither academia nor private practice is like we thought it was going to be or like it once was. We all do a lot of work that goes unreimbursed. We're all struggling, but we all have to figure this out from our own perspective. Medicare is going broke while private health insurers generate record profits, and we get the blame and the stick.

 

At 1/11/2006 12:18 PM, Anonymous RSM said...

Well put, Orac. I, too, am an "academic physician", which basically means that I am an employee of a medical school. I am expected to teach (students and residents), publish, and take care of patients. Ninety eight percent of my time is devoted to patient care, and interestingly, 60% of that care is provided at community hospitals which contract with us for services. I really am in private practice. I guess if I had any brains I would set up shop elsewhere, but after having built a practice out of nothing over the course of 12 years, it is hard to imagine starting over. I have the sense (no data, of course) that the model under which I practice will become common place for the majority of clinical faculty physicians in academic medical centers. Physicians such as you are a rare breed given that you are a practicing surgeon with a lab. (I don't even like latte's...)

 

At 1/11/2006 1:17 PM, Blogger Abel PharmBoy said...

I also have to come to your defense as a Ph.D.-only but who has spent his career training beside physician-scientists and then in M.D. career development in the basic sciences. Hell, even my blog namesake and co-founder of my basic science discipline was an M.D. researcher.

We are all up shit's creek if docs, and surgeons especially, lose the desire and/or support to do academic research. Look at what Vogelstein has done for cancer research or Brown and Goldstein for lipid research. As a Ph.D., my research can only go so far unless I have a human correlate to test my cell-culture-derived hypotheses. Just one example from my side as to why losing academic physician-scientists will impede all sorts of medical innovations. Of course, you guys come to my lab meetings and remind me to work in relevant systems and/or on relevant problems.

I also see way too many former K08 and K23 awardees wanting to stay in academia but bagging the NIH grant path and just doing Phase I/II trials for drug companies to simply pay their bills. We (NIH and academic med centers) have made a great investment in training translational researchers over the last 10-15 years and are now pissing away the investment because the business of academic medicine makes it incredibly difficult for you to see enough patients to break even while still doing research of a high enough caliber to compete at study section. NCI's payline has dropped from the low 20s to 13 percentile last cycle. I've only scored under 13 once in 14 years, and I spend 75% effort on research.

You folks really are in the private practice world these days, now having to pay all sorts of support costs out of clinical earnings, not to mention the crazy internal overhead costs and taxes that hospital administrators take off the top.

Greg P hit it on the head when citing the record profits of private health insurers and the tremendous amount of unreimbursed work you all do. The funds that used to provide the ivory tower with the *slush* to get young physician-scientists going is now going to the glass-and-steel towers and their stockholders and/or being eaten by internal cost-recovery for unreimbursed work.

I don't have any easy solutions, but I do think that Kevin M.D. was out of line.

 

At 1/11/2006 5:57 PM, Anonymous Anonymous said...

One point about academic physicians that you fail to mention is that all the time pressure makes communication with the private referring physician difficult. My experiences as a referring doctor involve a large private medical center with multiple pediatric specialists and also two large university med centers. A patient referred to the med center is basically lost to follow-up unless we track them down. I can count on one hand the number of times I have gotten a phone call over a 10 year period from a particular nationally ranked institution. Most of those calls were from fellows or even residents. In contrast, the private pediatric surgeons, ENT's, neurologists are on the phone with me the day my patient is seen. They are in my office for lunches with talks about current topics of interest. Their office booking procedures are transparent and efficient. All of the above are generalizations but the lack of "face time" with academic physicians definitely contributes to the lack of sympathy.

 

At 1/11/2006 9:20 PM, Anonymous Bruce McNeely said...

Your comments really struck a nerve with me. I had ambitions of getting on the academic track after having worked for a time in a private sector medical lab, where my job was essentially management. I did a fellowship, did clinical research, presented papers, the whole nine yards. I enjoyed it, but I didnèt have the passion that I have for direct involvement in patient care. The ivory-tower fantasy is just that - a fantasy. Academia struck me as being more like the army, with rank order promotions, politicking etc. Not for me! I have had a good 14 years working in a community hospital and hope for at least 10 more. I admire those who have a true dedication for research, something I donèt have. Oh well, different strokes etc.

 

At 1/12/2006 1:16 AM, Anonymous Anonymous said...

All of us, when in training, felt that the academic center was the only place that could possibly give high-level care. And then those of us who went into private practice found that, by gosh, it's no longer true. I trained at a very academically oriented place, and most of my fellow residents are in academe. We all have frustrations; some of a kind, some peculiar. In particular, my professorial friends find the 80 hour restrictions frustrating in teaching surgeons. It creates a "shift worker mentality," one says. Having lots of friends in academe, I have sympathy. But if the ultimate goal is to deliver care to patients, I think the ideal venue might be private practice. And I find getting hold of the profs an exceedingly frustrating venture, on those occasions when I make an attempt. In my practice, when called by another doctor, I answer immediately. And I'm not sitting around twiddling my thumbs...

 

At 1/12/2006 12:28 PM, Blogger Aggravated DocSurg said...

Your comments are well put. As a surgeon in private practice, I have seen the "town and gown" game played, unfortunately, both sides. Neither private practitioners nor academicians has a lock on appropriate behavior and understanding of the other side.

We are really at a critical time in medical education and research. The financial pressures faced by everyone in medicine is squeezing the life blood out of academic institutions. In the long run, I think there will need to be greater involvement of private practitioners in the education of residents -- but that will take a hefty dose of humility from both sides of the aisle. We in the private world need to understand that academicians have to have time for research and teaching; those in the academic world need to understand that private practitioners do see a large chunk of "interesting" cases and provide good care, and that their residents would benefit from private practice experience.

 

At 2/02/2006 8:58 PM, Blogger Impatient Patient said...

It seems to me like physicians of all types are undervalued and overworked. It also seems that insurance companies are making an awful lot of money at the expense of people who practice medicine.

Research seems incredibly important to focus on. If there were not researchers ..... I shudder to think of what the lack of real research would do to medicine. Clinical trials are so important especially now with the emphasis on evidence based medicine.

I think that academic physicians are invaluable to medicine, as they are the ones that get to "think the thoughts" and then put them into practice. If this--then that? If it works and provides another avenue to help patients, then it is work that should be supported by universities and governments.

Unfortunately, I think that this government is not as science based as it could be, and that top down attitude trickles down. If you don't believe in science, then what is th point of providing clinicians with funds or supports that allow them to flourish.

I am neither a doc nor a patient- just a peon that thinks that what you do is beyond remarkable. Please continue.

 

Post a Comment

Note: Only a member of this blog may post a comment.

Links to this insolence:

Create a Link

<< Home