One last word on "towns vs. gowns"

A couple of days ago, I took a bit of issue with Kevin, MD for an off-handed remark he had made welcoming us academic physicians "to the real world" in response to an article about how demoralized and depressed young academicians have become due to the increasing encroachment of financial pressures and demands to generate more clinical income. I gently pointed out to him that we have been living in the "real world" for many years now. Noting my response, he said he sympathized but thought that proposed solutions coming from academia for the woes of the primary care physician pointed to a lack of connection with the "real world." Maybe so in this instance, although the two suggestions by academicians that the two articles he referenced as evidence of how "out of touch" academic medicine is didn't seem to support his contention all that strongly, at least not when I consider that I haven't seen any suggestions coming from docs in the trenches that seem to me any more "practical."

Be that as it may, however, one comment in Kevin's response by a primary care physician named Dr. Hebert reinforced my point that some PCPs in the community having misconceptions about academic medicine:
I agree with you, Kevin. I just finished residency in 2001 and, though academics certainly work hard, I also have the strong impression that they are out of touch with the "real world." Even when an academic has an active clinical practice, the organization he is with is so large and bureaucratic that he does not face the same situations and decisions a doc in private practice does.

Academics don't have to discipline employees, worry about salary structure, choose hospitals to apply for prividges for, decide on managed care contracts, deal with partnership issues, or deal with patient access issues (like having to treat RA yourself because there isn't a rheumatologist within 100 miles).

These differences in experience do make pronouncements of academics seem out of touch.
No one actually said that we faced the "same" decisions, but certainly we face many pretty analogous decisions and situations, and perhaps some of the misunderstandings come from how one define's the "real" world. Also, Dr. Hebert is completely wrong about academics not having to worry about disciplining employees or about salary structure. I have two people working in my lab and at times have had three or four, not counting students. These are employees, not postdocs. More successful academicians with multiple grants (among whom I hope to be one day) can have double or triple that number or even more. In fact, I'd propose that it is probably more difficult for academicians to discipline employees for the simple reason that most smaller private practices don't have to deal with a union and university policies that make it very hard to get rid of incompetent employees. As for the salary structure, it's can be as complicated as anything I've ever heard described to me in private practice. Faculty pay can derive from university base salary, clinical income, various bonuses, profit-sharing, and, for us researchers, from salary support deriving from grants. And the salary structure where I am for technicians and others that I hire is way more complex; indeed, there are at least nine grades of technician here, complete with different pay ranges, job descriptions, and qualifications. Getting a job posted is a nightmare that can take several weeks, even if you have the grant money to pay for it.

That sounds pretty "real world" to me.

His complaint about dealing with lack of access to care seems more due to a rural location than any difference between working in academia versus private practice. Private practitioners I know who work in nice suburbs and see mostly insured patients have little problem getting access to care for their patients. And, as another commenter pointed out, there can be access problems in academia that are just as bad as some private docs experience, if not more so. In our case, we see a lot of uninsured patients, and, to take one example, getting ininsured women with breast cancer access to a plastic surgeon to do a reconstruction after a mastectomy is a frequent and vexing problem, mainly because very few plastic surgeons around here accept Medicaid or our state's Charity Care.

Perhaps the best comment came from Aggravated DocSurg:
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.
I agree that medical students and residents would benefit from more exposure to private practice environments. The main reason is that such environments are going to be where the majority of them end up practicing, and Aggravated DocSurg's other reasons are right on. However, I wonder how feasible this would be under the current system of reimbursement. Teaching medical students and residents is a real efficiency-killer, which is one reason (of many) that academic institutions have higher costs and run less efficiently. To take one example, it usually takes mem 30-50% longer to take a resident through a case as it does for me just to do the case myself, but I understood that going in. Private practitioners would have to devote time to doing this, and, in a private practice setting, that time would likely not not be reimbursed. It would either take exceptional dedication to devote more unreimbursed hours or it would take seeing fewer patients or doing fewer cases, and thus generating less revenue.

One thing that's become apparent to me is that the relentless downward pressure on physician reimbursement, coupled with the present malpractice environment, is putting private practitioners and academic physicians in the same boat. Academic medical centers and physicians have had to change their practices to a financial model that more and more resembles that of very large private practices, leaving less time for the research and teaching missions that have traditionally been within their purview. It's becoming increasingly apparent that the present system is, if not broken, rapidly breaking down. It will be up to us, both private practitioners and academicians, to come up with a new model to replace it.


  1. I just happened across your comments on my comments on the Kevin MD website.

    I want to clarify my point. In no way did I ever intend to say that life is easier in academics. I am positive that it is not. But I can only speak from personal experience, and as someone who has trained in a large academic center (actually 2 different ones) and then entered primary care practice, I have to say that residency and medical school did not prepare me for private practice nearly as well as I thought it would. I was well prepared for the Step exams and Boards, but not private practice. There was something missing from my training. And I can get you the names of dozens of PCPs who would tell you the same.

    I didn't understand billing, overhead costs, insurance contracts, permits and licensing procedures, the list goes on and on. Maybe you teach your students that. If so, good for you. But a lot of academics don't.

    Running a private practice is as different from academic medicine as running a corner coffee shop is from being an executive at Starbucks. (Don't take offense. I consider myself the coffee shop owner and you the executive.) As someone who has been involved in running a corner coffee shop, I can tell you that such an enterprise is way, way harder than you would think. And being a Starbucks exec is probably not easy either. But the two are very different.

    I am afraid the pressures on academics is driving us even further apart. The problems you describe in your work get more unlike the problems I have in mine every day.

    Your comment about the difficulty firing employees points this out. For you it is hard. For me it is easy. I just have to say it, and it is done. This is why I say personnel issues are different. You have to document all kinds of things, and everything is reviewed by the personnel department, or legal department, or the department chairman, or God knows who else. It is all official and legal, and very difficult. I can do it without effort, which can get me in trouble quickly. For me it is a much closer and personal matter, and one I can share responsibility with no one. It is DIFFERENT. Not better, not worse, just DIFFERENT.

    I like academics in general, and always have. My father was a college professor. But I do not think you and I speak the same business language. Medical, yes. Business, no.


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