Thursday, January 29, 2004

A reader posted this comment on my January 24th entry.

Not all academic practices are the same. Many give a relatively small salary to the staff. The majority of their income is from the practice plan - i.e. from treating patients. Those of us in academic's are generally just as tied to our clinical practice as any other physician, and this includes paying for overhead as well as the "Dean's tax". It's not all milk and honey in an academic practice.

While the comment is, IMHO, more of a rebuttal to Dr. Smiths post than mine, I agree with what the author has written. The practice of medicine in the academic setting has changed greatly over the past few years. In the past an academic surgeon could expend a great deal of time and effort to research and teaching. They could do this because for the most part they left the mundane procedures and certain parts of the complex ones to the residents or fellows. An example would be on a CABG the fellow would open the chest, harvest the vein, cannulate the patient and call the attending when the patient was placed on bypass. The attending would come in and perform or assist with the anastomoses, and then leave. Barring complication the fellow would complete the case by themselves. If the program was large enough the attending could bounce from room to room when the "underlings" were ready for them. General surgery attendings would leave the hernias and breast biopsies (for example) almost exclusively to the housestaff.

With the rise of managed care, reimbursement has fallen and put pressure on academic health centers.

Cuts in Medicare reimbursement to hospitals made by the Balance Budget Act of 1997 threatened the financial viability of academic medical centers, with the AAMC projecting that half of its members would be losing money by 2002. The Medicare, Medicaid and SHIP Benefits Improvement and Protection Act of 2000, passed by Congress last December, will repair some of the damage, restoring $12 billion to all hospitals over five years. The Act also delayed implementation until 2003 a one percent reduction of a multiplier used to calculate GME payments, which Dickler estimates will yield $700 million to teaching hospitals over those two years.

The fiscal health of teaching hospitals and medical schools, however, remains at risk. One-quarter to one-third of AAMC's teaching hospital members still continue to show an operating loss every quarter, he adds.

Faculty were pressured into providing more clinical services to increase revenue. Departments of Surgery have not had much of a problem with this a they, for the most part, make money for their institutions. Surgeons have also been affected by lawsuits and audits that have required an increased presence of the attending surgeon in the OR. (A good thing, I might add). (More on the University of Washington problem may be found here, a situation where their chief of neurosurgery was convicted of felony fraud)

So while their clinical responsibilities increase they are still required to engage in teaching or research. But many are balking at it:

Harvard Medical School is struggling to persuade its physicians to teach its students, as doctors seeing more patients to stay afloat financially have less time to educate the next generation of doctors at one of the country's
most prestigious medical colleges.
The medical school dean, Dr. Joseph B. Martin, who was hired in 1997, appointed a task force to study the issue as part of a far broader curriculum overhaul, the first major rethinking of the school's curriculum in 20 years.
Earlier this year at a faculty meeting, Martin, who is generally soft-spoken, let faculty know he was upset about the teaching situation. ''Martin expressed deep and serious frustration at not being able to
convince more faculty that teaching responsibilities are the core of a faculty appointment and that faculty have an obligation to carry out their teaching responsibilities,'' according to the faculty report of the meeting
in February. ''He said efforts to convey this have been largely unsuccessful.'' Members of the Task Force on Faculty Teaching Responsibility said course directors are finding it increasingly difficult to recruit faculty to
teach -- despite the school having 9,000 physicians and researchers at its affiliated hospitals and institutions and a requirement that they teach 50 hours a year if asked. More faculty are saying no to requests, many
physicians in the hospitals will agree to teach students at patients' bedsides for only two weeks rather than a full month, and, in rare cases, course directors are hiring non-Harvard faculty to tutor small groups and oversee labs.

DB has an excellent post about this from June 2003. Be sure to read Dr. Henry's thoughtful comments.

The surgical journals are filled with academic job postings, since physicians are realizing they can earn much more money for the work they are doing in private practice. Although some at the Medical College of Georgia aren't doing too badly:

1. Mark R. Lee, department head, Medical College of Georgia, $439,482 (neurosurgery)
2. Julian J. Nussbaum, department head, Medical College of Georgia, $415,000 (ophthalmology)
3. Dennis M. Marcus, associate professor, Medical College of Georgia, $404,167 (ophthalmology)
4. Thomas R. Gadacz, department head, Medical College of Georgia, $374,958
(general surgery)

Nice work if you can get it.
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