Teaching Hospitals Are the Challenge and the Answer

By Marna Borgstrom

We have seen significant changes in health care with the passage of the Patient Protection and Affordable Care Act (PPACA) almost two years ago. However, the most challenging part of our work is truly just beginning. To ensure that we play an essential role in the evolving health care market, academic health center providers must take the lead by tackling the difficult issues of changing a deeply-embedded individualistic culture, and move towards improved alignment within the academic and clinical enterprise.

As leaders of organizations training much of the future health care workforce, all eyes are upon us. We cannot afford to throw this opportunity away; we must embrace it and demonstrate we can effect sustainable change. Recognizing and mitigating the dissonance between components of the academic and clinical cultures should be a priority at our institutions. At Yale New Haven Hospital, we are working to do this by implementing a system-wide cultural integration initiative among the health system members and our partners at the Yale University School of Medicine to define and align the current and desired cultures across our organizations.

We must find clarity and alignment between and among our missions and business imperatives to develop a sustainable funds flow. Finding harmony between the academic model of medical schools and the evolving market model in which academic health centers operate is critical in order for us to affirm our value. We are no longer in a position to keep the business and academic models separate and isolated.

We must better relate the vital roles of medical school-based research and teaching to the creation of an innovative, sustainable future healthcare workforce providing evidence-based affordable care. We must better-articulate the role of graduate medical education (GME) in enhancing the care we provide. We must define that which distinguishes us most and adds value to the populations we serve, and be prepared to discontinue activities and services that don’t.

The clinical enterprise needs to be great in order for the academic enterprise to operate with distinction and vice versa. Leaders at academic medical centers must seek common ground in order to fully align our business models and our culture.

Borgstrom—Marna Borgstrom is chair of the AAMC’s Council of Teaching Hospitals; president and CEO of Yale–New Haven Health System; and CEO of Yale–New Haven Hospital.

0 thoughts on “Teaching Hospitals Are the Challenge and the Answer

  1. Ms. Borgstrom uses words like “model” and “culture” to suggest things that need to change in order for medical schools and teaching hospitals to “move towards improved alignment,” “mitigate dissonance,”find harmony,” and achieve mutual greatness for the clinical and the academic enterprises. Blog posts are usually too short to permit nuanced discussions of complex issues and concepts and Ms. Borgstrom’s post is no exception. Medical schools and teaching hospitals are still inextricably bound together by the clinical mission, including clinical/translational research and clinical teaching at all levels, in whatever the “evolving market model” may turn out to be.

    In my view, the “dissonance” is less a matter of culture and “alignment” (the latter will not be cured by hospital employment of physicians), than it is of the fundamental differences in organizational structure between the knowledge industry and the health care industry and where they intersect in the clinical enterprise. The organizational structure of the knowledge industry, read medical school, is almost flat as opposed to the steeply hierarchical structure of the health care industry, read hospital. Thus, except at the upper levels, there is an inequality between the degrees of responsibility and authority held by individuals occupying the usual points of organizational intersection as each works to achieve the clinical mission in which their respective organizations are intertwined.

    A simple example: Hospital desires a faculty physician as chief of a small clinical service. The service administrator, at the fourth or fifth level of the hospital hierarchy, identifies a candidate physician and enters into negotiations for the “chief of service” position. There is early agreement on the nature of the position, the desired characteristics of the incumbent, perhaps even the scope of the incumbent’s responsibilities. The discussions come to a grinding halt when it becomes clear that the position under discussion is for 20% time for which the administrator has the authority to offer compensation in the amount of $6,000 per year. This could have been a successful negotiation, advancing the clinical mission, if the hospital representative had had the appropriate level of responsibility and authority to negotiate realistically with a physician at a similar level of responsibility and authority. It doesn’t take C-suite level administrators (as the the denizens like to refer to themselves) to relate to knowledge industry workers (faculty), but it does take administrators at the next level or possibly the next who understand the structural differences in the components of academic medical centers and can deal with them in a realistic manner.

    To me, academic medicine occupies the “crease” between the knowledge industry and the health care industry. I hope to expand on that concept in future Wing of Zock posts.

    James E. Lewis, PhD