Life in the “Crease”: Academic Medicine–Where the Knowledge Industry and the Health Industry Meet

pattern_anlysisBy James E. Lewis, Ph.D.

The “crease” is what I call the interface between the academic world (part of the “knowledge industry”) and the health care delivery world (part of the “health industry”). It is where academic medicine lives and, in my opinion, misunderstanding of that fact is the root cause of many conflicts between medical schools and their clinician faculty, and the teaching hospital. Those conflicts arise when medical schools and teaching hospitals seek individual greatness for the clinical and academic enterprises rather than greatness for the academic medical center in which they are inextricably intertwined. I stress, “inextricably intertwined.”  Nearly everything done in the academic medical center, whether teaching, research, or clinical care, is a “joint product” created through inseparable efforts and components.

Professional intellect is the main resource for the knowledge industry. Its organizational units are characterized by flat organizational structures in which numerous professionals report to designated appointed or elected individuals who are responsible for organizational performance and success. In medical schools, authority is decentralized, spread among many faculty decision-makers and faculty-led “business units” that have programmatic and fiscal responsibility for a complex mix of overlapping education, research, and clinical activities. These faculty leaders, really chief executive officers for the focused activities of their respective responsibility centers, are “know-why” and “care-why” professionals: people who are  inspired by their desire to bring success and recognition to the organization and themselves in exchange for autonomy and institutional rewards.

In contrast, the health industry’s steep and deep hierarchical structure is characterized by centralized authority and many non-executive decision-makers who have narrow spans of control, limited scopes of activity, and strictly controlled budgetary authority. In a sense, these non-executive decision-makers can lead but they don’t have the authority to act on decisions. Only the comparatively few executive decision-makers can do that.

Non-executive decision-makers in the health industry have narrow managerial and gate-keeping roles but bear job titles (director, manager, vice president) that suggest a level of authority they do not have. Yet, their positions in the organizational hierarchy bring them into direct juxtaposition with faculty leaders on the knowledge side who do have the authority to make decisions, even if it is only to decide how they will allocate their time and skills. This dissonance creates conflict and organizational stasis, wastes incredible amounts of expensive time, raises levels of frustration and distrust, and deters positive movement toward overall institutional goals.

In academic medicine (and health care delivery in general), the ability of a hospital or health system to serve its market requires professional intellect held by members of the knowledge-based organization.  Without that, the health care entity cannot offer or deliver a valid “product.” All else aside, only physicians (and some oral surgeons and dentists) can legally admit patients to hospitals in this country, a fact that cannot be ignored.

Marna Borgstrom, like many of her C-suite colleagues, uses words like “model” and “culture” to suggest necessary changes for medical schools and teaching hospitals to “move towards improved alignment,” “mitigate dissonance, ”find harmony,” “respond to the “evolving market model,” and achieve mutual greatness for the clinical and the academic enterprises. I emphasize mutual. Medical schools and teaching hospitals will continue to be inextricably bound by the triple mission. The academic medical center must be managed as such, not as either/or.

In my view, the “dissonance” is less a matter of culture and “alignment” than it is of the fundamental differences in organizational structure between the knowledge and health care industries and where their hierarchies intersect in the clinical enterprise. Except at the uppermost levels, there is inequality between the responsibility and authority held by people at the intersections of medical school and hospital organizational structures as each works to achieve the intertwined mission. It may be possible to bridge or ameliorate this inequality, but first, its existence must be recognized by those with the authority to act.

Twenty-five years of attempts to improve the management of academic medicine by separating the so-called academic from the clinical, often into nearly unrelated organizations, has produced no great success stories. There is no more futile human effort than trying to fit round pegs into square holes or vice versa.  The fact is that, for academic medicine, both the pegs and the holes are hexagonal. They fit together seamlessly when understood and appreciated for what they are.

Lewis James—James E. Lewis, Ph.D., is an independent consultant to departments and schools of medicine, and teaching hospitals. He served as Deputy Dean for Operations and Vice President for Academic Administration, The Mount Sinai School of Medicine and Medical Center, and Senior Executive Officer, Department of Medicine, University of Alabama at Birmingham. His quarterly column, “Pattern Analysis,” appears on Wing of Zock. He can be reached at

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