“Inextricably Intertwined:” Income Streams in Academic Medicine

pattern_anlysisBy James E. Lewis, PhD 

In the past four decades, many people have said that the triple missions of academic medicine—education, research, and patient care—are “inextricably intertwined.” I even visualize them as the sides of an “eternal triangle” that maps to a mirror image for health care whose sides are “quality,” “cost,” and “access.”

With that image in mind, it seems obvious that the respective income streams are inextricably intertwined, too. They are, of course, as multiple studies have shown that academic medicine produces “joint products” in which education, research, and patient care are inseparable. But over the past two decades, many  academic medical center leaders have concluded that it is a good idea to sell  teaching hospitals, ambulatory care centers, faculty practice plans, research programs—and sometimes all of the above. The result of this fragmenting of educational programs is a loss of institutional direction, cohesion, and quality control. At the same time, other AMCs seem to stand by and watch competitive activities, sometimes involving or even led by members of their faculties, evolve in ways that are harmful to them and their programs.

Almost five years ago, Nancy C. Andrews, MD, PhD, dean of the Duke University School of Medicine, challenged her colleagues to think about the state of academic medicine and the need for institutional leadership that recognized and appreciated the fragility of the institutions and the need to unify and strengthen them without succumbing to organizational fads, divisive centrifugal forces, or the complacency that tends to accompany success. In her prescient presidential address to the American Society for Clinical Research, she asked:

What happens if we do not change? Here’s a possible scenario. Academic medical centers will become even more fractured, fragmented, and unhappy. Competitors will emerge who can do the same work outside of academic medical centers and do it less expensively and more efficiently. Younger generations will lose interest and go in other directions. And we will forfeit an incredible opportunity to better the human condition in our own time.

Five years later, out of the blue, comes an example of a potentially disruptive force that seems to meet Dr. Andrews’ description of competitors but, while fraught with practical, philosophical, and ethical import for academic medicine, appears to have flown under academic medicine’s radar.

The headline in the Memphis Business Journal is deceptively bland: “Medtronic Opens New Jacksonville Training Facility.” Medtronic Surgical Technologies has completed a $14 million, 17,000 square foot surgical training facility at its Florida headquarters. Named after a longtime Medtronic official, the “Dr. Glen Nelson Surgeon Education and Training Center will provide training for surgeons in cranial, spinal, and ear, nose and throat procedures.” The facility business plan calls for training 750 surgeons and health care professionals from all over the world each year. According to President Mark Fletcher, the Center will “meet the growing need from our customers to train with our products and discover how our products can be applied to meet their patients’ surgical needs.”

Presumably, Medtronic sees this investment as a lower cost and higher quality (in terms of surgical skill level) alternative to training surgeons in the use of its products onsite in its customer hospitals and ambulatory surgery centers. Thus, an ethical question: Are the surgeons trained first with the intent that they will become advocates for purchasing Medtronic instruments in their home settings, or does Medtronic sell the products with the promise of training the user surgeons in appropriate technique and application at the Jacksonville center? In either case, Medtronic would have a short-term advantage over its competitors and a long-term advantage in that surgical residents would become accustomed to the Medtronic instruments and advocate for their purchase and installation wherever they enter practice.

Philosophically, what are the implications for surgical training? Should programs teach residents in the use of a particular vendor’s products; or endeavor to provide a broad array of products so that the graduating surgeon is professional, adept, and comfortable in most practice environments? Practically, are Medtronics’ competitors going to respond with their own training centers? And who is going to bear the trainees’ travel and per diem expenses during the training?

Perhaps of greatest importance to AMCs, is this an early attempt to fragment the unique institutional strength and character of medical education at all levels?

Lewis James—James E. Lewis, Ph.D., is an independent consultant and former Deputy Dean for Operations and Vice President for Academic Administration, The Mount Sinai School of Medicine and Medical Center, New York City, where his academic title was Professor of Medicine and Health Policy. He can be reached at greegmountain@gmail.com.