Medicine, Machines, and Medical Education.

While advances in science and technology continue to be at the forefront of the evolution of medical practice, the 21st century is also undergoing a unique and profound cultural shift that is changing the very nature of what it means to be a medical professional, namely humankind's transition to an information-based internet society. Medical care will increasingly depend on computer-generated probabilities guided and supported by a growing variety of individuals in health care-related professions, including statisticians, technologists, and information managers. Perhaps the biggest challenge to the profession will come from the erosion of professional autonomy, driven by smart machines, social networks, and internet search engines. As a result of these and other changes, physicians are facing a systematic loss of control, often without the direct input and leadership of the profession itself. In this commentary, the author urges the profession to adopt several strategies, including shifting its focus from reimbursement to the care patients value most, meaningfully addressing critical issues in health policy, becoming the definitive source for publicly available medical information, reimagining medical education, and overhauling the existing accreditation and licensing systems. Medical education must go beyond a focus on physicians whose professional identity revolves around being the exclusive source of medical knowledge. In the digitized 21st century, medical education should emphasize the centrality of the humanistic interface with patients such that the doctor-patient relationship is paramount in the complex medical world of machines and social media. Removing the roadblocks to successful professional reform is no small task, but the process can begin with a grassroots movement that empowers physicians and facilitates organizational and behavioral change. Failure to take action may well hasten the diminishment of patient care and the profession's trusted role in society.

Health Reform and Academic Health Centers: Commentary on an Evolving Paradigm.

The Patient Protection and Affordable Care Act (ACA), both directly and indirectly, has had a demonstrable impact on academic health centers. Given the highly cross-subsidized nature of institutional funds flows, the impact of health reform is not limited to the clinical care mission but also extends to the research and education missions of these institutions. This Commentary discusses how public policy and market-based health reforms have played out relative to expectations. The authors identify six formidable challenges facing academic health centers in the post-ACA environment: finding the best mission balance; preparing for the era of no open-ended funding; developing an integrated, interprofessional vision; broadening the institutional perspective; addressing health beyond clinical care; and finding the right leadership for the times. Academic health centers will be well positioned for success if they can focus on 21st-century realities, reengineer their business models, and find transformational leaders to change institutional culture and behavior.

A case for change: disruption in academic medicine.

Disruptive technologies allow less expensive and more efficient processes to eventually dominate a market sector. The academic health center's tripartite mission of education, clinical care, and research is threatened by decreasing revenues and increasing expenses and is, as a result, ripe for disruption. The authors describe current disruptive technologies that threaten traditional operations at academic health centers and provide a prescription not only to survive, but also to prosper, in the face of disruptive forces.

The role of academic health centers in addressing social responsibility.

Despite the many successes achieved by academic health centers and the significant attention paid to the importance of the impact of social determinants on health, a broader movement of the academic health center community to share best practices and standardize these efforts across institutions and communities has not taken hold. The "guild mentality" of the health professions, the existing university/academic health center structure, regulation and accreditation, and misaligned incentives in the health care system all inhibit the development of this movement. In this article, we propose a new model for how the academic health center community might better address the social determinants of health.

Resource allocation in academic health centers: creating common metrics.

Optimizing resource allocation is essential for effective academic health center (AHC) management, yet guidelines and principles for doing so in the research and educational arenas remain limited. To address this issue, the authors analyzed responses to the 2007-2008 Association of Academic Health Centers census using ratio analysis. The concept was to normalize data from an individual institution to that same institution, by creating a ratio of two separate values from the institution (e.g., total faculty FTEs/total FTEs). The ratios were then compared across institutions. Generally, this strategy minimizes the effect of institution size on the responses, size being the predominant limitation of using absolute values for developing meaningful metrics. In so doing, ratio analysis provides a range of responses that can be displayed in graphical form to determine the range and distribution of values. The data can then be readily scrutinized to determine where any given institution falls within the distribution. Staffing ratios and operating ratios from up to 54 institutions are reported. For ratios including faculty numbers in the numerator or denominator, the range of values is wide and minimally discriminatory, reflecting heterogeneity across institutions in faculty definitions. Values for financial ratios, in particular total payroll expense/total operating expense, are more tightly clustered, reflecting in part the use of units with a uniform definition (i.e., dollars), and emphasizing the utility of such ratios in decision guidelines. The authors describe how to apply these insights to develop metrics for resource allocation in the research and educational arenas.

Commentary: Academic health centers: the compelling need for recalibration.

Although academic health centers (AHCs) represent a unique combination of teaching, research, and patient care, it is no longer enough to say that their missions are solely education, research, and patient care. Rather, these "missions" must be viewed as functions that enable institutions to achieve their overarching mission: the improved health and well-being of their communities. Focusing more sharply on this goal requires a recalibration of the AHC enterprise such that education is more explicitly linked to societal needs, research to health, and patient care to specific community and regional needs. Guiding principles to lead this recalibration include an alignment of the functions of teaching, research, and patient care; a tangible commitment to a partnership with the community; and a collaborative engagement with other AHCs on a national and international scale.

Implementing a simpler approach to mission-based planning in a medical school.

Changes in the education, research, and health care environments have had a major impact on the way in which medical schools fulfill their missions, and mission-based management approaches have been suggested to link the financial information of mission costs and revenues with measures of mission activity and productivity. The authors describe a simpler system, termed Mission-Aligned Planning (MAP), and its development and implementation, during fiscal years 2002 and 2003, at the School of Medicine at the University of Texas Health Science Center at San Antonio, Texas. The MAP system merges financial measures and activity measures to allow a broad understanding of the mission activities, to facilitate strategic planning at the school and departmental levels. During the two fiscal years mentioned above, faculty of the school of medicine reported their annual hours spent in the four missions of teaching, research, clinical care, and administration and service in a survey designed by the faculty. A financial profit or loss in each mission was determined for each department by allocation of all departmental expenses and revenues to each mission. Faculty expenses (and related expenses) were allocated to the missions based on the percentage of faculty effort in each mission. This information was correlated with objective measures of mission activities. The assessment of activity allowed a better understanding of the real costs of mission activities by linking salary costs, assumed to be related to faculty time, to the missions. This was a basis for strategic planning and for allocation of institutional resources.