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.

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.

The Empirical Challenge of 21st-Century Medical Education.

Medical education is at a crossroads. Facing challenges wrought by science and technology as well as societal change, the curriculum is increasingly out of synch with new needs in teaching content and medical practice. The path to significant curricular reform is difficult because of a variety of factors, including deeply entrenched values, the natural resistance to change, and the accreditation process. Indeed, even the very definition of what it means to be a professional is changing with profound implications for the future role of the physician and the sacrosanct doctor-patient relationship.In this Invited Commentary, the author enumerates challenges facing medical education in the current era. To address these challenges, the author recommends specific curricular emphases for 21st-century medical education: knowledge capture and curation, collaboration with and management of artificial intelligence applications, a deep understanding of probabilistic reasoning, and the cultivation of empathy and compassion in accordance with ethical standards. Given these needs, it is imperative that schools act today to undertake significant curricular reform and, in so doing, strive to make the hard changes necessary to produce optimal practitioners in a rapidly transforming 21st century. The author provides first steps an institution can take to begin to address these challenges.

Reimagining Medical Education in the Age of AI.

Available medical knowledge exceeds the organizing capacity of the human mind, yet medical education remains based on information acquisition and application. Complicating this information overload crisis among learners is the fact that physicians' skill sets now must include collaborating with and managing artificial intelligence (AI) applications that aggregate big data, generate diagnostic and treatment recommendations, and assign confidence ratings to those recommendations. Thus, an overhaul of medical school curricula is due and should focus on knowledge management (rather than information acquisition), effective use of AI, improved communication, and empathy cultivation.

Medical Education Must Move From the Information Age to the Age of Artificial Intelligence.

Noteworthy changes coming to the practice of medicine require significant medical education reforms. While proposals for such reforms abound, they are insufficient because they do not adequately address the most fundamental change-the practice of medicine is rapidly transitioning from the information age to the age of artificial intelligence. Increasingly, future medical practice will be characterized by: the delivery of care wherever the patient happens to be; the provision of care by newly constituted health care teams; the use of a growing array of data from multiple sources and artificial intelligence applications; and the skillful management of the interface between medicine and machines. To be effective in this environment, physicians must work at the top of their license, have knowledge spanning the health professions and care continuum, effectively leverage data platforms, focus on analyzing outcomes and improving performance, and communicate the meaning of the probabilities generated by massive amounts of data to patients, given their unique human complexities. The authors believe that a "reboot" of medical education is required that makes better use of the findings of cognitive psychology and pays more attention to the alignment of humans and machines in education and practice. Medical education needs to move beyond the foundational biomedical and clinical sciences. Systematic curricular attention must focus on the organization of professional effort among health professionals, the use of intelligence tools involving large data sets, and machine learning and robots, all the while assuring the mastery of compassionate care.

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.

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.

Revisiting the idea of a national center for health professions education research.

The need for a national center for health professions education research is more compelling today than when originally proposed 15 years ago. There is a general consensus as to the need for better assessment of the educational outcomes of U.S. health professions schools, especially in light of the large investment society makes in the health education infrastructure. The author reviews briefly the current state of research in medical education as an example of health professions education research, from both qualitative and quantitative perspectives, and uses the emergence of the teaching academy movement as an example of how innovation in medical education is often implemented (i.e., the "cottage industry approach"). The substantial obstacles facing medical education research are discussed, including significant conceptual, curricular, financial, and outcomes-related challenges. The author proposes the creation and organization of a national center for health professions education research, consisting of four research divisions: basic, translational, applied, and systems. The funding for the center would be derived from a research and development assessment on existing federal investments in health education. The hurdles to the creation of such a center are reviewed and include intellectual, financial/political, and regulatory ones. The author suggests that a national center for health professions education research can be an effective mechanism for the study of many complex issues in health education and health care delivery for which the public desires accountability.

Perceptions of medical school deans and state medical society executives about physician supply.

CONTEXT: Physician shortages are appearing, yet controversy about their significance and uncertainty about their remedy exist. OBJECTIVES: To sample the perceptions of medical school deans and state medical society executives about the adequacy of physician supply, to determine the perceived impact of any shortages on medical schools, and to assess the capacity of medical schools to expand. DESIGN, SETTING, AND PARTICIPANTS: Medical school deans in the United States and Puerto Rico were surveyed by means of a structured questionnaire, and officials of US state medical societies were queried by means of open-ended telephone interviews. Information was obtained from 58% of medical school deans and 86% of state medical society executives. MAIN OUTCOME MEASURE: Reported perceptions of shortages or surpluses of physicians by specialty and plans to increase medical school class size. RESULTS: Approximately 85% of both deans and medical society respondents perceived shortages of physicians, usually in multiple specialties, while 10% perceived surpluses, usually coexisting with shortages. Among deans reporting shortages, 83% described a negative impact on their schools. Recent or planned increases in class size were reported by 27% of deans and expansion capacity by another 34%, but 7% noted recent decreases in class size. Applied generally, these changes in class size could yield 7.6% additional matriculants annually. CONCLUSIONS: Physician shortages are prevalent and they are negatively affecting medical schools. Little capacity exists to alleviate these shortages through class size expansion.

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.

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.

Screening for carotid artery disease in the general public.

BACKGROUND: Screening for various diseases is now being offered to the public in settings other than their physicians' office, often using expensive and sophisticated technology. Little is known about how patients decide to participate in such programs, whether they understand the implications of a positive or negative test, or if their primary care physician is involved in the decision to screen. METHODS: We surveyed a cohort of patients who participated in a free carotid artery screening using Doppler ultrasound at a tertiary care academic medical center. RESULTS: One hundred twenty-four patients participated and underwent the ultrasound exam. Their mean age was 68.8 (+/-9.8) years and 54% were female. Some 117 patients (94%) completed the survey. Five patients (4%) tested positive for significant carotid artery stenosis. Sixty-two percent (95% CI: 53-71%) of the patients learned about the program through a newspaper advertisement. Eighty-eight percent (95% CI: 82-94%) of the subjects stated that their primary physician had not suggested that they have the test, and 59% (95% CI: 50-68%) did not know that carotid artery surgery is often recommended for patients who test positive. CONCLUSIONS: This study of one group of patients who voluntarily took a screening test for carotid artery stenosis raises some important questions since most subjects did not understand the implications of a positive result, nor did they involve their physicians in their decision to take the test. Further studies are needed to evaluate whether providing patients with more information about the implications of a screening test would change their desire to have the test and about the nature of the informed consent required before such screening is carried out.