I wish I could claim responsibility for this essay but the mega-props go to Roy M Poses, MD, of the team blog, Health Care Renewal (blog mission statement: "Addressing threats to health care's core values, especially those stemming from concentration and abuse of power.").

Last week, Roy wrote, "Med Schools to Faculty: Show Me The Money," based on an interview with Dr Lee Goldman, the Dean of the Faculties of Health Sciences and Medicine, and Executive Vice-President for Health and Biomedical Sciences at Columbia University.

From Goldman's "cold hard facts about academic medicine" are:

There are four categories of faculty: 1) 'Taxpayers' who generate more than they cost and help fuel the academic mission; 2) 'Hired workers' who get paid to do a job that many people might like to do; 3) 'Loss leaders' who get short-term investments in the expectation that they will become successful 'taxpayers;' and 4) 'Welfare recipients' - faculty with more tenuous status.

To which Poses added:

At first glance, to someone outside of academic medicine, this seems nonsensical. The incentive system described by Dr Goldman seems to be like the commission system used to reward some automobile sales people (at the smarmier dealerships). The system seems utterly different from that used in other parts of "higher" education, in which faculty are usually paid straight salaries based on rank and seniority.

[...]

And this emphasis on generating certain kinds of external funding helps explain the neglect of teaching, and the increasing corporate influence over academic health care.

Poses speaks mostly of how academic general internists and other primary care physicians are disproportionately hurt by the current system, but the same structure holds true for PhD faculty in basic science departments who can only generate revenue with research grant dollars. Hence, in every place I've been the MDs are told that they are supporting the PhDs and the PhDs are told they are supporting the MDs when, in truth, neither are correct. Dr Poses taught me another gem of which I had been unaware: "Academic medical centers receive millions from Medicare for graduate medical education, that is, education of interns, residents and fellows, divided into direct graduate medical education and indirect medical education funds."

So, just where is all the money going in academic medical centers?

I can't do the topic justice here so just go read the post. And be sure to read the comment from Dr. BK.

As another commentor there pointed out, medical center economics explains why the worst medical teaching is often found at the best medical research universities.