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.
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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.
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I saw the article last night and almost blogged about it. While I agree with most of Dr. Goldman's points, I do have a a couple of nits to pick. For one thing, clinical revenue almost always trumps research revenue, for the simple reason that, unless you have multiple R01s or are the director of a SPORE or program project grant, you just can't bring in as much revenue in terms of indirects as a busy clinician can, at least if you're in surgery. I know surgeons who bill more than a million dollars a year, for example.
Maybe I'll add my two cents on my own blog sometime in the next few days.
Why would a physician pursue an academic career?
The chance to do research? Maybe, although you could still do research in private practice if so motivated.
The opportunity to teach? This appears to be downgraded to the point of being despised by the overlords.
The prestige? Yeah, it would be cool to go to your high school reunion and say that you're a Clinical Assistant Professor at Big Medical School. It it worth it?
The money? AHHAHAHAHAHAHAHA.
I think that you either want it or you don't, for purely non-logical reasons.
And as Orac points out, if you are a specialist with the ability to bring in substantial clinical revenues, those efforts trump almost any kind of research. So while having physician-scientists is of great value to both basic and clinical investigators, clinicians are pressured to provide more clinical services rather than write grants to compete for a 10-15% chance of being funded. Hence, Orac is one of a dying breed: a surgeon with an independent R01 grant. As Drs Goldman and Poses note, the only research that is truly encouraged in this enterprise are largely clinical trials supported by drug companies.