Peggy and I thank you for the privilege of serving in the Presidency of the American Clinical and Climatological Association (ACCA). The ACCA is unique among professional societies because of the special emphasis it places on fostering great friendships among families even as we gather to share our scholarship. To be entrusted with the reins of this special organization has been a singular honor, one that we will count among the highlights of our careers.
For the most part, service as ACCA President has been a pleasurable experience, one marred only by the requirement to deliver the Presidential Address like that you are about to hear. Deciding what to say and how to say it has been arduous because, like many of you, I am far more comfortable with a reportorial rather than a discursive style of discourse. On the other hand, this address is a chance to speak off-the-cuff about things that matter to me, and to do so before this august audience of treasured colleagues, friends, and mentors. In that spirit, I thank you in advance for the gift of your presence and your attention.
What I have to offer today in return for the next 20 or 30 minutes of your time are my personal, highly subjective, and completely qualitative musings about the future of academic medicine. This is the ecosystem in which we have been so lucky to thrive throughout our careers. As all ecosystems inevitably do, ours is struggling to adjust to a rapidly changing environment that is disrupting the niches in which we have built our comfort zone. Some would even have us believe that our surroundings are being altered as profoundly as the earth was by the meteor that killed the dinosaurs. In this scenario, of course, we get to be the dinosaurs! I do not happen to believe that the changes already occurring are that catastrophic, but they do pose a significant threat to academic medicine nonetheless. My topic today is about preserving the essence of what academic medicine can contribute to society in these disruptive times, and some things we must do to ensure that we preserve sustainable niches for our successors.
We are members of this Association because we have thrived in this ecosystem, excelling as scholars, teachers, mentors, clinicians, or leaders. We have, individually and collectively, received a great deal in return. The rewards for our many years of education, training, and contributions to our fields have been substantial. We enjoy an interesting and fulfilling professional lifestyle, academic tenure, a reasonably high level of compensation (most of us fall within the now infamous 2%), and broad networks of friendships, even among those we regard as our competitors. We have been the beneficiaries of several decades of unprecedented expansion in public and private support for our endeavors. Indeed, the past seven decades have blessed us with perhaps the greatest expansion of any scholarly enterprise since the Renaissance.
That era of largesse is over now. We, the beneficiaries of this phenomenon, owe academic medicine our best efforts to ensure that the enterprise will continue to thrive and make its contributions to society despite a much tougher environment. We owe this to our successors, our patients, and to the society that supported us so generously.
If we are to do our part to guide our endeavor through these perilous times, we must first understand the essence of what it is we are trying to protect and preserve. Each of us would likely articulate what that is in individual ways. My version of what we must preserve is a national enterprise supported by institutions that are dedicated to fostering discovery, innovation, scholarship, education, and career development in all disciplines needed to enhance our understanding of human health and disease, and which will accelerate application of that understanding in ways that improve human health and well-being. These institutions must also nurture the development of the next generations of scholars and professionals who will continue the pursuit and ultimate accomplishment of those daunting goals. We need to protect the core missions of discovery, translation, education, application, and service. We need not protect the existing way that we go about our business. Indeed, maybe we should do the opposite. This is not about our titles, our compensation, our reputations, our personal legacies, nor is it ultimately about budgets, programs, buildings or balance sheets. It is about the impact of what we do for others that merits the gift that we are given in return—the way that we get to live our professional lives. In what other profession can you care for the sick, teach and mentor the best and brightest, work in an environment populated by brilliant and committed people, all while pursuing our strongest intellectual interests? And in what other endeavor can you do all of that with a rather comfortable lifestyle and job security that most other professions envy. Most importantly, in what other endeavor can we, individually and collectively, have such a positive impact on the health and well-being of individuals, their families and loved ones, and society in general? We have been able to wake up each morning knowing that our efforts would in one way or another contribute to those lofty goals.
We all expect that the future is going to be far more daunting and uncertain for those following in our footsteps. Those succeeding us must perforce be even brighter, more creative, more committed, more dedicated, and more forceful than we have been in advancing academic medicine and what it has to offer. The majority of us are in the latter stages of our career. The finest legacy we can leave is a vibrant 21st century version of Academic Medicine, an ecosystem robust enough to attract the most exceptional people to become our next generation, and to extract from them all of the societal benefits of their creativity, energy, brilliance, and talent.
What follows is not a comprehensive manifesto or prescription for “fixing” academic medicine. Indeed, many things that academic medicine must accomplish to survive are not even on my list. For example, I have not attempted to delve into the extraordinarily complicated business issues, many of them local, that each academic medical center faces in this era of healthcare reform and declining federal funding. I am also not going to dwell on our need to work harder than ever to influence public policy and the public itself about the importance of what we do to this nation's future. Those are givens. They have been discussed extensively by many individuals who are more qualified than I to opine about these matters. Rather, I will focus on some things that, while hardly sufficient, are absolutely necessary if we are to emerge from this highly disruptive period as a thriving enterprise. These are things that do not get discussed quite as often or loudly, but are essential if we are to deliver on the promise that science will create better health for everyone.
Here are five things that I believe to be essential to that future:
We need to get over it and stop the whining.
We need actually to embrace change not merely to react to it.
We must save our young.
We must do a better job of understanding our customers in all of their dimensions.
We must master the convergence of research and care that our own discoveries are creating.
LET'S GET OVER IT AND STOP THE WHINING
Some level of discontent with our circumstances is perhaps human nature. However, my four decades in academic medicine have convinced me that we are particularly prone to express that discontent widely and loudly to whomever chooses to listen. In bad times, we complain about our present circumstances. In good times, we complain about our prospects for the future. In Table 1, I have listed the woes that I hear in our corridors, offices, and lunchrooms every day. First is the belief that our world is collapsing because of the reduction in federal research funding. Second is the conviction that our academic health systems will be wiped out by healthcare reform. Third is our resentment that the public is not paying sufficient attention to us or appreciating our contributions. Fourth is our hand-wringing that no one wants to go into the field of academic medicine any more. The problem that I have with our constant obsession with these woes is that Table 1 is an only slightly modified version of a slide that I showed during my Presidential Address to the American Society of Clinical Investigation in 1992. Times were not as bad as they are now, but they were believed to be. Since then, we have more medical schools than ever, the NIH budget has nearly tripled, the number of medical school faculty has more than doubled, and our academic health centers are stronger forces in the healthcare marketplace than ever before. Indeed, in many communities, we are major economic engines of the regional economy.
TABLE 1.
What I Hear and Overhear Every Day
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Times are as bad as any of us can remember. My argument should not be taken as one that minimizes or overlooks the seriousness of today's threats to our success. All of us need to double and re-double our efforts to make that environment better by advocating for adequate resources to do our work. That being said, we only make things worse by dwelling on our woes. Too many of us do that in too many forums. It's a waste of time and energy. Nobody does or will feel sorry for us. Indeed, many in Congress believe that any support they send our way is “white coat welfare,” or a redistribution of wealth from the heartland of America to the ivory towers concentrated in decadent coastal blue states. Support for biomedicine is regarded in the world of government and business as an investment, not a donation; investors back winners not whiners. Most importantly, our complaining is driving young talent away from us.
Most critical among the things we must do is to ensure that there is an ample supply of outstanding talent and leadership among the people coming into the field after us. Perhaps the most important job that we face in these difficult times is to be outstanding ambassadors for the careers that have brought many of us into forums like this one today. My concern about our collective psyches in times like this is that we, by obsessing with what we are afraid we will lose, distract ourselves from focusing on what we need to do and what we can offer to this brave new world. Most tragically, we send terrible messages to the very people that we most need to sign up for a career in academic medicine. Indeed, based on what too many of us tell our young people, anyone smart enough to deal with the challenges inherent in a career in academic medicine would never be dumb enough to sign on! We must be certain that all of us take the long view. This is a field still rich in opportunities, particularly for the most innovative and forward-thinking young emerging leaders. It may end up 5%, 10%, or even 20% smaller than it was at its peak, but it will still be, relative to many other endeavors, a verdant field in which careers can take root and blossom.
EMBRACE CHANGE
If we were to eavesdrop on a strategic planning exercise at any one of our campuses, we could bet that the conversation would be filled with exhortations about how “we” need to change. These exhortations are true. As an enterprise we need to embrace massive change. We have developed a system for performing research, teaching, and delivering healthcare that was perfectly adapted to the latter half of the 20th Century. It is woefully out of touch and out of date with the way the rest of the 21st Century society works. We have failed to take advantage of technological and systems advances that have radically altered so many areas of our lives. When, for example, is the last time that you actually walked to the TV set to change a channel? When did you last spend time with a bank teller? Most other industries do their business in a way that would have been entirely unrecognizable to them a decade or two ago. Even though we have incorporated vast changes in the technological tools we bring to the direct care of our patients, we have done relatively little to utilize technology or to modernize the systems that we use for delivering healthcare. We take advantage of too few opportunities to allow our patients to receive the benefits of our expertise from home, or to use methodologies that have been perfected in other industries for tracking outcomes, efficiency, patient satisfaction, and cost impact.
When we sit in those strategic planning rooms, we tend to think that the “we” that needs to change does not include the “I.” If we are to make academic medicine a thoroughly up-to-date enterprise in the way that it operates, supports itself, and demonstrates its value, then each of us must be prepared to change in ways that will take us out of our comfort zones, force us to identify the essential DNA of academic medicine that must not change, and put everything else on the table as available for change. The core values which drive us, the essential boundaries of our missions, and the principles of professionalism, collegiality, collaboration, and compassion that distinguish a field built around the needs of people who are ill or could become ill must not change. Everything else can be modified or eliminated even if that might cause temporary distress.
We must change from a system that depends too much on ad hoc situational decision making to one that looks coolly at what our organizational framework should be and how we should do our work. For example, do we have the right spectrum of faculty to support the many facets of our mission? Do we have a sufficient number of people who can be true innovators in the systems of healthcare delivery? Do we have the scientists who are masters of the art of applying science as well as the discoverers of the foundational facts of pathobiology that will make our care more effective, safer, cheaper, and less toxic? Can we configure ourselves to be a true distributed system of healthcare that utilizes all of the capabilities available to us to promote the care of populations of patients whom we access? Can we reduce reliance on hospitals and clinics headquartered in our increasingly gigantic academic hubs and promote well-being closer to home? As academic health centers, do we interact constructively and productively enough with one another to form a national network of resources which all of us can tap but none of us can maintain on our own? Or, will we continue to measure our success by competing with other centers for talent, donors, and grants?
These are but a few of the fundamental questions that we must ask and can answer correctly only if we are prepared to embrace real change and to abandon some of the rituals and false value sets that, as is true for any great enterprise, have crept into the system over time. Brent James, who has been a driving force in making Intermountain Health System the prototype of a high-value, high-quality healthcare delivery enterprise, has been widely quoted as saying “the only person who enjoys change is a baby with a wet diaper.” Change will not be enjoyable, but it will be regarded, once accomplished, as well worth the discomfort it caused. We can maintain our core values, our mission, and our ethos. To do so, however, we must evaluate and prepare to alter the habits, rituals, tactics, and even some of the strategies that may have worked before but are maladaptive now.
SAVE OUR YOUNG
I have repeatedly argued that our future depends more on who will be there to create it than on what we will encounter. As senior members of our academic health centers, individually and collectively, we must commit to recruiting, retaining, and nurturing outstanding young people who have the talent, compassion, and drive to succeed in academic medicine. This is even more essential during these very difficult times. I have talked about the need to project positive messages, but there are more material measures that we can also take.
The first is that we must treat everyone of our new recruits like the National Football League treats its number one draft choices. Everyone joining our training programs or our faculties must become the object of an intense, deliberate, and intentional mentoring and nurturing program. It is no longer sufficient to bring even the most talented and self-reliant individuals into a great environment and to let them figure out how to find success on their own. That was how many of us in this room got started; it simply won't suffice today. The progress of our younger successors needs continual and constant monitoring and support. Those with the talent and inclination to pursue careers within the walls of academic medicine must be identified early in training and their career paths must be delineated with them. Those career paths must then be designed and initiated even as training continues because the competition for dwindling resources will be stiff. Momentum as one emerges from training will be even more critical in the future than it is now. Admittedly, in this era of constrained resources, there will likely be fewer positions available with that level of support. As difficult as it will be, we will have to be more selective and strategic about whom we bring on board. The older system of planting a thousand flowers in the hopes that many will bloom will no longer suffice.
One thing that strikes me as ironic is our notion, one that we convey too stridently to our younger colleagues, that opportunities are becoming more limited. This is a time when opportunities in academic medicine should and will be broader than ever. If they are not, it is no one's fault but our own. It is true that there are fewer resources for people to pursue careers at the bench in the traditional mode of physician-scientists. Yet, there are still great opportunities even in that area although that career path, in fact, is not preferred for many of our most promising young scholars, younger students, and faculty. They wish to work closer to application in translational or clinical research, in health services research, or as academic clinicians. We desperately need them to do just that if we are to be the principal authors of the next century of health care. Yet, we have done very little in most academic institutions to create clear career paths for those individuals.
It is for these reasons I believe that the success of our enterprise will never be assured unless we fix our faculty promotion system. By changing the promotion system, I mean changing the way we actually promote people, not merely writing new or broader set of criteria and categories by which people can potentially achieve faculty advancement. At every institution where I have worked, people have made diligent efforts to create mechanisms by which faculty pursuing excellence in non-traditional ways can get promoted. Yet, even today, the very same faculty members whom we intend to serve by those changes are still finding it difficult to figure out how they can make their case for promotion. All too often, they come far into their careers or the actual promotion process only to be turned away or deferred for inadequate numbers of “papers.”
We simply must take a more sophisticated view of how people can demonstrate excellence. We must be certain that achievements in non-traditional areas are monitored and documented as people move through their careers. Most importantly, we must insist that promotion committees do the difficult work and undergo the uncomfortable change of defining and recognizing excellence even when it cannot be pigeon-holed into the traditional view that grants and papers are the sine qua non definition of promotability or academic accomplishment.
Academic health centers will succeed only if we celebrate and make room for the academic clinician, the educator, the clinical investigator, the innovators in health systems delivery, the computational biologists and informaticians, and those who focus on the qualitative as well as the quantitative aspects that make for the best expressions of our profession. If we fail to do that, we will not be able to make the case that our contributions to the public good are uniquely important and should be supported.
At the turn of the 20th century, academic medicine was rescuing healthcare in the United States from a disgraceful era. Care was managed by poorly educated physicians whose requirements for entrance to medical school in some cases did not even include the ability to read and write. Medicine was practiced in a ritualistic fashion that bore little relationship to the admittedly small base of scientific knowledge available about health and disease. The system of care that transformed medicine around the world was innovated largely by the incursion of science and the scientific method into medical care in the United States and a few European countries. At the turn of the 20th century, the revolution in healthcare delivery grew out of a more scientifically based paradigm of care, driven largely by academic health centers. These centers amassed the expertise needed to advance and execute this approach.
We are not leading or even participating properly in today's revolution. Most of the changes in the systems of care are coming from places as unrelated to us as Google and CVS pharmacy, from employers and insurers, and from healthcare systems that have only loose affiliations with academics such as Inter Mountain, Geisinger, and Kaiser Permanente. We need to recapture our role in deciding what innovations will alter the delivery care in the same way that our discoveries in the lab determine what will be available for that care. To meet that obligation, we need a new kind of faculty whose accomplishments will be measured in their impact on practical applications, not necessarily in New England Journal of Medicine or Cell papers. That is why we have to look hard at our system of rewards and advancements within academic medicine and be certain that we are advancing both those who improve the care that can be offered and how it is delivered. We cannot lead the way to this future without faculty who can define, master, and execute the changes that must occur.
UNDERSTAND OUR CUSTOMERS
Like most of you, I recoil from the notion that we have “customers” at the receiving end of our services and capabilities. It implies that our relationships with our patients and their loved ones are about the same as the relationship we have with our ATM machines. However, I can find no better word to force us to think in terms of to the very best experience to those who encounter us and will decide whether to use what we have to offer. This is true whether we are talking about our patients, their loved ones, biotech and pharmaceutical companies, payers and vendors, or any of the myriad parties with whom we interact, including donors.
One healthy aspect of thinking of the word “customer” in this manner is that it forces us to realize that we are fundamentally seen as customer service organizations in the eyes of the outside world. We are barely regarded as an academic ivory tower even within the ivory tower institutions, our colleges and universities, in which we reside. In the contexts in which we are a service organization, we need to be certain that we are providing the very best experience for those who access our services. Thus, every center must ask why someone would choose it and why someone would pay the prices that we charge, whether they be in the form of the price for an MRI, the indirect costs for a grant, the terms for clinical trials, or the royalty and licensing percentages that we ask for intellectual property.
We must also realize that the future will change the kinds of customers whom we must access if we are to be able to offer the best available care to patients and their families. Patients will be increasingly constrained from choosing us solely on the basis of their personal preference or a conviction that they should be seen by us. Accountable care organizations, large provider groups, insurance companies, employers, and, as we are learning painfully in Massachusetts, local, state, and federal governments are increasingly inserting themselves into that decision, and their insertion is largely for the purposes of obtaining the lowest prices, even if that does not always translate over time into the lowest cost or best healthcare. These “customers” will only choose us if we are high value, cost competitive and user friendly. We cannot, as we have too often done in the past, assume that those individuals and organizations will accept without question the proposition that we deliver the best care and offer the most value simply because we are academic centers. Increasingly, we will be assessed by metrics that compare us to alternative providers.
We must do a better job than we are doing in assuring that we are the ones who decide what those metrics will be. We must have a much stronger role than is presently true in defining what is meant by high-value care and what is meant by cost efficiency. At the present time, these notions are based on unit pricing which has very little to do with the cost of providing outstanding healthcare to individual patients over their lifetimes, or to populations of patients observed as a group. We do not yet have adequate programs or faculty talent massed in our centers to invent and drive the adoption of the proper system of metrics. This speaks once again to the need to be certain that our system of opportunity, rewards, and advancements are aligned with what the system needs for the future.
MASTER CONVERGENCE
In much the same way that the functionalities of our telephones, CD players, cameras, and laptops have converged into our cell phones or tablets, human biology, biomedical research, and clinical care are converging around the study of individual patients. Whether we call this personalized medicine, individualized medicine, customized medicine, or high-precision medicine, the concept and the momentum of convergence are similar. Measurements that were once made only in the context of the most advanced wet bench laboratory research are now being used in clinical trial support cores, and even at the bedside. Witness the now routine use of genomic sequencing to care for patients with certain forms of lung and breast cancer, melanoma, sarcoma, and leukemia. This information is not merely for documentation and subclassification of the disease processes occurring in these patients. For a small but increasing percentage of patients, information like this is used to guide treatment. In many cases, these treatments are superior to those that were once available, but only for patients with specific matching molecular characteristics.
Our academic centers have been the creators and architects of this convergence. If we master the best ways that the most exciting discoveries in science are quickly converted into clinically useful diagnostic, therapeutic, or preventative strategies, we will be unquestionably the indispensible driving force that creates a healthcare system that functions as we think it should. Fortunately, no one is sure how to make this convergence happen in a way that the care of every patient will benefit. No one is sure how to do in humans the kinds of studies that can only be done ethically in cellular or animal models at the present time. We have the opportunity to lead this revolution. Better noninvasive ways or minimally invasive ways of imaging, tissue procurement, isolation of informative stem and progenitor cells from peripheral blood, development of biomarker assays from blood, urine, or exhaled gases or by whatever means, are needed. This research can only be done by direct investigation of human patients. Cellular and animal models will clearly be important contributors and hypothesis generators, but proving the utility and biologic validity of any of these approaches will ultimately require better ways to study every patient who comes through our doors.
Once again, we need to ask whether we have created the opportunities, the rewards, and clear pathways to advancement needed to attract the people who are able to do this. Disease-oriented basic laboratory researchers revolutionized medicine in the years after World War II. We now also need clinical investigators who are well-versed in laboratory methodologies, the scientific method, and the culture of research, but who are also embedded in our clinical settings and are masters of the methods of human studies. We need astute academic clinicians who, in addition to being the best at diagnosing, treating, and supporting patients, are also the most astute observers of the behavior of pathologic processes in living patients. They often are the ones who provide the important clues needed to uncover opportunities for the application of science to healthcare. We also need a new breed of health services scholars who can develop paradigms for the safe, cost-efficient, and ethical application of genomic-based technologies in broad clinical settings.
For lack of a better term, I like to think that the discipline that we need more of is “human pathobiology”: the direct study of pathologic disruptions of normal biological processes as they occur in real time in living human patients. Among the clearest lessons of the post-genome era has been the fact that differences in the basic building blocks of organisms alone do not explain their vastly different behaviors. Our genomes are far more similar to those of animals who can behave very differently when treated with agents targeting specific diseases. We need better ways to follow those processes and the effects of our interventions in real time in living human patients. We need to create a generation of human pathobiologists who will be as impactful in the mid-decades of the 21st century as the great physician-scientists who transformed medicine in the mid-years of the 20th century have been.
In this scenario, every patient that we see, indeed, every individual for whom we have responsibilities in a population sense, should be regarded as an object of study even as we provide the very best care. Regardless of whether those individuals are on a clinical trial or not, we should master the use of so-called “big data” so that every document, every measurement, every description of that individual's journey through our healthcare system can be preserved, accessed, curated, and analyzed to see what might be learned.
It is becoming increasingly easy to gather overwhelming amounts of biological, clinical, and administrative data about patients, and to identify differences between the normal and pathologic state of organs, tissues, cells, and molecules within patients. What is becoming increasingly difficult is discerning which of those differences are important. Ultimately, it is the changes occurring in the patient's well-being and clinical parameters that will instruct us about what is important. The discipline of genetics, the forerunner of our fascination today with genomic measurements, taught the lesson, all too often forgotten, that we should work back to mechanisms from phenotypic changes. That is the way to know that what we are studying is important. We are all too often overly fascinated by our ability to measure genotypes, gene expression patterns, etc., without noting that it is only the variation in phenotype that defines the importance of those changes. This defines the critical role of academic clinicians who are the “phenotypers” in this new ecosystem.
CONCLUSION
The list that I have just offered is incomplete and arbitrary. It reflects my bias that we must emphasize some things not discussed often enough or explicitly enough in our current conversations about our future. There are some common threads that constitute clear calls for action within this list. First, we must constantly remind ourselves that a life in academic medicine is a good thing, well worth whatever travails and uncertainties occur from time to time. We need to communicate that promising view and to stop the whining. Second, we must embrace change even if everything but our core values and mission goes by the boards. Third, we must recruit and nurture the best talent with a more diverse blend of scholarly interests. Fourth, we must change our promotion system. Fifth, we must be the ones to master the convergence of research and clinical care that we have catalyzed. It is only by doing these things that we can be certain that we are succeeded by the most brilliant and dedicated students and faculty. They will be the systems thinkers who help us integrate all of the incredible but somewhat disconnected resources that exist in abundance in our academic health centers: basic and applied research; preventative, curative, intensive, and primary care medicine; education and training of a broad spectrum of healthcare professionals; and an outreach into communities where issues of public health as well as medical care can be addressed. Finally, we must think much more about linking our centers in a functioning network, an “internet” of healthcare, discovery, innovation, and application. That network would have the potential horsepower, if applied in common directions and toward common goals, that is unmatched anywhere in the world. Even if these goals are difficult to achieve, they are mobilizing aspirations, something that we desperately need in these difficult times.
We are the beneficiaries of many decades of public largesse and the steady expansion of opportunities in academic medicine. As we think about our legacies and the end of our careers, we must focus on who comes next and how well we position them to succeed. They will determine how academic medicine fares in the broader, more complex, more intricately integrated, and more challenging future that we must master to deliver on the promise that has inspired so many to support us.