Table 2.

Practical Integration Issues Identified by School of Medicine Deans When Community Physicians Affiliate With Academic Medical Centers^a

Categories	Responses
Clinical productivity	Different electronic medical record usage across sites creates barriers Equipment, supply standardization across system takes time Standardization of clinical protocols/procedures important (community and academic faculty should work together to create system-wide protocols) Who resolves quality/productivity differences between groups (community/faculty)? (Chair vs CMO vs practice plan vs hospital)
Communication issues	Inadequate communication about hospital/clinical expectations Transparency with contracting important What are best ways to communicate to all physicians across the system?
Culture	Academic faculty concerned education/research missions may be lost with increasing emphasis on clinical productivity Community physicians can be frustrated initially by slower AMC “system,” not as responsive to their demands Crucial to embrace strengths of each group (so not 2 classes of physicians) Cultures (community/academic) different; Chairs/leaders need to be welcoming to community physicians Slow process to integrate 2 cultures (easier for new graduates, may take a decade for senior physician integration) Research trial payment should be identical across system (all paid, or not paid, equally) Teaching should be an expectation in contracts for everyone when students, residents/fellows available “Us vs them” mentality can develop if not careful Academic physicians may “look down upon” community physicians as clinical workers only Community physicians may “look down upon” academics as not as efficient nor patient-centric
Governance issues	Are department chairs, CMOs, hospitals, or practice plan responsible for quality issues in their specialty? (many chairs want to have new practitioners report through them to ensure same clinical quality) Contracting needs to be transparent Need to clarify oversight/governance structure throughout health system (problem cited by several deans) Noncompetition clauses (if exist) should be in place for all clinicians in system (ultimately), or clarified based on location of practice in transparent way Who is responsible for credentialing/recredentialing new providers? Who do new community physicians report to? Practice plan? Chair? Who has authority hire/fire new providers? Does it matter if they were hired by hospital vs AMC department? Who is involved in initial, and continued, contracting?
Resources	Competition for trainees (who gets to work with residents, fellows?) How can limited clinical space be shared most equitably? Who gets support personnel (nurses, MA, NP, PA)?
Salary issues	All physicians should have equal opportunity to earn clinical incentive payment for extra work Concern private community physicians earn more than academic physicians in same system (equal pay may take several years to achieve Fear of special deals for community physicians joining (some deans state there needs to be a glide path toward target of equality over a few years) How does overnight and weekend call affect pay? Who takes call? Opportunity vs shared burden? How to continue honoring social contract of caring for poor and most vulnerable patients? How does this affect salary? Internal competition for better payer mix can occur (how to resolve while maximizing insured patients?) Should salary/pay be location dependent?

^aAMC, academic medical center; CMO, chief medical officer; MA, medical assistant; NP, nurse practitioner; PA, physician assistant.