The 1910s was the decade of tomorrow. The decade saw the invention of the modern zipper, stainless steel, the pop‐up toaster, the Ford Model T, and the army tank. Einstein established the General Theory of Relativity, crystals were first used to diffract x‐rays, and the first photographic images of Halley’s Comet were obtained when the earth passed through its tail in 1910.
It also marked the dawn of the “Golden Age” of academic medicine in the United States with the publication of the Flexner Report (Carnegie Foundation Bulletin Number Four) in 1910, so named after its primary author, Abraham Flexner. Flexner was an internationally known educator and was the first director of the Institute for Advanced Study in Princeton where he recruited a collection of geniuses, including Albert Einstein. He attracted the attention of Henry Smith Pritchett, President of the Carnegie Foundation, who commissioned Flexner to write the report on behalf of the Council on Medical Education of the American Medical Association. It was Pritchett’s belief that medical school reform was needed to root out substandard teaching and enrollment practices.
The immediate and long‐term effects of the Flexner Report are hard to undervalue. Flexner himself visited all 155 medical schools in operation when he sat down to write the report. By 1935, due to the guidelines enacted from the report, that number had been cut in half. Of the 14 medical schools operating in Chicago in 1910, Flexner wrote that they were “a disgrace to the State whose laws permit its existence … indescribably foul … the plague spot of the nation.”
Flexner found American medical schools to be far below European standards and his report detailed changes that should be made in academic medical centers in order to achieve excellence. These changes included higher admission requirements, increased duration of training, appropriate curriculum content, and the closing of proprietary medicals schools. For many years following the report, US academic medical centers performed teaching, basic, and applied research and provided cutting‐edge patient care, often to the poor and uninsured. This was the Golden Age. The public gained greatly during this period by having highly educated physicians, great medical discoveries, and, perhaps most of all, a quintessential filter through which to purify new concepts in the diagnostics and therapeutics before recommending them to the public.
Although the report is more than 90 years old, many of its recommendations are still relevant, particularly those concerning the physician as a “social instrument... whose function is fast becoming social and preventive, rather than individual and curative.” But what of that role now, in a climate when health care reform is equated with cost cutting and our academic medical facilities are crumbling?
Flexner never said exactly how academic medicine was to be funded. However, he did say how it was not to be funded: medical schools were to appoint full‐time clinical professors who would become “true university teachers, barred from all but charity practice, in the interest of teaching.” Flexner placed great emphasis on the need for these clinician/investigators to preserve academic excellence. Early on, academic medicine was able to thrive by financial support from private health insurers paying ever‐increasing fees for service, generous support from the National Institutes of Health (NIH) and, later, through subsidies built into the Medicare program.
But as if ushered in by the next passing of Halley’s Comet (1986), “managed care” (sic) gained force in the 1980s when the largesse from insurers and the NIH began to dry up. This meant that the source of medical school resources was overturned. Between 1965 and 2002, funding to academic medical centers from federal research grants dropped from 40.9% to 11.5%, and from other contracts (typically private insurers), from 21.3% to 11.5%. This, while medical school funding from practice plans (read managed care) jumped from 2.8% to 34.3% (AAMC Databook, January 2002).
Academic Medical Centers had gone from the Golden Age to the “Business Age.” As a business, their focus had been shifted from university teaching and charity practice to the evaluation of product lines and bottom lines. Thus was created the greatest conflict of interest that has ever existed in academic medicine, ie, how to balance the scholarly approach to research, teaching, and the practice of medicine with the need to practice for the sake of making money. This need to make money continues to drive medical resource utilization and has a pernicious effect on community medical practice. The tentacles of business‐oriented academic medicine extend to every facet of health care.
Over these years, my academic colleagues and I have witnessed a loss of the traditional clinical academic role models that stressed scholarship in medicine as first and foremost. It is now increasingly common for our bright young medical faculty to obtain their Masters of Business Administration before they ever practice medicine, thus increasing their image and salability to the medical corporate culture. Academic discourse and debate have been subdued. Previously, national medical meetings were characterized by often fiery debate over proposed new treatment modalities or technology. Today, such discourse might detract from the product line of medical service.
Medical students, house officers, and fellows are now being trained in medicine as a business. Academic teaching environments frequently require those in training to perform enough procedures to satisfy insurer and legal requirements, rather than requirements based on the scientific method. It has become increasingly difficult to recruit gifted young clinician/investigators for a career in academic medicine. NIH funding is reduced. There is a decrease in translational and applied clinical research. There is a loss of focus on preventive medicine. The difference in earning potential, always understood to be higher in private medical practice than in academic medicine, is an ever‐widening gulf. Morale in academic medicine is very low. It is this practice‐based model for academic medical centers that is at least partially responsible for the ills affecting the cost and quality of health care in the United States today.
Solutions
A renaissance of the Flexnerian Academic Medicine model is possible but will require bold action by government and a new social contract of academic medicine with the public. The basis of the “Flexner model” is that research and teaching are the major priorities of the center, with practice done to support these activities. The “Business model” has practice as the driving force, with teaching and research as secondary. If the business model is abandoned, then from where will the revenue come that will permit protected time for faculty to teach and do research?
An academic medical center cannot subsist solely on tuition, endowment (except for very few), contracts (eg, faculty at Veterans Administration medical centers), and research grants (at current levels of funding). Likely sources for additional support are government funds, increased funding from the NIH, and savings from deconstruction of the large practice infrastructure required to run a large practice.
For example, in 1999, the late US Senator Patrick Moynihan of New York, introduced S.210, the Medical Education Trust Fund Act of 1999. Funds from the trust would go to support medical schools, teaching hospitals, and non–Medicare teaching hospitals. Money from the fund would come from a new 1.5% tax on health insurance policies. Besides the public, who benefits more from having excellent physicians if not the insurance industry? Oversight of the expenditure of these funds would be provided by a Medical Education Advisory Commission. The details of such an arrangement would require careful consideration of transparency and monitoring of productivity. Funds would go directly to academic centers with academic freedom guaranteed.
Increased funding of research from the NIH must occur. The amount of NIH funding should approximate in today’s dollars the proportionate expenditure that existed during the Golden Age. The concentration of research funds into fewer academic medical centers has a negative influence on the rest of the institutions and therefore a new approval process will probably be likely. This will be possible with increased funds. To accomplish this, the budget of the NIH must be markedly increased. Arguably, a dollar invested in the NIH provides the greatest return to the American taxpayer than virtually any other program.
Finally, a return to the Flexner model would result in some savings for academic medical centers. Much of the resources of the academic medical center are expended to maintain an infrastructure for clinical practice. This includes paying many physicians, and others, for essentially practicing medicine without much contribution to teaching and research. Thus, by “getting out of business,” a cost savings would occur. Academic medical center hospitals and other teaching hospitals should sit on their own bottoms, and the medical schools should not have a financial obligation to the hospitals.
The renaissance of the academic medical center is necessary regardless of the type of health care reform that occurs, including universal coverage, single‐payers, multiple‐payers, government‐run, privately managed, and hybrids of public/private. The path to health care reform will always run through the academic medical center. The 100th anniversary of the Flexner report is in 2010. For the sake of the current and next generation of our patients, we can’t wait for the next visit of Halley’s Comet in 2061 for this renaissance to occur.