BOSTON, November 7, 2004 - Jordan J. Cohen, M.D., president of the Association of American Medical Colleges (AAMC), delivered the following statement today, at the AAMC's 115th Annual Meeting:

"Two months ago, something quite remarkable happened. Former President Bill Clinton - a vigorous man of 58 - entered a New York teaching hospital because of chest pain and shortness of breath. In short order, he received a battery of definitive tests to identify his problem, was stabilized with the latest anti-coagulants, and had life-saving, quadruple bypass surgery. In less than a week, he was out of the hospital and well on the way to a full recovery - that is, assuming he now follows his doctor's advice and takes his statins!

Remarkable, yes, in many respects:

• when you consider how much recent knowledge and new technology were involved in saving his life
• when you consider that his favorable outcome would have been much less likely just a few years ago
• and, when you consider that the techniques that saved his life were pioneered by our community and now save thousands of lives every day at hospitals around the world.

Yes, medicine has changed a lot in a remarkably short period of time. And the pace of change both within and beyond medicine is about to get even faster. Genomics and stem-cell research promise to alter fundamentally the way tomorrow's doctors will care for their patients. New information technologies are transforming our lives, our work, and our relationships with patients and with each other. The demographics of our population are changing before our eyes. We're getting older, more urban, and much more diverse. The burden of illness is shifting dramatically from acute, self-limited diseases to chronic, unrelenting disorders and disabilities.

The question is this: Are we in academic medicine ready for the fundamental changes that are coming? Do we have a culture conducive to making the changes needed to prepare our students for the revolutionary new medicine of tomorrow; to refashion our research mission to fully exploit the new frontiers of science; and to transform our patient care systems to provide cost- effective, universally accessible, and high quality health care?

My friend Daniel Federman once remarked to me, 'We in academic medicine love progress, but we don't like change!'

And with good reason, some might say. After all, we've been incredibly successful doing things just the way we do, thank you very much. Why would we change the way we educate when we think we produce the best doctors in the world? Why would we change the way we do research when we think we're responsible for most of the miraculous scientific advances in modern times? And why would we change the way we care for patients when we think we provide the best care available anywhere?

Besides, prudent institutions do not rush to make changes; after all, what seems like an urgently needed change today could prove to be a passing fad tomorrow. Which is not to say that we haven't undergone some pretty significant changes in the past several years. Just consider:

• the phenomenal growth in the number of faculty, in the size of our budgets, and the number of new buildings on our campuses
• the rapid rise in the number of women in our student bodies and on our faculties? Talk about change!
• and all the new modes of education that we've adopted, such as problem based learning, multidisciplinary basic science courses, and standardized patients.

Look at what's happened in our research enterprise. We've deciphered the human genome, created brand new fields of inquiry - all the way from knockout mice to health services research - and spawned a whole new biotechnology industry that's based on discoveries from our laboratories. Look at our hospitals and practice plans. They've demonstrated remarkable adaptability in the face of an unforgiving marketplace. And if you want to see change, how about all those mergers that took place in the '90s - and, of course, all the de-mergers that followed?

And yet, at a time when the cost of health care is continuing to skyrocket, when unconscionable health care disparities are rife, when information technology is transforming virtually every other sector of our economy, when public demands for transparency and accountability are escalating daily, indeed when the whole world seems to be in flux, we are seen by many, including many of our own colleagues, as stagnant, complacent, rooted in our time-honored traditions, and hell-bent on resisting change.

So, which is it? Are we awash in change or frozen in time? The answer is: we're certainly not stagnant but, at the same time, we're still doing a lot of our core activities much as we've done them for decades.

Most of the good teaching cases have long since left the hospital, but our students and residents still spend most of their time on the wards. Even after limiting resident duty hours to 80 per week, graduate medical education is still driven too much - as it was when I was a house officer in the 60s - by the hit or miss service needs of our hospitals and clinical faculty rather than by what our residents actually need to do to achieve the requisite competencies for high quality practice.

Individual investigators initiating their own studies remains our most revered model of research, even though the state of science now begs for more multi-disciplinary research involving the collaborative efforts of multiple investigators.

Our promotion and tenure criteria still place the highest value on individual research accomplishments, despite the clear need to reward those who contribute prominently to successful team efforts, and despite the increasing importance of recognizing the excellent teachers and world-class clinicians whose academic contributions are no less important to the success of their institutions.

Many of our institutions still rely on paper and pencil to manage and document their complex patient care activities even though computerized order entry, computer-based decision supports, and computerized health records are known to greatly reduce errors and improve quality.

And we still depend on a fragmented, uncoordinated model of health care delivery - a model that may have been well suited to the needs of a former age dominated by acute disease, but today is patently ill-suited to manage the growing burden of chronic disease and disability in a progressively aging population.

No doubt about it, compelling arguments can be made that major changes are needed in the way we carry out each of our core missions to meet the demands of the 21st century. Not nibbles around the edges, but basic changes in the way we educate, in the way we perform and reward research, and in the way we care for patients. And not just change for the sake of change, but positive change that responds to the significant shortcomings we all know exist, and that address the rapidly evolving needs of the society we're pledged to serve.

Pushing us to change is the accumulating evidence that our current practices are, indeed, falling far short of needed and achievable improvements:

• evidence that our model of clinical education - as our recent Dean's Report acknowledged -- is out of alignment with the realities of 21st -century medicine
• evidence that we are not preparing a sufficient number of physicians to be clinical investigators and not nurturing the careers of those we have
• evidence from a recent Rand study that patients have at best a 50:50 chance of getting optimal care from our country's current system
• evidence that the lack of racial and ethnic diversity in our profession contributes to unconscionable health disparities
• and evidence now from many sources that our vaunted clinical settings are not nearly as safe as they could and should be.

Pulling us to change are the unprecedented opportunities that exist for using current knowledge to make quantum advances in all of our missions:

• knowledge about how adults learn through active work on meaningful tasks
• knowledge about how computer and mannequin-based simulations can help doctors learn critical clinical skills without risking real patients
• knowledge about how to reliably and ethically translate new scientific information into better strategies for prevention, diagnosis, and therapy
• knowledge about how evidence-based, patient-centered care leads to more reliable and less costly outcomes
• knowledge about the effectiveness of teams of health professionals in caring for the chronically ill
• and knowledge about the capacity of information technology to improve the efficiency and quality of virtually everything we do.

With all that push, and with all that pull to improve our performance, we should be well-positioned to make rapid progress on all fronts. And, indeed, one can see many examples throughout our community of striking innovations, pockets of real change that evidence the creativity, the commitment to public service and the devotion to excellence that has long characterized academic medicine. But it would be hard to argue that the present pace of change within medical schools and teaching hospitals, as a group, is commensurate with the magnitude of the challenges and opportunities we face.

Why is that? What is it that prevents us from responding more quickly to all those pushes and pulls? The simplistic answer is that we're just like everyone else - everyone resists change; it's human nature. But that answer fails to adequately explain what goes on within academic medicine. What is it that accounts for the enormous changes evident in some aspects of what we do, and the profound resistance to fundamental change evident at the same time in other, arguably more basic endeavors?

One frequently cited barrier to change is our devotion to autonomy, one of our most deeply rooted and cherished cultural traits. Some degree of autonomy, of course, is called for in our social contract, which gives us the right - indeed, the obligation - to set and enforce our own standards.

But it's not autonomy, per se, that's the problem; it's autonomy untethered from accountability that is the bar to change. It's autonomous indifference to the compelling calls for substantial improvement that threatens our credibility as accountable public servants. It's failing to recognize that self-satisfaction with past success is no excuse for ignoring the need to change to secure a better future.

Another common explanation of our resistance to change is our complexity. No doubt about it, academic medical centers are among the most complex organizations ever devised. Compounding our complicated structures, the issues we deal with often interact with one another in extremely complex ways.

To say nothing of the complex external environment with which we have to deal, with its onerous regulatory burden and its arcane systems of financing our missions. Producing fundamental change in the face of such complexity is exceedingly difficult. Besides, everyone is already too busy; who has time to think, let along think about change?

Yet, while our devotion to autonomy, our organizational complexity, and our busy lives may all be valid explanations for the difficulties we face in making needed changes, we dare not use them as a pretext for remaining wedded to outmoded ways of fulfilling our core missions.

Several years ago at a spring meeting of the Council of Teaching Hospitals in Seattle, we were treated to a great talk by Philip Condit, then the CEO of Boeing. He described the challenges of taking over a company in need of major restructuring because of murderous competition that was threatening to drive Boeing out of business. He said the biggest barrier he faced in initiating needed changes was the firm belief among his managers and department heads that 'airplanes are different.' Things that had worked wonders in other industries faced with similar threats were considered irrelevant. 'Airplanes are different' was the constant refrain.

Sound familiar? How often do we hear that what we do is totally different from anything anyone else does? It wasn't until Condit convinced his people that making airplanes was not a unique activity, that it had many features in common with other manufacturing processes, that Boeing was able to begin making the large-scale improvements that pulled the company back from the brink.

While this story can teach us several lessons, it emphasizes, first and foremost, the critical importance of leadership. Students of the change process know that nothing can substitute for having institutional leaders who are driven by the highest values, who recognize when fundamental change is needed, who signal their serious commitment to change, who articulate a clear vision of a better future, who have a strategy for how to get there, and who know how to forge consensus.

And not just leaders who are 'hero-CEOs,' as Peter Senge calls them. But leaders at every level of the organization, from top executives to people on the front lines. Both kinds of leaders are necessary; neither alone is sufficient. Senge writes:

'It is always important to remember how limited executive leaders are in their ability to genuinely initiate change. They can encourage. They can provide a ompelling case for change. They can continually work to reduce barriers to change, but they depend critically on committed front-line leaders to integrate new ideas into day-to-day practices.'

In my opinion, we have many leaders in academic medicine - deans, associate and assistant deans, hospital CEOs, practice-plan directors, department chairs, division chiefs, GME program directors, clerkship directors, and many others - leaders who have exactly the right qualities who are chomping at the bit to get their institutions to change. What we generally lack is the second ingredient that gurus of change identify as critical - an organizational structure and a decision-making apparatus that can translate leadership direction into coordinated action. Let's face it: academic medicine's typically fragmented administrative structures practically paralyze our ability to change. Our traditionally autonomous departments and divisions are simply not well suited to pursue purposeful, harmonized, high-level institutional goals. Put more plainly, having a thousand points of veto is a sure recipe for constipated decision-making. Nowhere is this more true than when attempting to coordinate activities that span the clinical/academic interface.

But there is no getting around it. A sine qua non for achieving effective, meaningful change is having the ability to make deliberate, timely decisions that quickly permeate the organization and that truly govern the activities of an institution's disparate units. To call for a quick fix for these well-ensconced cultural barriers to change may be more than a bit optimistic, to be sure. But organizational structures and decision-making processes are the products of people and, in theory at least, these obstacles can be minimized once vested interests are convinced there is more to be gained than lost from giving up some autonomy.

Which brings us back to leadership.

It seems clear that organizations willing and able to embrace needed changes in their administrative and decision-making arrangements will have one thing in common. They will be led by individuals at all levels with the capacity and courage to temper their longing for autonomy with a heavy dose of reality. And the reality is that we are failing to recognize how serious our shortcomings are.

We are altogether too complacent, too willing to assume that our record of past accomplishments will ensure future success, no matter what. We are too wedded to the forms of the past. We are not prepared to take the necessary risks. We lack the sense of urgency we need to match the magnitude of the problems we need to solve. The reality is that our old platform is burning and we are just beginning to smell the smoke.

So, what's needed, it seems to me, is to raise the decibels on the fire alarm so that more of our leaders will hear it and will respond to it. And that is precisely what the AAMC hopes to do. But to do so effectively, the association itself must explore new ways of fulfilling its traditional missions.

I believe that well-targeted, catalytic assistance by the association can unleash the tremendous capacity for creativity that exists in our community. To signal our intent to become more assertive in supporting our constituents in the very hard work required to make fundamental change, the association has launched two new institutes: the Institute for Improving Medical Education and the Institute for Improving Clinical Care. Both of these initiatives are devoted to enhancing the association's effectiveness in triggering the concerted, collaborative efforts that will lead to widespread adoption of the improvements we all know are needed.

The methods at our disposal to accomplish this ambitious task are not new; what is new is our more explicit and bulked-up commitment to be an agent for change.

By calling on those of our members who are already actively engaged in robust improvement activities, the AAMC will identify and celebrate the early adopters, the pioneers who can pave the way for the rest of the community.

By inviting key stakeholders to workshops, colloquia, symposia, and the like, the AAMC will forge consensus on needed improvements.

By partnering with other like-minded national organizations, the AAMC will leverage our limited resources to achieve more bang for the buck.

By commissioning white papers authored by thought leaders within and outside the academic medicine community, the AAMC will encourage fresh thinking about opportunities to improve.

By acquiring foundation and government grants and channeling the funds to interested constituents, the AAMC will stimulate innovation.

By conducting relevant research and by marshalling existing expertise, the AAMC will sharpen its advocacy agenda, which in turn will educate Congress and the Administration about needed changes in public policy.

Here are some of the challenges we have already begun to tackle in pursuit of our change agenda:

• modernizing the content and structure of clinical clerkships for medical students
• implementing proven models of chronic disease management in academic ambulatory settings where learners are integral members of the health care team
• capitalizing on the opportunity created by the 80-hour limit to look carefully at how in-patient services and resident education might be fundamentally redesigned to improve the quality of both
• supporting ready access by everyone to peer-reviewed, computer-based teaching modules, including virtual patients
• strengthening the recruitment and retention of clinical investigators to facilitate the translation of our scientific discoveries into human benefit
• encouraging the reporting of valid quality measures to stimulate improvement in clinical care, and
• sharpening the focus of our professional development activities to strengthen the roles of faculty leaders.

No one is prouder than I am of the achievements that medical schools and teaching hospitals have made over the past decades and that they continue to make. But the stage is now set for us to make even more magnificent contributions to the welfare of humanity in the future.

The integrative power of information technology, the predictive power of genomics, and the regenerative power of stem cells constitute an unprecedented confluence of scientific and technological advances that offer our generation more powerful tools for improving the length and quality of life than any previous generation could even imagine. Seizing the full potential of these opportunities demands that we loosen our hold on outmoded practices and embrace the fundamental changes needed to succeed in a far different future. The status quo will not suffice.

The IOM stated it clearly in its seminal report, Crossing the Quality Chasm: 'The current system cannot do the job. Trying harder will not work. Changing systems will.' That wisdom applies not just to our clinical mission but to our education and research missions as well.

We need to take to heart the wise counsel of Dee Hock, the genius behind Visa, who said:

'Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving the substance of the past by clothing it in the forms of the future.'

Our substance is found in our most basic and enduring cultural traits:

• our devotion to serving others
• intellectual curiosity
• scientific rigor
• our commitment to integrity
• our zeal for innovation
• our pursuit of excellence, and, perhaps above all,
• our tradition of moral leadership.

We must clothe those enduring - and endearing - qualities in new forms designed to meet the tests of a future that is already upon us.

As T.S. Eliot wrote: 'Only those who risk going too far can possibly find out how far they can go.'

Others have done it. We, too, owe it to our country to find out how far we can go. Overcoming our cultural barriers to change will not be easy. But we have plenty of leaders to guide the way. They are in this room; and they are everywhere in our community. You know what needs to be done; and you know you can't do it by yourself. So, let's take up the challenge to work together to unleash our enormous potential for delivering on tomorrow's promise."

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The Association of American Medical Colleges is a not-for-profit association representing all 129 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 68 Department of Veterans Affairs medical centers; and 94 academic and scientific societies. Through these institutions and organizations, the AAMC represents 109,000 faculty members, 67,000 medical students, and 104,000 resident physicians. Additional information about the AAMC and U.S. medical schools and teaching hospitals is available at www.aamc.org/newsroom.

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