AAMC Reporter: January 2006

Thomas M. Priselac, M.P.H., President and Chief Executive Officer, Cedars-Sinai Health System; AAMC Chair, 2005-06

Viewpoint: "The Leadership Imperative for Academic Medicine"

Academic medical centers (AMCs) represent the best of American health care. They offer the latest technological advances and provide vital primary and secondary health care services to many people, including the most vulnerable populations. Either on their own or through collaboration with industry and private partners, AMCs have catalyzed the explosion in medical knowledge through basic science and translational and clinical research over the last half century, positioning America at the forefront of medical capability in the world.

Moreover, AMCs have created standards for medical education that are recognized worldwide. The most ambitious and creative centers are helping to shape and improve medical education around the world as they engage in their own version of globalization.

Academic medicine occupies the place of respect that it does today because, for decades, it has provided responsible leadership in the context of the economic, social, and political factors. It has earned the public's trust. The issue now is, How can it maintain that trust? The answer is, in part, still leadership.

In the past, our ability to meet public expectations has generated substantial government and private investments in our respective communities, thereby making AMCs the leading health care providers and, in our local markets, one of the most significant economic engines. Today, however, the American health care system has entered a fundamentally different and unprecedented era. To be sure, the fruits of our national research infrastructure have created stunning improvements in diagnostic and treatment capability. But in today's economic, social, and political environment, medicine's expanded capacity to heal has raised serious questions about how well we can sustain our current system. And while there are many ideas about how to improve things, there is a broad consensus on what some of the major problems are: rapidly escalating costs, increasing numbers of uninsured people, and unacceptable variations in quality, resource use, and safety.

With many policy and operational interventions needed to confront these problems, academic medicine has an opportunity to provide leadership.We must address the underuse, overuse, and misuse that simultaneously drive unnecessary costs in health care, as well as unacceptable variations in quality, resource utilization, and safety. Within the framework of an ever-expanding diagnostic and treatment arsenal, the American health care system must remain focused on continuous efforts to find answers to the question,What is the least expensive way to reach an appropriate clinical outcome?

But those answers should be based on professionally determined definitions of the appropriate processes for providing quality health care and clinical outcomes. And we must address this issue in a prioritized, systematic way — through the collective research, educational, and clinical missions of AMCs, together with the relevant professional societies, and supported by targeted government and private funds.

Without compromising their fundamental research mission of advancing diagnostic and treatment capability, AMCs can make better use of their extensive research potential to advance medical evidence as a guide for clinical decision making. Efforts to eliminate overuse will require a substantial expansion of research that better delineates clinical indications for diagnostic modalities, treatments, and procedures. That should lead to quality improvements associated with eliminating underuse across the continuum.When resulting standards can be introduced in the clinical setting, they can be applied to quality and safety concerns related to misuse.

At the same time, we know that improving value in the American health care system will require us to address the sociology of medicine. The resources available in the larger educational enterprises with which AMCs are affiliated can help us address this complex topic.

The clinical operations in AMCs can be harnessed to demonstrate both the effectiveness of such improvements and their limitations. Academic medical centers, with their more closely integrated physicians and other health practitioners, could be a powerful force for demonstrating the benefits of using information technology and other approaches to enhancing the quality, safety, and cost-effectiveness of treating individual patients and populations, on both an episodic and longitudinal basis.

Besides ensuring that undergraduate and graduate medical education is constantly adopting the emerging standards, our organizations also can redesign our continuing medical education programs to address another significant problem—namely, an insufficient rate of adoption of evidenced-based standards in clinical practice. As well, AMCs will be challenged to develop new approaches that lower the inherent cost structures of undergraduate and graduate medical education, both to manage those cost structures more effectively in an increasingly cost-conscious environment and to provide some financial relief for people pursuing medical careers.

True, a great deal of effort has already gone into initiatives of this type. But the message being sent by those who purchase health care is clear: Meaningful change is not occurring as deeply, as broadly, or as quickly as possible. So we must ask ourselves whether we have truly initiated sufficient change in our health-services research, clinical operations, and educational missions.

How academic medicine responds to this issue will determine whether or not we continue to earn the public's trust in this new era. Far more important than the practical benefits for AMCs, medical education's values and professional standards obligate us to use our unique capabilities to create a more responsible, more equitable, and more responsive health care system.

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