AAMC Reporter: March 2007

Viewpoint:
"Collaborating for the Future"

Richard D. Krugman, M.D., AAMC Chair and Dean, University of Colorado School of Medicine

In December 2006, AAMC executive staff and officers along with councils and leadership of the AAMC's Organization of Resident Representatives and Organization of Student Representatives met to discuss the future strategic direction for the organization. The meeting was led by AAMC President Darrell G. Kirch, M.D.

No doubt the AAMC has been successful and stable for quite some time, and so naturally we might think: "Why change anything?" We could just keep doing what we have always done, and inevitably good things will happen along the way. After leaving this meeting, I remembered a meeting many years ago in which Jordy Cohen had asked me to come to the AAMC staff retreat and give a "view of the AAMC from the outside constituency." I was struck then, and continue to be struck, by how much the AAMC organization reminds me of our schools of medicine.

The AAMC is a complex association, housing three councils, 14 groups, two organizations, 125 medical schools, and approximately 400 teaching hospitals. More than 3,500 individuals (most of whom are from our educational enterprise) attend our annual meeting. Each AAMC council, organization, and group meets individually during the year, and some have regional meetings as well.

How is this like our schools of medicine? In the 17 years I have helmed the University of Colorado School of Medicine, I have seen our research, clinical, and educational enterprises change dramatically into more of a complex organization.We used to have 20 departments. We now have 24, along with more than 100 interdisciplinary centers or programs with their own resources and meetings. The vast majority of these are research programs (like cancer, nutrition, neurosciences, molecular biology, etc.) that bring together faculty from many of our "basic science" or "clinical" departments. In the clinical arena, we have become more collaborative as well.We used to have separate, competing hand surgery and spine programs in several of our surgery departments. Even our education was balkanized. Individual basic science departments had their piece of the medical school curriculum. Six clinical departments had their own clerkships. The other 10 clinical departments saw only fourth-year medical students during electives. Now, it's far more integrated.

There are a lot of pressures driving us to work more collaboratively. Surprisingly, I do not think the main reason is cost, although there is no questioning the economic benefit of collaboration. For the most part, a multidisciplinary approach to science, clinical work, and education turns out to be a better way to do things. We learn more by bringing individuals from different areas and backgrounds together to solve the complex problems the National Institutes of Health and others are asking us to solve. We are providing better care to patients with complex chronic conditions when we work across specialties and with our nursing, public health, and other colleagues. And, we believe, our students will get better education if there is a coordinated curriculum linking internists, psychiatrists, and neurologists together to teach around the very complicated patients now populating our teaching hospitals.

So, how does this compare with the AAMC? As I see it, we have had the same governance structure for some time. It reflects what the organization has needed to be to best represent medical schools and teaching hospitals. Yet, in just the time I have been involved with the organization, the character and revenue streams of our constituents have changed dramatically. For example, over the past 20 years, faculty practice revenue has grown from 21 percent of the average medical school budget to 37 percent. Back in 1982 here at Colorado, our practice revenue contributed just $7 million to the school's budget—less than 12 percent. It now contributes $250 million of our $600 million budget, or 42 percent. The faculty practice organizations in our institutions are as varied in structure and function as are the institutions themselves. And yet they do not have much of a voice in the governance of the AAMC.

A second (and even larger) group of individuals who are not well represented in the governance are the 3,000 or so faculty, assistant, and associate deans who are involved in our educational missions.

How did this happen? Interestingly, I have heard that the AAMC's Council of Deans represents educators or the faculty practice. I am not sure either is true.

Further, the isolation of deans, hospital directors, and the practice plans has some risk. Maintaining the revenue streams to which we have become accustomed, or in some cases addicted, will become increasingly difficult. If our medical schools, teaching hospitals, and faculty practice groups do not figure out how to work together, I believe we will put the educational and research missions of our medical schools at risk.

I was encouraged, then, with some of the discussion at the strategic thinking and planning meeting. Over the course of the next several months, we will look for the advice and thoughts of you, our colleagues, who are living through these pressures every day. I congratulate Darrell Kirch for opening this topic of conversation, and I look forward to working with him and with you to see if we can organize our organization to better reflect what our current and future needs will be.

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