Change and the academic health science centre: a 1997 perspective
Stuart M. MacLeod, MD, PhD
Clin Invest Med 1997;20(6):399-404.
Dr. MacLeod is professor in the Departments of Clinical Epidemiology and Biostatistics, Medicine, and Paediatrics, Faculty of Health Sciences, McMaster University, and Director, Father Sean O'Sullivan Research Centre, St. Joseph's Hospital, Hamilton, Ont.
Reprint requests to: Dr. Stuart M. MacLeod, St. Joseph's Hospital, 50 Charlton Ave. E, Hamilton ON L8N 4A6
Contents
Introduction
For at least 20 years, there has been a growing sense of the inevitability of change in the medical academic world. It would be hard to find an engaged academic in a Canadian medical school who does not recognize the changing sociopolitical environment for health and the impact of new technology on the education of health care professionals.
In the past decade, there have been 2 World Summits on medical education, held in Edinburgh in 1988 and 1993. The first of these meetings resulted in the Edinburgh declaration, which was hailed as an appropriate template for future medical education.1 At least one skeptic, however, lamented the absence in the declaration of any feeling for "the fun, enjoyment, and the intellectual and emotional satisfaction that courses in medicine have given to so many."2 In 1993, delegates were challenged by "the urgent need to respond to serious pressures on medical education in all its stages and the growing criticism directed at the health sector, at doctors themselves, and at the medical educational institutions that produce them." The report of the 1993 summit on medical education summarizes issues that, while generalized for an international audience, are almost as current today as they were in 1993.3
The 1997 Annual Meeting of the Association of Canadian Medical Colleges (ACMC), the Association of Canadian Teaching Hospitals (ACTH) and the Canadian Association for Medical Education (CAME) addressed the Canadian sociopolitical and economic changes currently influencing the environment for health care and the education of health care professionals. Particular emphasis was placed on advances in information technology and on the new capacity that has been generated for timely dissemination of up-to-date information on best clinical practices. It is generally recognized that the revolution in information technology has provided a powerful tool to help professional educators, which, if properly used, will permit them to effectively meet the learning requirements of health care reform. In this issue, Dr. Rolf Sebaldt, a prominent medical informaticist, offers a personal perspective on the place of information technology in the academic health science centre. A parallel view has recently been published by the Advisory Panel on the Mission and Organization of Medical Schools, struck by the Association of American Medical Colleges.4
In spite of the obvious pressures for change in the education of health care professionals, some would argue that an evolutionary process is under way and that academic health science centres should simply run with the tide. While it may be true that academic centres are powerless to change the course of events, we must ask what consequences will result if there is no planned response to current pressures. One of the most popular activities in medical schools over the past 15 years has been strategic planning. A great deal of time and energy has been expended to produce reports that often languish in the darkest recesses of the library or the Dean's filing cabinet. Krauss and Smith5 have recently argued that academic medical centres should turn to strategic thinking, rather than strategic planning, if they wish to regain a leadership position within the restructuring of the health system. It has been argued that more differentiation among medical schools should be sought and that planning for the future should encourage recognition or even amplification of institutions' unique qualities.5,6
What follows is a broad overview of the discussions that took place at the 1997 Annual Meeting. Those in attendance were more than willing to look at the successes and failures of the Canadian academic medical environment. The result was a great deal of thoughtful discussion of sociopolitical and economic trends in health, leading to suggestions of preferred directions in the continuing discussion of the education of health care professionals.
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The environment of societal change
It has been said that "the future isn't what it used to be," but it is clear that those who wish to foresee where we are going must understand where we are coming from. The process is somewhat akin to rowing a boat forward to a preferred destination with with one's gaze fixed firmly on the shoreline that has been left behind. As with rowing, a 1 or 2 degree difference in course may translate into a radical alteration in the point of arrival. Clearly, there is a need within Canadian academic medical institutions for a better sense of institutional history than currently exists. Perhaps because of the pressures of modern academic life or perhaps because of rapid turnover in faculty, it is sometimes difficult to find seasoned faculty members who maintain a full awareness of the evolution of a faculty's programs or a sense of the foregoing process of institutional decision-making. It is sometimes difficult, as well, for faculties to justify positions for individuals who are prepared to devote a major part of their intellectual energy to the understanding of sociopolitical realities and their impact on the overall health care environment, including its education and research components. The result of these deficits in faculty understanding may be a less-than-adequate awareness of the societal and economic changes influencing the education of health care professionals.6
The keynote speakers at the Annual Meeting, Ms. Diane Francis, Dr. Richard Cruess and Dr. Bernard Shapiro, identified 5 major societal and economic changes that warrant consideration by the academic health science centres:
- the tyranny of the debt,
- the corporatization of medicine,
- the globalization of information sources,
- "disintermediation" or a foreshortening of the medical care process, and
- a growing public distrust of political and professional elites.
The tyranny of the debt
The last 5 years in Canada have seen widespread public acceptance of the need to control government expenditures. Health and education programs have been sacrificed at both federal and provincial levels in the name of deficit reduction. Total health expenditures in Canada in 1994 were $72.5 billion (9.7% of GDP). In 1995, total health expenditures were reported as having fallen to 9.5% of GDP.7 Public sector expenditures for health were recently reported as accounting for just less than 70% of total health costs, a decline from 76.4% of the total in 1975.8
It is clear that Canada has become less tangibly committed to the previously recognized national commitment to social justice, and this has major implications for health and health care, as well as for education and research. The most striking observation is the degree to which Canadian voters have accepted the severe cuts to the Canadian health and social transfer payments as inevitable. There is, however, evidence that Canadians are now beginning to worry about the quality of health care, and there are plentiful signs that the vast majority consider health and social programs a top priority for public expenditure.7,9
Corporatization of medicine
As provinces have struggled to cope with reduced health and social transfer payments from Ottawa, they have increasingly adopted an approach which, in many jurisdictions, would be called "managed care." The provincial health care programs across Canada are beginning to look similar to large managed care programs in the United States, with a major commitment to cost containment, sometimes at the expense of efficiency and often at the expense of quality. In the view of some, the provincial health care system in Ontario should be regarded as the largest managed health care initiative in North America. The overwhelming emphasis on cost containment in the 1990s has resulted in a considerable erosion of autonomy for health care institutions and agencies, and particularly for health care providers and their patients. To counter these pressures, new ways have been found to bring private resources into the health equation, resulting in what some have called "passive privatization." With the private component of health care funding growing steadily, the definition of "core" medical services is likely to be progressively narrowed in the future.
Globalization of information sources
There has been an unprecedented explosion in the volume of available information, perhaps most notably in public access to health information. Health information is transmitted through a variety of channels, including the print media, radio and television, and the Internet. The explosion of the Internet, in particular, has been astonishing. The Arthritis Society, for example, has offered a Web site (www.arthritis.ca) for approximately a year, and the site is now receiving more than 120 000 visits per month (D. Morrice, President and CEO, The Arthritis Society: personal communication, 1997).
While there is considerable quality control of medical and scientific publications, and, to some extent, other print media, there is no mechanism for quality control of information on the Internet. For every carefully designed site, such as that of the Arthritis Society or the Canadian Medical Association (CMA Online), there are numerous others purveying unfiltered information. The average patient has access to unprecedented amounts of health information, but much of it may be wrong. Nonetheless, patient interactions with physicians are often generated on the basis of information gleaned from unreliable sources.
Disintermediation
The term "disintermediation" was coined by Ms. Francis in her address to the Annual Meeting. She uses this term to mean the loss of influence of those who normally interpret information to their clients. Of particular concern is the effect that this may have on health care professionals, who have been trained to be interpreters of new knowledge and advocates on behalf of their patients. Increasingly, the public is obtaining information from nonobjective sources and moving directly to advocacy positions with respect to their own health or to public policy. Clearly, the influence of health care professionals who have specialized in the assembly of evidence and the interpretation of scientific data is being rapidly eroded in this environment.
Growing public distrust of political and professional elites
Recent years have seen a rapid movement to populism, which rests on a "show me" attitude in which the expert opinions of scientists, educators and professionals are portrayed as elitist. When this degree of skepticism is coupled with a decrease in public trust of the traditional political parties and of individual politicians, the result is what Dr. Shapiro referred to as a "dumbing down" of medicine and health care. This trend is discouraging for academic health science centres, which have contributed much of their effort to better informing the public and to encouraging a sense of realism about medical and health outcomes. At its worst, the shift in public attitudes may result in an inappropriate nihilism about evidence-based treatments or unfounded optimism about unproven remedies. Academic health science centres are under urgent pressure to contend with disruptive forces threatening good health, which often remain in play because of their unrelenting exposure through the media and the Internet.
Impact of societal changes
The impact of the trends enumerated, which are only representative of a much broader array, is not in question. The successful planning of the 21st century academic enterprise will lie in anticipating the future and helping to shape it with enthusiasm. One cannot help thinking of the inimitable Stanley Kubrick film Dr. Strangelove and "how (he) learned to stop worrying and love the bomb." Academic centres must somehow learn to relish the challenges that surround them and to take pleasure in the confrontation. Each academic health science centre must engage in a review of its unique capabilities and must be prepared to make hard choices about those elements to be developed and those to be relinquished. There should be no perceived threat in the differentiation of academic programs.
At meetings of the ACMC, the ACTH and the CAME as recently as 5 years ago, the discussion was centred almost entirely on social contracts or covenants between the institutions/professions and society. The concern at that time was with the "deliverables" expected from the academic health science centre to improve the health of the public. In the intervening 5 years, there has been a change in focus on the part of medical educators. In 1997, there is a new fixation on redefining educational institutions and, to some extent, the medical profession. There appears to have been an erosion in confidence and a diminution of self-esteem for the profession, and this is reflected in introspection about professional roles and the responsibility to maintain high standards in education, research and service. While this is not incompatible with other objectives, it may sometimes appear to be in conflict with society's demand that modern graduates act as public servants, primary healers and often unquestioning caregivers.
It is noteworthy that the Association of American Medical Colleges has recently assembled a Forum on the Future of Academic Medicine.10 That body is beginning to grapple with many of the issues enumerated above. In summary, the sociopolitical environment is volatile but nonetheless rife with opportunities for adaptation that may strengthen academic centres.
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Key responses in education required of academic centres
Four areas of opportunity were highlighted in discussions. The list is not comprehensive but provides some focus to continuing strategic thinking.
First, there is a need for better description of the products of educational programs. The Liaison Council on Medical Education (LCME) mandates that North American medical schools graduate an "undifferentiated physician." This terminology in itself may compound the difficulty in product definition; however, it should be seen as a call for the development of comprehensive and well-integrated educational programs that effectively marry basic, social and clinical sciences while avoiding an excessively narrow focus at an early stage. Implicit in the LCME standard is the notion that other health care professions should also provide comprehensive preparation at the undergraduate level while leaving room for later differentiation. The challenge is clearly put to postgraduate medical education and continuing medical education programs to provide the means of differentiation.
Second, multidisciplinarity in educational programs is critically important. Health care will not, in the future, be delivered mainly by individual physicians practising in isolation. Ways must be found of preparing students to function in cross-disciplinary, problem-solving teams. Again, corresponding adjustments to the undergraduate programs for other health care professionals will be required.
Third, Canada is suffering from a lack of highly trained individuals with expertise in theoretical and applied science, and this is as true in health sciences and medicine as in other fields. Universities must re-emphasize the importance of graduate studies in both applied and theoretical domains in faculties of medicine and health sciences.11 Society will increasingly look to academic health science centres as the source of essential expertise, and graduate students may, in the future, be seen as a product of our programs as important as medical or health practitioners.11
Fourth, throughout the conference, the importance of information technology to the future of education and research was highlighted. It is necessary to move beyond the recognition of information technology as an essential tool to the understanding of informatics as an integrated research and educational activity that will underpin 21st century health care practice. Many private sector organizations are vying for leadership in this area, but it is critical that universities maintain a dominant role, because of their interest in the quality of the knowledge/information and in the research data supporting it. Undergraduate, postgraduate and continuing education students must be better prepared to function in an information-driven health care system.
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Key responses in research required of academic centres
Canadian society requires a continuing supply of new knowledge from basic medical, social, behavioural and clinical health sciences. Universities are well established as the primary source of basic biologic and medical knowledge in Canada. Their record has been less consistent in the other relevant domains, although population health sciences, including epidemiology and economics, have grown exponentially in the past decade. One notable advance in which Canadian academic centres have played a prominent role has been the development of the Cochrane Collaboration, with its commitment to the preparation of systematic overviews of medical and scientific knowledge relevant to important health issues. Canadian academic centres have been less successful in assuring that the fruits of their research labour are applied to the development of public policy, but this must be seen as an important target for the near future. Success on that front will be more likely if academic centres are able to mount balanced research programs and to provide the data needed by policy-makers.1113 Academic health science centres must increase their efforts to develop a comprehensive, responsive and well-integrated research enterprise.
Universities have a key role to play in public advocacy for health. They must lead the demand that public policy be informed by appropriate research and participate in establishing the research agenda. The Canadian academic establishment should also play an advisory role to the public in helping laypeople to understand the need for posthoc evaluation of the changes to the health care system. Universities and teaching hospitals cannot stand back from the need for this kind of evaluation, even though it often does not appear academically challenging or theoretically exciting. Educational programs are needed to prepare applied health scientists who can support the public policy agenda.11
Finally, the greatest opportunities in research clearly lie at the interface between the publicly funded universities and private sector partners. It is unlikely that resources will be found for world-class science unless exciting strategic partnerships are forged with those who have financial resources and recognize the need for the intellectual capital in universities. It is critical that the changing realities at the publicprivate sector interface be approached with enthusiasm rather than with the sense of impending doom that characterizes many current university pronouncements on the subject. Recent budgetary initiatives from the federal government and some provincial governments have once again made it clear that the political leadership looks to public/private partnerships as the preferred route to improving Canadian research and development in basic medical science and in information technology. Canadian medical centres must respond to these opportunities in their educational and research programs or forgo much of the opportunity for growth and innovation.
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Conclusion
The delegates from the ACMC, the ACTH and CAME are clearly ready to become engaged in strategic thinking about the future of the academic health science centre. There is widespread appreciation of the magnitude of change sweeping the health care system. The 1997 Annual Meeting presented a welcome opportunity for systematic review of the forces that will shape the academic centre of the future. We are sailing into turbulent waters and will need strong leadership. In fact, it may be timely to consider the development of the next generation of leaders for academic centres.6,14 This could be seen as a priority for the educational and research agendas in Canadian medical schools.
One is left with the inescapable conclusion that there is no issue more central to the Canadian consciousness than health and health care. Academic medical centres in Canada possess intellectual assets that position them well for a major future role in redefining the system of health and social services. Strong leadership is vital, and there is no source more appropriate than the Canadian academic community. Awareness and understanding of societal changes driving health reform are not the problem. What is needed now is the collective will to act.
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References
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