The business of education: a new paradigm.

MANY PHYSICIANS WHO PRACTICE AND TEACH IN academic medical centers feel that the changes in health care delivery and financing threaten the fulfillment of their missions. (1, 2) While there is little question that the pressures of the marketplace are rapidly transforming the workplace for all physicians, academic medical centers are feeling particularly threatened. (1) Academic physicians have functioned in a world where there were resources and a culture that supported the interplay of clinical practice with teaching and research. These centers are said to be more costly because of added costs and inefficiencies in delivering health care while engaged in education, training, and research. Even carried out with efficiency and prudence, these responsibilities compromise the ability of the academic medical centers to be economically competitive in the contemporary environment.

The purported advantages to patients of being cared for in an academic center, at least for routine problems, are not supported by any hard evidence of better outcomes. While outcome measurement of real meaning is still in its early phases, nonetheless, the rapidly evolving world of managed care places new pressures on the academic medical center. (3) It must change its ways and learn to function in today's market, competing with non-academic providers if it is to survive. (4,5) A growing cohort of payers demonstrate little or no interest in training the next generation of physicians, paying only toward the costs of the care provided and not toward the costs of education or research. The academic medical center needs to revise how it does business and how it will support its multiple missions. (4, 5, 6)

In response, emphasis has been given to changing the model of care delivery to look more like that of the non-academic model, while preserving the academic mission. (5) The focus has been on expanding primary care, creating or extending a network of providers, building integration of services, and expanding the market share. The assumption is that, if one is more efficient in care delivery, one can preserve revenues and margins to continue funding education and research. But by simply streamlining the operation, can we continue with business as usual?

The problem

Business as usual is not the answer these days. While the term is overused, a new paradigm for educational and research endeavors nevertheless needs to be defined. There is increasing pressure to separate the costs of providing care to patients from the costs of educating students and residents. It is evident that academic medical centers will not enjoy the flexibility of the past to cross-subsidize the educational effort.

It is not the intent of this article to argue over who should pay academic-related costs and how they should be calculated. It is enough to point out the need to look at the educational goals of the academic medical center as distinct from providing care. Because the two have been so intimately intertwined, it has been difficult to see the educational or research missions of the institution as distinct from delivering patient care.

The three-part mission of the academic medical center has always been thought of as just that--three different parts of one whole (see Figure 1). But, are not those parts actually three separate worlds that often come together in one place? As Mitchell T Rabkin, MD, former President of the Beth Israel HealthCare System and now Chief Executive Officer for CareGroup[SM], the new parent corporation, has put it, we have to separate our business of education education from our business of research and our business of clinical care. In this way, we can begin to see how one affects the other and think about the cost of each and new ways to support their respective costs (see Figure 2).

[FIGURES 1-2 OMITTED]

A new design

In mid-1995, discussions began between the leadership of Harvard Medical School and Beth Israel Hospital in Boston. Their leaders felt that in the rapidly changing world of health care, there was a need to recognize the areas of commonality between the institutions, as well as the differences. Together, they decided to design a new model for academic medicine and proposed a novel joint venture for the academic mission that would be non-profit in nature, have a fiscal construct separate and removed from dependence on clinical revenues, and provide internal advocacy for the academic mission these institutions share. As a result, the President and Fellows of Harvard College and the Board of Directors of the Beth Israel Hospital established the Harvard Medical School/Beth Israel Hospital Foundation for Education and Research.

In establishing this entity, the School and the Hospital set out: to create a new model for the organization of academic medicine by forming a joint venture between Harvard Medical School and Beth Israel HealthCare that will sustain the academic mission as distinct from its clinical business and promote innovation in medical education and research through intellectual leadership, dedicated state-of-the-art facilities, and a focused development effort.

In October 1996, Beth Israel Hospital and its parent corporation merged with the Deaconess Hospital, another major affiliate of Harvard Medical School, and its parent Pathways Corporation, and with the Mount Auburn Corporation, parent of the Mount Auburn Hospital, a community affiliate of Harvard Medical School, to form CareGroup[SM]. Beth Israel Hospital and Deaconess Hospital merged to become the Beth Israel Deaconess Medical Center and the new Foundation was renamed the Harvard Medical School Beth Israel Deaconess Mount Auburn Institute for Education and Research (the Institute).

The Institute is a separate, not-for-profit entity from the Medical Center and the Medical School. Its budget is developed by the Executive Director and approved by the Institute's Board of Directors. Its revenues are not tied to any one department or to clinical performance. In this way it can independently pursue its mission of educational and research innovation. To help establish the Institute, both the Medical Center and the Medical School have jointly funded it for its first three years. Beyond that time, the Institute is expected to be largely self-supporting.

The Board of Directors of this joint venture consists of representatives from Harvard University, the Beth Israel Deaconess Medical Center, the Mount Auburn Hospital, department chairpersons from clinical disciplines at the Beth Israel Deaconess Medical Center, and a departmental chairperson from the basic sciences at the Medical School. The Dean of Harvard Medical School and the Chief Executive Officer of CareGroup are co-chairs.

In keeping with the concept of the Institute as a separate "business" of the academic medical center, the Institute headquarters and some of its facilities were housed in its own space. The Harvard Medical School Medical School Beth Israel Deaconess Mount Auburn Center for Clinical Education was opened in the Fall of 1996 and is housed in the Carl J. Shapiro Clinical Center, a newly constructed 1O-story facility for ambulatory care on the East Campus of the Beth Israel Deaconess Medical Center. Much of the Institute's organized teaching activities will occur throughout the Shapiro Clinical Center, alongside the delivery of care.

The Center for Clinical Education houses the offices of the Institute, as well as the components of an "education laboratory," including a computer laboratory for the creation of medical education programs and simulations, and a classroom and a conference room with video-conferencing and telemedicine capabilities for use by the faculty throughout the hospital. In addition, there are two teaching exam rooms with videotaping and playback capabilities, as well as one-way mirrors for observation. There is a study area/ lounge or "common room" where students can come together, share experiences, and enrich their education. Here they have access to computer workstations that feature multimedia educational programs, as well as links to the hospital computer system, the medical school, and the Internet.

Two key elements in furthering the mission of the Institute are the Council on Research and the Council on Education. Each is composed of faculty members designated by their respective department chairs, and charged with reviewing and developing policies related to their fields. In addition, the Councils will oversee the broad perspective of furthering education and research at the institutions.

Under their mandates, the Councils are concerned with the educational and research objectives of the institutions and not the service responsibilities. They are expected to look at the educational or research value of a program or project independent of its relationship to the provision of care to patients. This provides a healthy balance among the three worlds of academic medicine designed to foster innovation, collaboration, and improvement. The accountability of the chairs for all these areas remains, but the performance of departmental responsibilities of teaching and research will be facilitated and enriched through the efforts of this relatively autonomous yet closely interwoven joint effort.

The Institute's budget includes "seed money" for new educational and research grants. This money will be used for educational and research projects undertaken by faculty at both hospital and medical school locations. A "request for proposals" went out in late 1996 for educational projects. Grant applications will be reviewed by the Education Council of the Institute, and it is anticipated that the first awards will be made in mid-1997.

The Institute, its directors, and faculty acknowledge the reality of clinical practice today and the tight interweaving of education, research, and clinical care. The goal is to foster and develop programs and teaching tools for the future. In some cases, this may mean working with computer simulations or standardized patients. At other times, this can mean programs that blend easily into the world of patient care.

By virtue of its unique position, the Institute can acknowledge the reality of the marketplace and the educational needs of students, house staff, and fellows, and act accordingly. One goal is to foster well-designed programs that efficiently provide for education without interfering with the provision of cost-effective care to patients. Another is to facilitate growing intellectual interactions among researchers of diverse backgrounds and interests as the challenges of research and funding further mount. In so doing, the Institute bridges the worlds of health care delivery, medical education, and research to help faculty work toward better preparing the students and trainees of today for their evolving careers tomorrow.

References

(1.) Kassirer JP, Academic medical centers under siege (editorial), N Engl J Med 1994, 331 (20):1370-1.

(2.) Macilwain C, Managed health-care adds to woes of US medical schools, Nature 1995, 378:117.

(3.) Brown M, Power and New Economic Relationships, Physician Executive December 1995, vol. 21, #12:5-10,

(4.) Souba W, Professionalism, responsibility, and service in academic medicine, Surgery 119:1-8.

(5.) Goldman L, The Academic Health Care System, Preserving the Missions as the Paradigm Shifts, JAMA 273(19):1549-1552.

(6.) Rogers MC, Snyderman R, and Rogers EL, Cultural and Organizational Implications of Academic Managed-Care Networks, N Engl J Med 1994, 331:1374-1377.

Leon Goldman,MD, is Assistant Professor of Surgery at Harvard Medical School, Chief Division of Surgical Education, and a member of the Department of Surgery at Beth Israel Deaconess Medical Center in Boston, Massachusetts. He can be reached at 617/667-9120.

Jane Neill is Assistant Faculty Dean for Academic Programs at Beth Israel Deaconess Medical Center, Harvard Medical School and Program Director for Academic Affairs, Beth Israel Deaconess Medical Center in Boston, Massachusetts. She can be reached at 617/667-9120.

Michael Rosenblatt, MD, is the Robert H. Ebert Professor of Medicine at Harvard Medical School, and Senior Vice President for Academic Affairs and HMS Faculty Dean for Academic Programs at Beth Israel Deaconess Medical Center in Boston, Massachusetts. He can be reached at 617/667-9120.