The death of the traditional academic physician.

FEWER GOVERNMENT RESOURCES, COUPLED WITH changes in the health care marketplace, are threatening academic medicine. Decreased societal commitment to academic health centers (AHCs) is reflected in trends, such as reconsidered support for medical education, decreased research funding, and the increased power of managed care organizations. In order to survive, AHCs must undergo fundamental changes. Unfortunately, we lack a paradigm for understanding the emotional reactions to the changes affecting this segment of the health care industry.

In her book, On Death and Dying, Elisabeth Kubler-Ross outlines the emotional stages that patients transition through after being informed that they have a terminal medical condition.[1] The model she proposes for terminally ill patients can be used to explain the sense of loss that we are experiencing as medical faculty coping with the challenges that threaten AHCs. Kubler-Ross' stages provide us with an objective interpretation of where we are where we have been emotionally, and more importantly, where we must go as academic faculty in order to ensure the success of our organizations. Kubler-Ross describes five stages in the grief response. They are:

1. Denial

Denial is an emotional defense, used to buffer the initial shock of an undesirable change. Denial can help a patient withstand the shock of unpleasant news, without experiencing overwhelming anxiety. When it persists too long, however, denial can lead to dysfunctional behaviors. A patient who believes that "this is not really happening to me" may not plan appropriately for his or her death.

Denial in the academic environment can lead to a continued focus on missions and values that may need to be questioned. Faculty members in denial might view edifices to old economic paradigms, such as large medical school classes and new buildings, as indications of success, despite evidence suggesting that these represent poor allocations of resources. Another manifestation of denial is the assumption that AHCs can continue to compete for patients in the current financial climate, without significant modifications in their standard operating procedures. Although the future may be brighter for AHCs than is commonly thought, failing to address the possibility that they are at risk is not a prudent business practice.

2. Anger

The anger stage is associated with rage and a feeling that somehow an anticipated change is unfair. For a terminal patient who loses his bodily vigor and independence, anger is a natural reaction. Such anger is often not directed at the problem, but is projected broadly in many directions. Family, friends, physicians, and others may feel the brunt of a patient's anger.

Like an ill patient, we physicians feel like we are losing our professional independence. This loss represents more than just a change in the business arrangements that influence the provision of health care. In a broader sense, the integrity of the medical profession is at stake. Within AHCs, there is a belief that commitments to medical education, research, and high risk patient populations exemplify absolute moral good. When they are threatened, the resulting anger is often directed at managed care organizations and the "evil" executives working for them. Another target is the politicians who vote to cut funding for favorite programs. These external targets are safe. Anger seldom leads us to focus internally at, for example, the economic inefficiencies within the academic enterprise.

3. Bargaining

Kubler-Ross describes the bargaining phase as the search by a patient for an agreement to prevent or postpone an inevitable event. While the threat is acknowledged, there is a delusion that it can be avoided. At our institution, bargaining has led to minor cosmetic alterations (decreasing patient waiting times and sending thank-you letters to referring doctors) as a means of coping with the fundamental changes occurring in the health care market. Another form of bargaining popular at AHCs is a reshuffling of reporting relationships and management hierarchies. The wish is that by bandaging the institution's wounds, we can preserve past missions and successes.

4. Depression

Kubler-Ross' depression phase is the true grieving period in which a patient faces current and anticipated losses. During this active mourning stage, a patient lets go of previous expectations. This allows for acceptance of the situation, such as death in the case of the terminally ill.

When AHCs change in order to deal with a new external environment, they must first unsell old policies, so that "past virtues have become vices."[2] They must adopt new approaches to interacting with a changed environment. Between the jettisoning of old policies and the adoption of new ones lies depression. There is a true acknowledgment of the loss, which is indeed profound. Loss of job security, diminished freedom to conduct research, and constraints on clinical practice are but a few of the losses that academicians are experiencing. The essence of what it means to be an academic physician is changing.

5. Acceptance

Acceptance occurs when one has worked through the previous stages of grief. A patient is now able to cope with the inevitable--although undesirable--experience of death. The patient no longer expends a large amount of energy protecting him or herself through denial and anger from feeling the pain of loss. The result is a sense of inner peace. For academicians, acceptance of decreased societal commitment to AHCs does not necessarily mean capitulation of all that we value. Acceptance is accompanied by increased freedom to operate within new constraints. Indeed, acceptance implies preparation for the changes that will inevitably occur.

Many of us at AHCs are stuck in the first three stages of the grief response. We are still avoiding the painful acceptance of changes that will occur to the institutions where we work, hoping the forces causing these changes will go away. We are spending hours of precious planning meetings lamenting actions by managed care organizations and government agencies. We are offering up minor changes in order to avoid acknowledging the magnitude of our challenges. Ironically, it is coming to terms with the inevitable loss that will allow us to accept economic realities end' enable us to engage in more appropriate behavior. Such a transition would free up our personal and collective mental energies so that we could face the threats to AHCs in innovative ways. With such acceptance, we may yet be able to preserve the greatness of our academic institutions for the patients and the physicians of the 21st Century.

References

[1.] Kubler-Ross, E. On Death and Dying. New York: The Macmillan Company; 1969.

[2.] Peters, JP, Tseng, S. Managing Strategic Change: Moving Others From Awareness to Action. Hospital & Health Services Administration 29(1984): 7-20.

Crayton A. Fargason,Jr., MD, MM, a Robert Wood Johnson Generalist Physician Faculty Scholar, is Assistant Professor of Paediatrics at the University of Alabama at Birmingham. He can be reached at 205/939-9585, by fax at 205/934-5411, or via E-mail at fargason@uabedu.

Rachel E. Fargason, MD, is Assistant Professor of Psychiatry in the Department of Psychiatry at The University of Alabama at Birmingham. She can be reached at 205/934-4301.