Academic Medicine: In need of an examination?

Being a physician in an academic setting, my attention was drawn to this recent article in Academic Medicine: “Time Well Spent: The Association Between Time and Effort Allocation and Intent to Leave Among Clinical Faculty” by Pollart et al.

I had mixed gut reactions to this topic; ranging from the notion that this is an awesome topic long overdue for attention, to the questioning of why academia is spending its valuable time on such internally focused research.

But I found that there is a significant practical problem facing academic institutions that is driving this and similar research—the ongoing loss of experienced and capable faculty. What the study reports to have found is that the intent to leave an academic institution and academia in general was related mostly to the clinical staff’s impression as to whether the amount of time in a given area (clinical, research, teaching, administration) was too much or too little. The authors proposed that, “academic hospitals can work with individual faculty members to find the right mix of clinical, teaching and administrative responsibilities.” This seems simple enough, but do individual organizations have such flexibility? For example, very few said that they spent too much time in research (@ 1%); the dissatisfaction here was that too little time was spent. I suspect that the demands to produce revenue through clinical duties make it unlikely that all those desiring more time for research can be accommodated.

This first article then led me to a second in Academic Medicine, entitled “Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools,” by Pololi et al.

What was disturbing about the results was the authors’ “central and concerning finding…that faculty dissatisfaction was saliently associated with faculty members’ negative perceptions and distress 
about the nonrelational and ethical culture of the workplace.” The last thing the medical professional needs is such an environment in which medical students acquire their professional values. As the authors point out, “the detrimental culture for faculty members constitutes part of the hidden curriculum for medical students, who often become less altruistic and more cynical through the four years of medical school…” and that “if faculty project that the moral, ethical, professional, and humane values articulated in the formal curriculum are not reinforced in their own experience as faculty (through the medium of the hidden or informal curriculum), the goals of educating and graduating competent, professional, and humanistic physicians may be undermined.”

My academic setting is a smaller hospital and not the large university medical center and school setting, making it impossible for me to perceive the extent of the concerns; the article itself only highlights them, but does not help to clarify the scale of the problem. However, we ought to ask why there is such a questioning of the moral and ethical environment of medical schools, which are the formative environments of our medical profession. Perhaps the practical limits on advancement and the inherent competitive nature of large organizations (filled with driven professionals) prevent development of mutually supportive relationships. Perhaps it is but one manifestation of the consequences of the growth in cost of a highly complex medical system arising out of the advances in science and technology. Our capabilities exceed what we can pay for, and the institutional environment demonstrates the effects of the demands to produce something to justify the cost. Such demands can lead to ethical compromise.

I also wonder if ethical misdirections of our academic centers arise from a shrinking of the ethical foundation of medicine itself, to the narrow principle of autonomy. As the authors state, “[t]he scale of ethical/moral distress
 reflects reactions to the prevailing norms and possible erosion 
of professionalism and increased organizational self-interest.” If we have elevated autonomy to the highest principle, we should be unsurprised when self-interest begins to crowd out other professional motives.

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