Understanding the Economic and Social Effects of Academic Clinical Partnerships

The Netherlands, a country of 16 million people, is home to eight university medical centers (UMCs), institutions that are closely analogous to U.S. academic health centers and play in important role in Dutch society. The authors' purpose was to test the extent to which an analytical framework developed in one setting can be transferred to another and to yield fresh insights into the value and limitations of different theoretical perspectives on organizational design in the specific context of the academic-clinical enterprise. The authors applied a conceptual framework originally developed in the U.S. context to analyze UMC structure, governance, and organizational dynamics. Three UMCs, selected for their differences, were used as case studies, and data were gathered through interviews and document review. A multilevel approach is used to present the data. At the highest level, an overview of the composition, functions, and accountabilities of UMC boards is provided. Below this, the authors describe how functional integration for delivery of the tripartite mission is achieved at the sub-board level. Finally, the authors describe some of the detailed mechanisms used to bind together different interest groups within the UMCs. The authors found that the U.S.-derived framework for analysis required modification for the context of the Netherlands, but that the study validates the view that many challenges involved in the management of the academic-clinical enterprise are international.

Academic health centers (AHCs) in the United States have had a leading role in educating the medical workforce, generating new biomedical knowledge, and providing tertiary and quaternary clinical care. Yet the health status of the U.S. population lags behind almost every other developed world economy. One reason is that the health care system is not organized optimally to address the major driver of health status, the social determinants of health (SDOH). The United States' overall poor health status is a reflection of dramatic disparities in health that exist between communities and population groups, and these are associated with variations in the underlying SDOH. Improving health status in the United States thus requires a fundamental reengineering of the health delivery system to address SDOH more explicitly and systematically. AHCs' tripartite mission, which has served so well in the past, is no longer sufficient to position AHCs to lead and resolve the intractable drivers of poor health status, such as unfair and unjust health disparities, health inequities, or differences in a population's SDOH.AHCs enjoy broad public support and have an opportunity-and an obligation-to lead in improving the nation's health. This Perspective proposes a new framework for AHCs to expand on their traditional tripartite mission of education, research, and clinical care to include explicitly a fourth mission of social accountability. Through this fourth mission, comprehensive community engagement can be undertaken, addressing SDOH and measuring the health impact of interventions by using a deliberate structure and process, yielding defined outcomes.

Implementing cultural change and aligning organizational cultures could enhance innovation, quality, safety, and job satisfaction. The authors conducted this mixed-methods study to assess academic physician-scientists' perceptions of the current and preferred future organizational culture at a university medical school and its partner health system. In October 2010, the authors surveyed academic physicians and scientists jointly employed by the University of Oxford and its local, major partner health system. The survey included the U.S. Veterans Affairs Administration's 14-item Competing Values Framework instrument and two extra items prompting respondents to identify their substantive employer and to provide any additional open-ended comments. Of 436 academic physicians and scientists, 170 (39%) responded. Of these, 69 (41%) provided open-ended comments. Dominant hierarchical culture, moderate rational and team cultures, and underdeveloped entrepreneurial culture characterized the health system culture profile. The university profile was more balanced, with strong rational and entrepreneurial cultures, and moderate-to-strong hierarchical and team cultures. The preferred future culture (within five years) would emphasize team and entrepreneurial cultures and-to a lesser degree-rational culture, and would deemphasize hierarchical culture. Whereas the university and the health system currently have distinct organizational cultures, academic physicians and scientists would prefer the same type of culture across the two organizations so that both could more successfully pursue the shared mission of academic medicine. Further research should explore strengthening the validity and reliability of the organizational culture instrument for academic medicine and building an evidence base of effective culture change strategies and interventions.

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What a Patient With Refractory Idiopathic Detrusor Overactivity Should Know About Botulinum Neurotoxin Type A Injection

Lung Cancer in the United Kingdom

Valuing the Education Mission: Implementing an Educational Value Units System

Cadherin-11 Up-Regulation in Overactive Bladder Suburothelial Myofibroblasts

Changing the health care workforce: lessons from foundation-sponsored programs.

To investigate the prevalence and characteristics of faculty rock stars, a subset of academic health center faculty who greatly enhance the reputation and/or success of their home institution, oftentimes at the expense of a disproportionate share of institutional resources. In 2008, the authors surveyed the deans of 126 U.S. medical schools accredited by the Liaison Committee for Medical Education, using a 13-item instrument consisting of Likert scales, pick lists, and open-ended questions. Sixty-four (51%) surveyed deans responded. Respondents were more representative of public than private institutions (P < .001) but were proportionately representative of institutions of varying faculty size, U.S. New & World Report research rankings, and geographic location. The prevalence of rock stars was 1.42% (range 0.07%-6.42%) of full-time faculty. Over 74% (46/62) of deans felt that these talented faculty contributed to institutional prominence. Most deans were usually willing to offer greater resources to recruit or retain these faculty stars, and 39/62 (63%) believed that these individuals were a good investment. Although 53/64 (82.8%) of deans believed that other faculty are often or almost always aware that these individuals receive preferential treatment, only 37/64 (57.8%) believed that other faculty agree with that treatment. Fifty percent or more of deans (depending on the characteristic) selected self-promotion, a strong work ethic, opportunism, charisma, and political savvy as characteristics that were more common in rock stars. Deans appreciated both the value and the leadership challenges associated with the academic medical center rock star.

Academic medicine in the United States is at a crossroads. There are many drivers behind this, including health care reform, decreased federal research funding, a refined understanding of adult learning, and the emergence of disruptive innovations in medicine, science, and education. As faculty members are at the core of all academic activities, the definition of "faculty" in academic medicine must align with the expectations of institutions engaged in patient care, research, and education. Faculty members' activities have changed and continue to evolve. Academic health centers must therefore define new rules of engagement that reflect the interplay of institutional priorities with the need to attract, retain, and reward faculty members. In this Commentary, the authors describe and explore the potential effects of the changing landscape for institutions and their clinical faculty members. The authors make a case for institutions to adapt faculty appointment, evaluation, and promotion processes, and they propose a framework for a standardized definition of "faculty" that allows for individual variability. This framework also provides a means to evaluate and reward faculty members' contributions in education, research, and clinical care. The authors propose a deliberate national conversation to ensure that careers in academic medicine remain attractive and sustainable and that the future of academic medicine is secure.

Reflections on Pediatrics in Academic Health Centers

Commentaries on health services research

Learning From the Past and Working in the Present to Create an Antiracist Future for Academic Medicine.

This paper outlines the perspectives of the two currently appointed representatives of the Association of Psychologists in Academic Health Centers (APAHC) to the Council of Faculty and Academic Societies (CFAS) of the Association of American Medical Colleges (AAMC). The authors focus on why it is important for psychologists, especially those in academic health centers (AHCs), to be part of CFAS. The goal of the paper is to demonstrate how involvement in organizations like the AAMC helps AHC psychologists serve as ambassadors for psychology in AHCs and assists AHC psychologists in staying fluent regarding hot topics within academic medicine. The first author is a more senior member of APAHC, and so reflects the perspective of long-serving APAHC members; the second author reflects the perspectives of newer generations of APAHC members, those who have been active in APAHC for 10 years or less. The authors discuss their experiences being at national CFAS meetings. They describe meeting events including presentations such as those by national policy experts and scholars; and speed mentoring with medical residents from the AAMC Organization of Resident Representatives. Of special importance has been their opportunities for informal conversations with the AAMC's President and CEO, Board Chair, and Chief Public Policy Officer. They also have participated in networking functions that encourage interdisciplinary knowledge sharing and relationship building.