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Sunday, April 12, 2009

Med Schools need to get BACK TO BASICS...

JAMA had a good study published on the need for medical education (academic) centers to get back to basics in light of the decline in graduating MDs.

A Single Mission for Academic Medicine

Improving Health

Paul G. Ramsey, MD; Edward D. Miller, MD

JAMA. 2009;301(14):1475-1476.

Mission statements capture and express the heart and soul of an organization. Mission may be defined around function—a statement or declaration of fundamental purpose or strategic direction. A mission statement may offer the organization's definition of vision and values, or it may articulate an inner calling or vocation to pursue an activity or perform a service. In all cases, mission statements ultimately attempt to answer one question: What does an institution or organization seek to achieve?

In 1497, the first known academic chair of medicine in the English-speaking world was established at King's College in Aberdeen, Scotland. Its mission was the "pursuit of health in the service of society."1 Five centuries later, academic medicine has lost sight of this mission. It is critical that academic medicine now return to the original meaning and mission.

Some argue that the mission of academic medicine is to improve human health via the advancement of knowledge.2 More frequently, leaders of academic medicine describe a tripartite mission consisting of education, research, and clinical service.3-4 Although the time allocated to each of these mission components by individual faculty members may be uneven, it is now generally assumed that the contemporary mission (or missions) of an academic health center consist of teaching, research, and clinical practice.3-5 For example, in his 2008 address as president of the Association of American Medical Colleges, Kirch reiterated the importance of balance among these 3 missions.6 Similarly, the mission statements of many medical schools and academic health centers list the 3 interrelated missions.1

In the first "modern" mission statement at King's College, the chair of medicine was assigned a single mandate: the pursuit of health for all.1 Although this remains the ultimate raison d’ĂȘtre of all health care professions, adherence to this mission on the part of academic medicine continues to be carried out using the tripartite-mission model: teaching the next generation of physicians, performing research to advance the understanding of human biology and the practice of medicine, and providing direct health care for individual patients and populations. These activities have waxed and waned in relationship to one another in academic settings, with clinical care predominating prior to the Flexnerian era, giving way to a research focus after World War II, and again shifting to clinical care in recent years as public support for academic health centers has declined.3, 7 Education has maintained a constant, if sometimes tenuous, role in the academic health center.

These 3 activities are connected and interdependent in fundamental ways that are, at their core, independent of finances. Medical students learn the foundations of basic science from researchers; medical students and residents learn their clinical skills under the tutelage of clinicians; research depends on the clinical setting for testing hypotheses and conducting safe experimentation to advance knowledge; clinical care, in turn, evolves and progresses through the knowledge that results from research. Over time, these 3 activities have developed interdependent financial relationships as well.

When these activities are treated as a single 3-part mission or 3 connected missions, they are in danger of becoming ends in themselves rather than activities that support a common purpose. Furthermore, although the demands on faculty imposed by this tripartite model are significant, the expectation has developed that faculty members will excel in all 3 missions. From this expectation, the concept of the triple-threat faculty member has evolved into an accepted standard for academic medicine.

Whether it was ever possible for more than a small number of productive and highly efficient individuals to achieve excellence in all 3 activities, the triple threat has in recent years been seen increasingly as endangered and counter-productive. Petersdorf and Turner8 observed nearly 15 years ago, "It cannot be done." For too long, faculty have been expected to achieve substantial productivity in all 3 realms to advance in their careers. This understanding has led some to conclude that the triple-threat model is inefficient and that an alternative, more efficient model of specialization is required in which each faculty member specializes in 1 or 2 areas.9

There are other risks in the current model as well. Pressures from an inefficient, stressed, and overly demanding health care delivery system are driving trainees from the academic medical center setting.10 Furthermore, the 3 components under the current mission model may shift and vacillate in importance depending on financial imperatives. Shifts in external and internal budgeting priorities can result in intense competition among the 3 missions. A financial climate that favors research, for example, rewards the research mission to the detriment of the other 2, creating divisiveness and factions by pitting faculty member against faculty member, department against department. The danger under these circumstances is an inadvertent creation of the organizational silos that so many management experts warn against. Despite these concerns, risks, dangers, and ramifications, the 3-mission, triple-threat model remains firmly in place as the standard for academic medicine.

It is time for academic medicine to return to its historic roots by focusing on the long-established mission of improving the health of the public. Academic medicine can do this by uniting and integrating its unique strengths—excellence in education, research, and clinical care—within an administrative structure that encourages and facilitates the use of all resources to support the mission of improving health. The administrative structure that best accomplishes this goal is an integrated health system in which the school of medicine, hospital(s), and research enterprise are within a single integrated structure with strategic planning occurring in all 3 activities and with the ultimate goal of improving the health of the public.

In this model, some faculty members may assume all 3 roles as clinicians, teachers, and investigators and can serve as triple threats. Others can and should specialize in 1 or 2 of the 3 roles, and they should be valued and supported for their contributions to the mission. One approach should not be seen as superior to the other. Ultimately, a balance of teaching, research, and professional service is important. That balance should be achieved across the faculty, staff, students, and trainees of the entire academic medical center. Budgetary decisions should be based on the extent to which individual activities contribute to the core mission of improving health.

Academic medicine is the acknowledged leader in today's medicine. It also retains its obligation to facilitate and support a mission of social responsibility. The most fundamental and socially responsible mission for academic medicine is working to improve health for all. If the mission of academic medical centers remains confused with the activities in support of the mission, academic medicine is in danger of perpetuating an inefficient system and ultimately a confusing set of goals. Research cannot and should not be a mission in itself, nor should education or clinical care.

Reclaiming the mission of improving health will be a major step toward recalibrating the 3 activities that support that mission and will refocus faculty—and academic departments—on a common goal. In doing so, the great and historic mission held so dear by medical academicians will be realized. Academic institutions will benefit, and patients will benefit. There is no greater mission than this.


Corresponding Author: Paul G. Ramsey, MD, UW Medicine, University of Washington, Box 356350, Seattle, WA 98195-6350 (

Financial Disclosures: None reported.

Author Affiliations: UW Medicine, University of Washington, Seattle (Dr Ramsey); and The Johns Hopkins University School of Medicine, Johns Hopkins Medicine, Baltimore, Maryland (Dr Miller).


1. Lewkonia RM. The mission of medical schools: the pursuit of health in the service of society. BMC Med Educ. 2001;1:4. FULL TEXT | PUBMED
2. Turka LA. Lost in a dark wood. J Clin Invest. 2007;117(7):1734-1735. FULL TEXT | ISI | PUBMED
3. Friedenberg RM. Academic medicine: boom to bust. Radiology. 2001;220(2):296-298. FREE FULL TEXT
4. Association of American Medical Colleges. The Handbook of Academic Medicine: How Medical Schools and Teaching Hospitals Work. 2nd ed. Washington, DC: Association of American Medical Colleges; 2008.
5. Lobas JG. Leadership in academic medicine: capabilities and conditions for organizational success. Am J Med. 2006;119(7):617-621. FULL TEXT | ISI | PUBMED
6. Kirch DG. The tough questions: AAMC president's address 2008 annual meeting. In: 2008 Annual Meeting of the Association of American Medical Colleges; October 31-November 5, 2008; San Antonio, TX.
7. Ludmerer KM. Time to Heal. New York, NY: Oxford University Press; 1999.
8. Petersdorf RG, Turner KS. Medical education in the 1990s—and beyond: a view from the United States. Acad Med. 1995;70(7)(suppl):S41-S47, discussion S48-S50. ISI | PUBMED
9. Pellegrin KL, Arana GW. Why the triple-threat approach threatens the viability of academic medical centers. Acad Med. 1998;73(2):123-125. ISI | PUBMED
10. Marks AR. Lost gold: the decline of the academic mission in US medical schools. J Clin Invest. 2004;114(9):1180


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