University of Alabama, Birmingham is in the process of selecting a new Dean for its medical school. I have worked in academic medicine for almost 20 years and my father was in academics throughout the period that I was growing up so I understand the ebb and flow of the academic setting. In fact, Wallace Sayre summed up the problems very succinctly by saying “Academic politics is the most vicious and bitter form of politics, because the stakes are so low.”

This is never more apparent when it is time to hire a high-ranking executive in an academic setting. Universities typically use a “Search Committee”  to develop a list of candidates that the Provost (in this case) might choose from. Here is a quote from the University of New Mexico policy on hiring such people:

An effective search committee strategy will do much to facilitate, rather than undermine, an effective search. Keep in mind that the goal when using a search committee is to optimize the effectiveness of the search process from the perspective of all parties concerned-the hiring authority, members of the search committee, colleagues, and in particular, the applicants. Since the search process sets the stage for the future employment relationship, careful attention should be paid in effectively managing this very important phase of the staffing process.” (emphasis mine)

Imagine if  all HR departments had to run potential executives in front of a group of disgruntled folks with their own axes to grind. It would be a wonder if anybody got hired.

The reason this came up is that the Search Committee for the Dean at UAB does not contain a Family Physician, General Internist, or a General Pediatrician. The leadership in Family Medicine asked whether a differently constituted search committee might select a Dean that would place more emphasis on primary care and rural medicine.

It is my opinion that it would not and here’s why. Academic medicine sees Family Medicine as one of a number of competing clinical concerns that they need to balance as they provide education for undifferentiated students.  Traditional academic deans are concerned with maintaining or building revenue streams (typically family medicine is not helpful in this regard), maintaining the educational programs (in which case they need Family Medicine as well as Surgery, Medicine, OB, Peds, and Psych and Pathology  known collectively as the educational “six-pack plus one”), and growing research programs (typically not a Family Medicine function except at the Dukes of the world). Academic medicine in my opinion, does not seen themselves as producers of the physician workforce anymore than Colleges of Arts and Sciences see themselves as producers of the Chaucer scholar workforce. Colleges of Education tend to understand this workforce issue better than most (probably due to the initial charters under which they were founded and state mandates) but now with the charter school movement that might change.

Those of us in academic Family Medicine might see ourselves as producing tomorrow’ s healers but Deans and Provosts see us as  most equal to the others in the “six-pack.”

Medical schools typically don’t care about shortages, workforce needs, unless required to by external pressure. The reason is multi-factorial. One is that there is a lot of give in the system. We graduate 17600 allopathic physicians in this country. There are another couple of thousand osteopathic graduates. We allow almost 10,000 folks from other countries or from Caribbean schools into this country EVERY YEAR to fill the remaining slots. That’s one reason that medical schools don’t worry because this allows US schools to say that the “market” will fix things. We have been unsuccessful in the last 10 years in trying to develop a primary care workforce using a majority non-US grads.

The other reason is that the pipeline following medical school graduation is in the training hospitals and this portion of the pipeline is divorced from the medical schools. Medical schools point to the residencies and claim protection from these types of issues. The residencies point to success in the match as proof that their clinical care is vital and necessary. The way the payment structure is set up all of the grads get jobs, so why should the residencies worry? Of course, when we all get leukemia from CT exposure it’ll be a problem but more business for Oncologists as well.

What makes Deans worry about students attitudes towards a career in primary care? Mandates work for state schools. If the governor or key legislatures say “you gotta make primary care docs”, it happens. As it stands now, some in the Alabama legislature are securing funding fo an osteopathic pipeline as a response to the “shortage” but there are still no mandates in place so it’ll likely fail in this regard as well. This pipeline may have more success because folks educated in rural areas are more likely to go into primary care, all other things being equal.

What else works? Selecting the right students, educating them in a nurturing environment, and paying them (or at least not making them take out and pay loans) for doing the right thing. Paying primary care docs for doing the right thing makes students want to go into primary care. Lastly, making the communities conducive to quality care delivery works (which is why I would like to see collaboration between Schools of Public Health and Colleges of Medicine).

In summary, I suspect that UAB will select a Dean based on the weight of his or her CV and the perceived possibility of extramural funding and/or prestige regardless of the search committee composition. If Alabama wants primary care docs, the Dean will probably not matter one way or another. In fact, one Dean would argue that the Dean’s job is more of a mediator than anything else.  The Governor, on the other hand, will be a different story.

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