I was going to write an esoteric entry about training doctors and how to pay for it. I was going to talk about the fact that the budget deficit is caused in part by the payment of $9.4 billion into hospitals for training 110,000 physicians who have finished their medical school but are not yet ready for independent practice in their chosen specialty (data found put together at this link). I was going to talk about how this amount of money has gone up 5% per year DESPITE a cap put into place in 1997, and that less than 8% of these are  in family medicine  (a number that has been decreasing every year since 1997), the only primary care specialty that limits sub-specialization. I was going to talk about the fact that even if the positions were available we probably don’t have the students because of the payment structure that rewards doing stuff to people over taking care of people, especially at Academic Health Centers. I was going to write about how the budget crisis might allow us to rethink how we train doctors, except that the entrenched medical education bureaucracy believes that the status quo is just fine.

I was, that is, until I ran across two articles that led me to believe change is in the air for academic medicine regardless of how the budget negotiations end (well, OK, assuming I’m not working for chickens). The first is a traditional article entitles “The business of academic medicine is a business like no other: a perspective.” Although I can’t get the full text, the abstract intrigues me. Their initial observation, that

The financial challenges facing the academic medical centers and in particular the departments of medicine continue to escalate. In response, many centers have been increasing their expectations of clinical productivity while holding the physician compensation down.

is even more true at our institution. Our doctors are paid less than academic doctors at other institutions. I have wondered what our end game was. The article, which I will need to find, apparently feels that we are not headed in a good direction:

The willingness of many talented faculty members to forgo financial remuneration in exchange for opportunity to pursue scholarly activities can be misinterpreted by business planners as a prospect to muster a physician workforce with modest investments that are below market value. This mind-set fails to acknowledge the costs of creating the academic environment that will be attractive enough to faculty to practice medicine.

So if we don’t have a pool of physicians who are willing to see patients as if in private practice but for less remuneration because its “the right thing to do” then what direction should we be moving towards?

That was when I ran across “Not Running a Hospital,” a blog by the former CEO of major Massachusetts  hospital (the former title probably has a story behind it given RomneyCare). Paul Levy wrote a blog post that spoke to our problem. He points out that disruptive innovation is bound to hit academic medicine and when it hits, it’ll hit hard. We have large fixed costs with unpredictable or more frequently inadequate revenues streams. He points out that innovative methods of delivery of educational services will almost certainly pick off profitable aspects of education.

So what are academic physicians to do? At this point, I will yield to my better:

The future will belong to the efficient. Hospitals that are driven by their senior faculty and hopeful junior faculty to expand buildings and research facilities, that invest in high-cost but unproven clinical equipment, that do not engage in front-line driven process improvement, that fight transparency of clinical outcomes — and that plan to depend on private and government reimbursements, government grants, and philanthropy to pay for all this — will not do well. Those that limit capital investment in inflexible fixed assets, that focus on higher quality and reducing waste, that endorse transparency, that invest in the science of health care delivery as much as basic science, and that develop and implement treatment modes that take care to the patient rather than requiring physical visits by patients, will do well.