I love analogies and while no analogy is perfect, I find this one fascinating. If you are like us, you probably watch a lot of college sports this time of year. I was watching a basketball game the other day (KU vs Arizona) and I was thinking about the athletic department at our school. Like many large state schools, we have a pretty large budget for the athletic program. (more than $50 million in 2006) (1) All of that money may translate to some success , at least on the basketball court, not so much on the football field. A report last year from the Knight Commission on Intercollegiate Athletics detailed athletic department spending increases at major colleges and universities. Increases to the tune of 11% annually, and this was during the worst recession since the Great Depression.
Why do we spend so much money on the athletic department? And what does this have to do with medical education, which after all is what this blog is supposed to be about? It struck me that in a medical school system the clinical enterprise has some similarities to the athletic department at the undergraduate school.
Both the clinical enterprise and the athletic department are askew from the primary mission of the university at large. Each has a significant portion of the budget. Both generate significant revenue. Both attract philanthropy for their own use. World famous specialists and top athletic teams attract media attention. Attention leads to more patients and more fans and more money and higher rankings and goodwill from the local community. The highest paid people are the stars in these areas: the super subspecialists and the coaches for the money-making sports. They are arguably the highest paid because they bring in the most money. And, because of their ability to generate revenue, they seem to have a different set of expectations for their behavior. (2)
But here is where the analogy breaks down. It seems that few undergraduate universities have as part of their mission statement, “to have the best athletic department” or “to generate the most money on athletics.” And if US News and World Report has done a ranking on “most lucrative athletic departments,” I haven’t seen it. On the other hand, medical schools invariably have something about the clinical enterprise in the mission statement. And, that statement is not, “create a clinical enterprise that is sufficient to meet the educational needs of our students while providing excellent patient care.”
Perhaps the most important difference is that while the athletic department has some opportunity to impact the education of students, the clinical enterprise profoundly affects student education. The athletic department probably pulls some philanthropy away from other areas and definitely pulls attention away from other areas. But if the university decides to focus on football instead of swimming, the science majors are probably not affected by that decision. However, if the clinical enterprise focuses on higher revenue specialty practices and decreases lower paying primary care or generalist practices, the medical students are at risk of receiving inadequate or inappropriate medical training. If the clinical enterprise adopts policies that limit medical students' use of the electronic health record or participating in procedures, their education suffers. If the clinical enterprise needs the physicians to make more money by seeing more patients and spending less time teaching students, their education suffers.
Generally, about this time in the argument, someone pipes in with No Money, No Mission. And they go on to describe how the clinical mission funds the other missions of the medical school. Some people believe that the clinical enterprise and the athletic department works hard to make money for the university, so that the university can attend to its other, less interesting mission: education. And perhaps it does work that way in some places. Perhaps, but mostly they fund themselves. They make decisions based on revenue and they keep most of the profit. In fact, an article in USA Today says that for every dollar the university spends on the athletic department, they only realized one dollar in revenue. (3) Not a great return on the university's investment. At least the athletic department pretends that they aren’t trying to make money.
Medical student education at allopathic schools in the United States is clearly in a marriage with the clinical enterprise – sometimes an abusive marriage and maybe sometimes a partnership, but nonetheless a marriage. So what can be done? Perhaps that is a good topic for another blog – what would a counselor say about the marriage of the clinical enterprise and medical education?
(1) King, Jason. "Hawk Market", The Kansas City Star (June 11, 2006), pp. C1