Reflections on Pediatrics in Academic Health Centers

Article Outline

• Failures of Communication
• Balancing Clinical, Education, and Research Missions
• Basic Science Education for Faculty
• Financial Interdependency of Faculty Practice and Hospital Operations
• Conclusion
• Copyright

AHC, Academic Health Center

Over the past 4½ decades, I have served at various Academic Health Centers (AHCs) as a faculty member, Pediatric Chair, Dean and Vice President, and Trustee. I have also served as a Foundation Executive and, most recently, as the Director of a nonprofit health care consulting group. This has provided me with the opportunity over the years to visit and observe several dozen pediatric departments in a variety of AHCs and, often as a consultant, gain insights into ongoing institutional problems. Based on this experience, the following commentary reflects on some contemporary issues facing many institutions and pediatric departments.

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Failures of Communication 

Because of size, complexity, and diversity of activities, and despite the increasing number of ways to communicate, this issue seems to be present at many levels. At the highest levels of governance, there is often a significant lack of ongoing, regular, frank discussions among the pediatric department chair and hospital (CEO and key trustees) and medical school leadership. At the level of faculty, there are also major problems of transfer of information as well as participation in policy discussions. Often, the division structure within departments impedes rather than facilitates communications. At all of these levels, fiscal transparency is frequently inadequately addressed.

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Balancing Clinical, Education, and Research Missions 

This is a serious, ongoing problem for faculty in many departments of pediatrics. Although some departments have explicitly formalized systems that acknowledge the diversity of each faculty member's pattern of activities and relate each faculty member's pattern to evaluations and budgeting, in many departments this is an informal and ad hoc process. The latter often contributes to faculty concerns about fairness and a lack of appreciation for their contribution to the department's overall mission. The increasing number of academically committed faculty who desire part-time or flexible time positions and recognition of the changing career trajectories that occur as faculty age may exacerbate this problem. Career mentoring of faculty members is vital to addressing this issue but is often inadequate at the department or division level.

There are two other related matters that deserve comment. First, because individual faculty member's patterns of activities are increasingly divergent (eg, primarily clinical care, research, education, or administration), there often is a lack of mutual understanding and appreciation of the various contributions different faculty members are making to the department. For example, those not involved in “bench research” are frequently unaware of the years required to become an independent investigator and the daily laboratory time commitment required to be competitive for funding. Alternatively, quality clinical care and education activities are increasingly time intensive.

The second matter involves the evolving relationship between quality improvement activities or studies and clinical research. Increasingly, the former has come to resemble the latter. This will require institutional safeguards to protect patient interests. Institutional review boards may or may not be the appropriate vehicle for this, but clearly some type of oversight review is necessary for certain quality improvement studies.

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Basic Science Education for Faculty 

The ongoing changes in technologies and vocabularies of biologic science laboratory research are creating a cultural divide for many non-laboratory based academic faculty. To a lesser degree, this may also be the case with regard to health services/epidemiologic research. This divide is detrimental to the development of new knowledge relevant to children's health and disease. Bridging the gap should not be left entirely to chance interactions among faculty across departments and self-education; it must be facilitated by formal faculty educational activities. Although time and scheduling constraints make this a difficult problem to address, it should be afforded a high priority, using a variety of innovative educational/communication techniques.

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Financial Interdependency of Faculty Practice and Hospital Operations 

In many AHCs, these issues are a continuing and serious cause of conflict and frustration and consume a large amount of faculty and administrators' time. The net hospital operating income and operating margin of most freestanding children's hospitals are primarily driven by pediatric surgical subspecialty procedures and neonatal intensive care services. The medical subspecialty services supporting these activities, radiology, and the clinical laboratories are also major contributors to the hospital's bottom line. This fiscal pattern also applies to children's hospitals located within a general hospital although, due to lower volumes of services, the income generated may be less and hospital accounting practices may obscure the pattern.

Pediatric department practice income is usually primarily dependent on neonatology, cardiology, and gastroenterology. Pulmonary medicine, intensive care, and nephrology may also contribute significantly, or at least not require cross subsidization, in some departments. Most other medical specialties, primary care, and educational programs rarely break even and usually require subsidization from practice, hospital, medical school, or other sources of income. Research programs are usually dependent on grants, endowments, and start-up or bridging funds from the department, hospital, or medical school.

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Conclusion 

Explicit recognition and a general understanding of the intertwined fiscal and programmatic relationships by academic faculty, hospital and school of medicine administrators, and hospital trustees is important to aligning incentives and rationally resolving conflicts over priorities and resources. However, the most critical element in addressing problems that arise in AHCs is the development of personal trust among the institutional leaders and between the pediatric chair and faculty. Trust does not come easy in these complex institutions. It depends on personalities, honesty, openness, consistency, follow-through once agreements are reached, and a willingness to make reasonable compromises for the sake of the overall mission.