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Friday, January 8, 2021

The Decline of Academic Medicine in the US




In an article called “The precipitous decline of academic medicine in the United States" from the American Academy of Clinical Psychiatrists by Richard Balon, MD and Mary K. Morreale, MD, the authors describe how the profiteering currently infecting medical treatment in this country is also in the process of destroying medical education.

Some of what they wrote:

“Structural problems in academic medicine exist within all parts of its tripartite mission: education, clinical care, and research. With clinical care, there are tedious requirements for documentation in difficult-to-navigate electronic medical record systems, demands on productivity in the form of ever-increasing [office visits], and senseless demands from managed-care organizations. All of these clinical demands reduce the time for teaching, which, ironically, university deans expect us instructors to increase. Similarly, education has been increasingly regulated by what has been referred to as the ‘medical-education industrial complex.’ Regulatory agencies have introduced changes with possibly negative consequences and no evident benefit.

 

“Academic research—at least in psychiatry—has been experiencing an ‘intellectual crisis,’ leading to the conclusion that ‘evidence-based medicine does not appear to provide an adequate scientific background for challenges of clinical practice in psychiatry and needs to be integrated with clinical judgment.’ And despite the glow that research funding brings to investigators and administrators, the sad fact is that, for the institution, research is a money loser.

 

“Due to the pandemic, in anticipation of a loss of $350 million, Johns Hopkins ‘imposed a hiring freeze, canceled all raises, and warned about impending furloughs and layoffs….’…[despite] Johns Hopkins had $10 billion in assets and a $6 billion endowment …Leadership compensation at Johns Hopkins is similar to the business world, with the university’s president earning $1.6 million in salary and an additional $1.1 million in deferred and other types of compensation.

 

“In Michigan... the CEO of the William Beaumont Health system affiliated with Oakland University had a total compensation of $5.9 million in 2018, with a base salary of $1.85 million, a bonus of $1.6 million, deferred compensation of $1.66 million, and $810,000 in other compensation.”

 

And here I thought that this had only happened at the medical school I worked at, the University of Tennessee in Memphis. When I first started there as psychiatry residency training director in 1992, the faculty practice group called UTMG was a delight to work with. The administrators worked for the doctors. We were told that we had to bring in 160% of the UTMG portion of our annual salary in patient care activities. The department was flush with cash, with a million dollar reserve for research and other academic activities. Faculty could earn extra money by seeing extra patients, keeping a percentage of every additional dollar they brought in.

 

The psychiatric emergency room at the public hospital, run by our department, was a model. We also trained police to deal with mental illness through the formation of what was called a Crisis Intervention Team, which was copied by several police departments throughout the rest of the country. Police became experts at de-escalating conflicts and apprehending the seriously mentally ill safely, transporting them to the Psych ER for evaluation. (Does this sound like something that might help the police regain public trust in today’s atmosphere? I think so).

 

Meanwhile pressure was building to install managed care models, especially after Medicaid in Tennessee was changed into Tenncare, which called for the formation of several HMO’s to provide treatment. UTMG decided that they wanted to form one, which they called TLC. Having experienced managed care in California, I warned everybody what might happen, but no one would listen. One child psychiatrist thought managed care was a good idea and advocated for it.

 

Before long, the doctors were working for the administrators instead of the other way around. Top administrators were paid over a million dollars apiece. The department’s reserves suddenly disappeared. UTMG drained the Psych ER of funds until it had to close. The child psychiatrist who advocated for managed care had his own pet project, a day care center for teens, destroyed. Faculty members were told they had to keep working any extra hours that they had been working – but without any of the extra pay they had been getting! Faculty members were also suddenly told they were “losing money” for the organization, even though they were bringing in the same amounts they had been, and even though the state - not UTMG - was paying for the faculty’s office rent and the cost of their phone system!


2 comments:

  1. Fascinating essay. Yet more evidence that the same phenomena which have decimated research, development, and quality in other sectors of the American economy have been decimating American health care. This is why nations which allow the "free market" to run rampant eventually end up poor and dysfunctional. The parasite kills its host.

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  2. Spot on as usual, David. One can't help wondering if early exposure to stimulants leads to addiction in adults, though there is a dearth of online literature supporting this position. Most so-called ADHD experts claim the opposite; ie, that failure to treat ADHD with stimulants in childhood increases the addiction risk as adults.
    Regarding the corrupting influence of academic psychiatry on impressionable physicians, it was recently reported to me by a psychiatrist fresh out of residency that he was required during his addiction rotation to prescribe Suboxone, which is widely embraced as appropriate medication-assisted therapy for opiate addicts, and an apparent cash cow now for funding psychiatry residency programs. Great idea...prescribing a drug that's 40X the potency of Morphine and calling it treatment. That's comparable to treating someone addicted to Bud Lite with Jack Daniels. In my practice, I have observed the rise of first-time heroin users in patients who were addicted to hydrocodone or oxycodone and treated in an inpatient rehab facility with Suboxone. Unable to afford it following discharge, they discontinued it, quickly relapsed, but were unable to manage their withdrawal with pre-"treatment" dosages of their less potent opiates of choice. Next logical course for an addict?...HEROIN!

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