The effort to marry "town" (community medicine/community psychiatry) and "gown" (academic medicine/academic psychiatry) has been the heart of my career since I finished training. "Gown" represented the ethic of excellence. "Town" represented the ethic of care. The old joke - "the operation was a success, but unfortunately the patient died" - pointed to the absurdity of separating them.
Early on I pursued my dream of town and gown clinically, first in public sector community mental health and then at the not for profit Harvard Community Health Plan (HCHP) HMO. At HCHP, we referred to ourselves, with pride, as "academically minded LMDs." At the time, "LMD" was the dismissive term academic centers used for the community physician (the "local MD") - as in, "the LMD thought the problem was ABC, but we knew it was really XYZ."
More recently I've worked on town/gown integration via ethics - the question of how a society and health system can embrace, at the same time, a commitment to provide excellent care to meet the needs of individuals and to prudent stewardship of the available resources so as to meet the needs of the population. Since health care is not the only important social good, containing costs is an ethical responsibility, not an exercise in bean counting!
The New England Journal articles make clear just how challenging it will be for Academic Medical Centers to enter the ACO world:
- ACOs stand and fall on the basis of clinical integration. Academic Medical Centers are typically built around strong departments, which function as independent silos.
- Prestige and promotion at Academic Medical Centers typically track with publications and grants, not clinical care - especially community medicine. The system conveys the message that best and the brightest aren't primarily committed to making the health system work.
- Non Academic Medical Center physicians typically get most or all of their income from clinical care, whereas academic physicians often aim for an 80% research (grant supported) 20% practice split. It's hard to build a functioning care system around clinicians who practice one day a week!
- A well functioning care system develops standardized processes and seeks to eliminate unintended variation. Academic physicians take pride in their individual talents and idiosyncratic approaches. In medical school we imagined an academic teacher and a student walking alongside a wall. They hear galloping hoofbeats from the other side. The student asks "what's that"? The professor replies "it must be a zebra."
- ACOs depend on robust primary care. At most academic centers, specialties are the cat's meow. I recall one of my medical school teachers telling me that primary care was inevitably boring. I asked him why the thyroid gland was more interesting. His answer wasn't very persuasive.
It won't be easy for Academic Medical Centers to take on the ACO challenge of coordinating care within an overall budget. But because of (a) the impact academic centers have on regional medical culture and (b) future medical generations, (c) those that take on the challenge will be disproportionately important relative to their size.
This was Harvard Medical School Dean Robert Ebert's vision when he fostered formation of the Harvard Community Health Plan in 1969. He envisioned a care organization with a primary commitment to effective and efficient medical care, but with strong secondary commitments to teaching and research. (It was my privilege to practice at the organization - now known as Harvard Vanguard Medical Associates - for 33 years.)
To succeed, academically affiliated ACOs will have to marry the ethic of excellence with the ethic of care. Not many will try, and among those that try, not all will succeed. But the soul of our health system depends on the effort!