University-based, research-oriented academic medical centers, with training programs involved in cutting edge technology and highly specialized patient care services, are clearly a positive adjunct to any local community’s—or state’s, for that matter—capability to provide top-notch patient care and services. No one can deny the benefits afforded by this level of expertise. Problems arise when university-based medical centers set a powerful and lustful gaze upon the medical community at large.
During the 1990s, large medical centers across the country bought up community hospitals and medical practices. At that time, and continuing into the present, office overhead—building costs, liability insurance, personnel costs—for private practice groups has often exceeded the ability of these primary care groups to survive. Not unexpectedly, once incorporated into the system, these practices are used to support the subspecialty services at the university medical center, bypassing the community-based subspecialty physicians.
Additionally, large, academic medical centers set up funded and university-supported subspecialty groups that compete head-on with independent practitioners. Private practitioners view these circumstances as stacked competition. The primary-care doctor’s decision in selecting a subspecialty doctor for a patient is no longer based on service, timeliness, and competence, but is instead a result of proscribed referral patterns delineated by the academic institution. Discriminatory referral patterns—not based on merit—result in local discontent, frustration, and unhealthy competition.
Short-Term Savings, Long-Term Loss
These issues are complex. A case can always be made to consolidate resources at the university hospital and avoid duplication of services by stripping away departments in the community hospitals. If pursued to its logical end, this operational model effectively starves community hospitals until they evolve into low acuity, “feeder” stations for the main academic hospital facility. On paper, this plan presents economic advantages. In practice, it not only deprives the metropolitan area of community-based hospital options, but it also results in a dwindling population base and the general decline and disenchantment of the local medical community. As the medical community contracts, so does the patient-base referral radius.
University-owned community hospitals are subject to the discretion of the university medical center. Decision making is attributed to maximum utilization of resources and certification of need, but most observers see the basic principle as economic: ways of garnering a larger portion of the healthcare dollar in the university coffers. Services and even departments provided by community hospitals are likewise subject to the benevolence of the university medical system. Hospitals function like living organisms: If a department such as pediatrics is withdrawn, the hospital continues—but with a limp. Few children can be seen and evaluated in the emergency department; likewise, high-risk obstetrics must be transferred to a major university hospital because the patient may need a neonatal intensive care unit. Hospitalists and internists who happen to be double boarded in medicine and pediatrics steer away from hospitals without a pediatric department. The changes are subtle but, over time, the effects of the loss are apparent.
Hospitalists need to be cognizant of these issues when pursuing employment opportunities. Many career-minded hospitalists seek employment in community-based, full-service hospitals with university medical center affiliations. This combination can provide the best of both worlds: autonomy, opportunities for growth and development, and opportunities for working with house staff and teaching. Checking the status of the relationship between the community hospital and the affiliated university medical center may be an important factor in pre-contract negotiations and decision-making for career hospitalists.
The Bottom Line
The turf battle between community medicine and academic medicine is primarily one of economics. Interesting parallels may be drawn between this conflict and the teachings of Adam Smith. Prior to Smith, economic theory was based on the idea that every dollar you have is one less dollar for me. Smith proposed an entirely different concept: If I help you earn dollars, the economic house will grow, and I, too, will make more dollars, and then you will make more dollars. In this way, the entire system generates more than anyone could have previously imagined. This economic concept extrapolates well to the present discussion of the university medical center versus community medicine.