Medical Schools in the Era of Managed Care: An Interview with Arnold Relman
RPOBABLY NO ONE IN THE UNITED STATES knows as much about the current situation in American medicine as Arnold Reiman, professor emeritus of medicine and social medicine at Harvard Medical School and editor-In-chief emeritus of the New En,dand Journal of Medicine. At the AAUP conference, "Academic Values in the Transformation of American Medicine," held in Boston in May, Relman described the impact of the corporatization of the health-care system on the medical profession and on the cost and quality Of care. When Academe interviewed Relman at the Harvard Medical School in July, we asked him to talk about the ways in which those changes are affecting medical education as well. Reiman: Medical education, ever since the "Flexnerian" revolution, has been regarded as a form of graduate education comparable in many respects to that of the law.1 It has university aims and university characteristics, is controlled by academics who are members of university faculties, and its primary objectives are teaching and developing new knowledge. But also, because of the nature of medicine, clinical practice has been important. If you want to teach medical students how to practice medicine, it has to be done in the setting in which medicine is practiced.
So, academic medical centers have been more than just parts of the university, where students are instructed in basic science and practical things, and where research is done and new knowledge generated. They have also been places where health services have been provided so that students could learn by observing and doing. That's different from any other graduate or professional school in the university. The law school is not a place where law is practiced. The business school is not part of a corporate enterprise. But medical schools have always had to practice medicine at a high level to demonstrate to students what medical practice is and should be and to allow them to learn by doing. You cannot graduate from medical school without putting your hands on patients, examining patients, delivering babies, and so on.
Academe: But isn't that part of the educational function?
Relman: Yes, of course, but in order for that function to exist there has to be clinical care. And particularly if you want to train specialists, you have to have a lot of specialized, advanced medical care available. So medical schools, in order to teach clinical medicine, must have a close working association with hospitals. The hospital may be owned by the university, but most of the major teaching hospitals are independent corporate entities with their own boards of trustees and charters that created them as independent institutions, responsible for their own fiscal integrity.
Still, all the major teaching hospitals have always had very close contractual and historical ties to medical schools and have always looked for leadership to the medical schools with which they were affiliated. They viewed their function, part of their raison d'etre, to be a teaching arm of the medical school. They were proud that their chiefs of clinical services and often many of the other people who ran the clinical services were tenured professors at the medical school. Often, the financial arrangements were such that the hospital trustees paid the salary of the doctor or at least part of it, even though the doctor was tenured by the medical school, because few schools could afford the costs of clinical education (and that, by the way, is one of the seeds of the problems affecting tenure lately).
The point I'm making is that up until ten or fifteen years ago, medical schools were at the top of the pyramid of power and influence within the world of medicine. Even in the nonteaching hospitals--community hospitals-the influence of medical education was tremendous. After all, when medical school graduates applied for internships, it was the medical faculty that advised the students and oversaw the process by which students selected the hospitals to which they would go. …