Universities, Medical Schools, and Hospitals—Can They Coexist?

PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 24 ¦ Number 2 ¦ Winter 1981 UNIVERSITIES, MEDICAL SCHOOLS, AND HOSPITALS—CAN THEY COEXIST? ALVIN P. SHAPIRO* Ifwe couldfirst know wL·™ we are, and wither we are tending, we could betterjudge what to do and how to do it. [Abraham Lincoln, House Divided Speech, 1858] Background Medical education, as presently conducted in the United States, requires the melding of three institutions: the medical school, its parent university, and its working arena, the hospital. Each has multiple tasks to perform in society in addition to medical education. Increasingly, however , the demands of society, coupled with the financial problems common to all education, have stressed severely the ability of the institutions to cooperate [I]. Moreover, the administrative rules under which this tripartite relationship operates vary greatly from school to school and often seem to have been patched together by tradition and local convention , tending to come apart in times of stress. Many have written about these problems, but this paper will emphasize the difficulty of developing equitable and efficient relationships when the basic missions of the three institutions are philosophically different . My own experiences from 3 decades on several medical school faculties, including hospital and clinic work, research, and bedside teaching, plus periods in the dean's office and in departmental leadership , have provided me with some reasons, as well as with some evidence that the disparity of their missions is a major source of the problem. ?Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261. I appreciate the editorial assistance of Ms. Jane Hageman in preparation of this essay.© 1981 by The University of Chicago. 0031-5982/8 1/2402-0233$01.00 Perspectives in Biology and Medicine ¦ Winter 1981 | 169 Definitions THE UNIVERSITY The university has evolved from a long-standing tradition that has set it aside from the marketplace aspects of our society. It is an institution inhabited by scholars which, in theory, is dedicated to the development and preservation of knowledge. Scholars include both faculty and students and each learns from the other; their mutual goal is to foster this creation and expansion of knowledge. As the great universities developed in the Middle Ages, not all students were, or wished to be, absorbed into the faculty, and many left for a secular life. Their university experiences were not intended to be pragmatic preparation for whatever postuniversity activity they undertook, but rather they were expected to apply their scholarly habits to their profession, be it art, poetry, medicine, theology, business, or teaching. To be sure, the university as a "community of scholars" is an ideal perhaps only rarely realized fully even at the height of the golden eras of particular institutions. Then, as now, some students enrolled purely for prestige; some faculty were interested similarly in their personal enhancement . Administrators, although often elected by faculty and serving only brief or temporary terms, were nevertheless harassed by problems ofeconomics and communication. However, the primary activity of the university was, and is, its own self-nurture in order to accomplish its unique purpose in society—to be the source and sustenance of knowledge . Over the centuries, this single-minded goal of the university has become eroded by societal pressures, especially by the need for training in contrast to education, and by the blurring of the borders between the activities of the scholar and the pragmatist. With the present huge investments by government and industry in the universities, with scholarly elitism often a pejorative term, and with "self-nurture of knowledge" considered by many as "disguised selfishness," the question of whether the "university ideal" can or does still exist has become an ever more pressing issue. Nevertheless, the tradition still pervades university education . MEDICAL SCHOOLS Medical schools in the United States, after a briefflurry as branches of the university in the first years of the republic, developed through the nineteenth century as "trade schools" for the production ofdoctors. One went to a medical school to become a practicing doctor. This contrasted sharply with the European tradition of enrolling at the university to 170 I Alvin P. Shapiro · Medical SchooL· and Hospitals study medicine; "doctoring" in this tradition came later. Many of the U.S...