Letter to the Editor

The threat to higher education and to the integrity of research described in Derek Bok's Universities in the Marketplace (Bok 2003; reviewed in this journal by Rhodes 2004) has its counterpart in the world of academic medical centers. Diminishing faculty loyalty to the medical center and a closer association with the pharmaceutical industry increases the risks of distortion of the medical center's mission and of bias in its research (Aaron 2001; Angell 2004; Cohen 2004; Krimsky 2003).

Once traditionally committed to research, teaching, and focused patient care, academic medical centers today are burdened with seemingly unlimited clinical responsibilities, rising health care costs, decreased reimbursements, and mounting financial constraints. An increasing bureaucracy, lessening institutional autonomy, and failed affiliation attempts with competing hospitals have threatened their fiscal stability and forced them to function as corporate business enterprises with money a major objective (Cassedy 1991, p.142). Heretofore respected and admired for their contributions to new knowledge and the development of outstanding physicians and scientists, many urban academic medical centers have in recent years become costly health care providers for large numbers of patients, a change that has had a significant impact on their traditional goals of research and teaching.

Expanding clinical commitments and associated responsibilities have increased pressure on the faculty for additional clinical "productivity," which in turn has reduced valuable time for research and teaching and has contributed to the recently publicized unwillingness of some faculty to continue teaching in favor of income-producing clinical activity. The departure from the scholarly atmosphere of the ivory tower has decreased faculty involvement in the affairs of the center, increased externalization of their activities (meetings, committees, lectures, study sections), diminished faculty loyalty, and contributed to the leaving of valued faculty.

On the critical issue of faculty loyalty, the wisdom of the late Edward Weiss (Chicago), initially applied to the business world, is relevant also for medicine:

Loyalty is not just a moral virtue. It is an essential social lubricant; it keeps the machinery running smoothly and efficiently. . . . Loyalty to an institution exists for two reasons: the loyalty is returned, you are treated fairly and respected as individuals; and you have a sense of permanence and continuity in the institution. In the past, we had a sense of community; of mutual trust and mutual need . . . this has disappeared almost everywhere. . . . When this bond of loyalty disappears, the whole enterprise is disrupted.

My formative experience of an interacting, mutually helpful community of physician-scholars came in the early 1950s, when two of my research applications to the developing NIH had been rejected without explanation. Thanks to the timely and decisive support of the Dean of the Medical School, our clarifying discussions with the NIH leadership led to the development of the General Medicine Study Section in the National Institute of Arthritis and Metabolic Diseases. This created a much-needed opportunity for the knowledgeable evaluation and support of research proposals in internal medicine and its sub-specialties, including gastroenterology. The Dean's intervention was important to the academic community in general, but for me, it solidified my commitment to academic medicine. I fear that such high-level interest in faculty is less evident in today's busy university health care center.

With limited financial incentives, the absence of a long-term institutional commitment, and a feeling that ideas are less valued than previously, faculty interest in the "free agent" concept of seeking the best offer (tenure and financial support) is understandable. Most faculty today are no longer protected by tenure, and many academic medical centers have fixed or small salary increases each year, with investigators sharing little in the clinical profits. Young clinician scientists who observe senior faculty treated as interchangeable commodities are not likely to remain at such institutions; nor are students in this uncertain situation likely to consider careers as clinician-scientists. Some academic medical centers, as amalgamations of expanding clinical activities and with lagging research and teaching programs—occasionally complicated also by discordant leadership—now resemble large urban community hospitals. The question naturally arises as to whether such centers can continue to encourage loyalty from their faculty. Do medical centers today acknowledge...