Thoughts on Medical School Funding (part 2)

Nov 01 2017 Published by under Uncategorized

Medical School funding is one part of the problem that is driving the issues with career pathways, also know as the too many mouths at the trough problem. This is a follow-up to an earlier post,  but looking from a perspective of how the administration deals with its faculty.

Medical schools aren't poor. And they have different needs. But most of them have a "we must grow or we will die" philosophy. This need for funding has produced some market and intellectual distortions of its own. It used to be there was a push for more researchers to bring in more overhead. This is how BSD Medical Schools work. Some hard money/internal support is given to chairs to hire new people. Then you've got three years to bring your salary in, move off the hard money, so they can hire someone new, and start the process again. This is one way the private medical schools grew.

But now it has become more clear to most high level administrators, even at MRU schools that NIH isn't what it used to be. And while they may be able to hire Big Guns with multiple grants or patents, they're not going to be able to build a huge faculty based on NIH. I saw the turn towards clinical income at my old MRU. If you give clinicians a (for them) low base, and make their salary dependent on the clinical income they generate, a "commission" scheme if you will, then some of them are going to hit the ball out of the park. This is called incentivizing your staff. It doesn't work well for the researcher/teacher.

Medical schools are a bit different then when I was in a basic A&S Biology department, and there was always more teaching that could be done. Medical schools have a small curriculum, number of courses taught, and even if there are PhD students, there is  just not the need for non-majors intro courses (I taught one that had three sections, and an enrollment of about 1500 students. It's about as much fun as a colonoscopy, but it lasts longer and maybe of less ultimate social good).  When I started, med school faculty could teach 2-4 lectures a year, and have a grant that covered 20% of your salary. And those of us that did lab teaching, on the order of 50-100 hrs/term were looked down on. This can still work at the large, BSD/MRU places that have 100's of basic science faculty, so long as they are bringing in 60-80% of their salary.

There is a new scheme being floated around my less than MRU. The idea is to have "researchers" who would bring in "nearly all" of their salary, and "teachers" who taught in multiple courses, but all year round, especially lab courses and small discussion sections, who would have at last 20-30-ish contact hours a week.

One of the ways in which this is being enacted or "actualized" is to give some additional hiring decision authority to chairs, who in medical schools, tend to serve at the pleasure of the Dean, and not be elected / chosen by the faculty. The chair can use their (now even more) precious seed money to favor areas they want to enhance, often their own colleagues, at the expense of other areas (ok, you guys need help in teaching that histology/anatomy/physiology/neuro lab? you got it!). I've heard every possible bad argument why this is not Conflict of Interest. Aside: our focus on financial COI means that other forms do not get the scrutiny they deserve.

This is a disservice to the medical students. Yes, the teaching professors may be far more acutely attuned to the medical boards, and far more devoted (and incentivized) to giving medical students an education with which they are happy, judged as they leave medical school. But the people who are doing research bring a different perspective, and one that is valuable not just to the future clinicians in their student-hood, but to what they will do when they become physicians.

And... that will bring us to part 3. Stay tuned.

3 responses so far

  • Microscientist says:

    The idea of a anyone having 20-30 teaching contact hours is insane. I work at a Master's level comprehensive where we have 12/semester and it is overwhelming.

  • Ola says:

    At my R1 private Univ. w. attached Hosp. & Med Sch., the pivot from "get moar grants!" to "moar beds!" happened pretty quickly here once the NIH doubling was over. We get regular updates from the suits about their "regional strategy", but it all really boils down to one thing... clinical revenue is the cash cow, and the way to get more of it is to get more people in the front door of the hospital(s).

    What's interesting to watch is the way the whole process of regional growth (to become the local "provider of choice") is so intertwined at the back end. It goes something like this... (ii) Buy small community hospital in town 50 mi. away. (ii) Shut down some "non-essential" services. (iii) Those folks now come to the mother ship hospital. (iv) Mother ship needs more beds - apply to state for permission, claim "over-crowding". (v) Get more beds, increase revenue, become more powerful. (vi) Rinse and repeat. Another example... closure of ERs in small hospitals, now too many people in our ER, so justifying opening of several new "urgent care centers" to relieve stress on our ER. And so the empire expands...

    The trouble is, it's hard to argue with this strategy. Clinical revenue is 85% of the whole University budget. Tuition is about 2%. And everyone else is doing it too, so if we just sit still we'll get eaten up by one of the big networks from another state. The only real counter-argument is "you're building a house of cards". If the network/empire becomes too big and too dependent on a single source of revenue (the "payer-mix" here is about 50/50), and then the structure of that revenue fundamentally changes (i.e. Trump screws up healthcare) then the house falls down. Everything is predicated on the way the government pays for healthcare staying about the same, and there's not much wiggle room for alternative payment models. We're already seeing some changes creeping in, with more and more services farmed out to nurse practitioners, and increased caseload per attending physician (i.e. more patients see per billable hour). Again though, not much lee-way in those margins. A big jump in medicare/medicaid/private patient mix cold really screw the budgets.

    Oh yeah, and research, edumacation and all those other fringe activities we're supposed to care about.... crickets....

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