AAMC Board Chair Mark Laret Calls On Academic Medical Centers to 'Think Differently'

Mark Laret, chief executive officer of UCSF Medical Center and UCSF Benioff Children's Hospital, issued a call to action to transform academic medicine at the annual meeting of the Association of American Medical Colleges (AAMC) — the last in his role as AAMC board chair.

Mark Laret, chief executive officer of UCSF Medical Center and UCSF Benioff Children’s Hospital, says academic medical centers must reconsider their traditions, practices and culture to thrive amidst significant funding cuts.

In a Nov. 4 address before the 123^rd annual meeting of the Association of American Medical Colleges (AAMC) — the last in his role as AAMC board chair — Laret called on the more than 4,000 attendees in the audience to “think differently” about academic medicine.

He provided a bold prescription for positive change: valuing team-based scientific research over individual efforts in academic promotions, offering competency-based medical education and residency training across specialties, and ensuring that those appointed to chair academic departments have the business and management skills necessary to succeed.

“Mark's talk was an unflinching call for changes across our endeavor to create opportunities to become more effective, efficient and cost-effective,” said Keith Yamamoto, PhD, vice chancellor for research, executive vice dean of the School of Medicine and professor of cellular and molecular pharmacology at UCSF.“He points out that our society, political leaders and economic predicament all demand changes, but just as importantly, we must assume leadership in recognizing and addressing these challenges.”

Addressing Challenges in Academic Medicine

Laret listed a number of imminent threats facing teaching hospitals and medical schools. These include “unprecedented” cuts to education budgets, decreasing federal investment in medical research, and most critically, significant reductions in clinical income, which increasingly supports research and education.

“As clinical income falls, the entire academic enterprise is threatened as never before,” he said.

Cuts to clinical income will come from many different directions, said Laret. Medicare and Medicaid, which “already fail to cover the costs of providing care at most teaching hospitals,” will be reduced even further under every deficit reduction scenario currently under discussion.

Medical education supplements, both direct and indirect, are “under attack.” Insurance exchanges created in response to the Affordable Health Care Act “threaten to displace the commercial payments” that up to now have supported most teaching hospitals. Finally, cuts to disproportionate share payments “are just around the corner.”

Disproportionate share payments, Laret explained in a pre-address interview, are additional payments made to hospitals that serve a disproportionate number of patients with low incomes or no health insurance. However, under health care reform, “those payments will go away.”

Preserving Academic Medicine’s Core Values and Purpose

Despite the challenges, this crisis “is in fact an unprecedented opportunity, if only we have the courage to grasp it,” Laret said in his address. With the right changes, academic medicine might be able to achieve its goals “more effectively than we ever imagined, and at dramatically reduced cost.”

Laret said that the “core values and core purpose” of the AAMC — centered on training, research and care of patients and communities — “should always be preserved,” while “everything about how we are structured and organized must be in play.” Among the areas he suggested for reconsideration:

• Research. Laret asked whether academic promotion committees value the accomplishments of individual scientists over “team science, where we know many of the next important discoveries will emerge.” He wondered, “Are we snobs when it comes to working with industry, where billions have been invested in genomic infrastructure? While we salute the physician-scientist, do our basic scientists truly embrace collaboration with surgeons?”
• Education. “Why does medical school still take four years?” asked Laret. Why, he asked, is accreditation still mostly based on time, “when we’ve been talking about competency-based accreditation for years,” and why is there so little residency training “across specialties and other health professions?” In his pre-address interview, Laret noted that the best choice for many medical schools may be to specialize: “Rather than have a full spectrum of residencies, have residencies in three areas and make them really exceptional.”
• Patient care. Laret criticized a host of inefficiencies, including a focus on inpatient care; lack of integration of ambulatory care with skilled nursing, mental health, rehabilitation, home health care and hospice; and the persistence of the inefficient physician office visit as “the common denominator” of care models.
• Academic culture and traditions. To appreciative applause, Laret asked, “Why do we think it’s reasonable to appoint a stellar academic with zero business training or experience to run a $30 million departmental operation with 100 employees?”

In addition, Laret said, today’s health care challenges provide opportunities not only to dispose of old thinking but to form new collaborations — a realm in which he suggested the UC system might provide a model for AAMC membership.

Laret asked, for example, whether it is possible that the six UC medical centers could collaborate to operate more profitably and efficiently without six separate Institutional Review Boards and “six separate medical school curricula taught by six different faculties.” He also raised the possibility of new alliances within medical schools, suggesting that collaborations across schools of medicine, nursing, pharmacy, dentistry and public health would better train students for a future of team-based care and care for populations. Process improvement could bring “profound new benefits” as well.

“Mark called on the leaders in academic medicine to address the challenges we face with truly innovative solutions,” said Sam Hawgood, MBBS, dean of the UCSF School of Medicine. “His bold but inspiring presentation resonated strongly with me. At a time of both unprecedented opportunity and rapidly shifting sands, the School of Medicine must be prepared to lead transformative and even disruptive change across all our missions.”

At UCSF itself, Laret said before his address, new hospitals currently under construction at the Mission Bay campus will be “of tremendous benefit” in providing state-of-the-art clinical facilities while creating opportunities for reusing vacated space at the Parnassus Heights and Mount Zion campuses. “However, we will have to make significant changes in how we operate in order to reduce costs and be more efficient,” he said. “We may also have to give up some programs we have cherished for a long time.”

Leading With Courage and Collaboration

Laret concluded by encouraging academic medical leaders to have the courage to “nurture, protect and celebrate those who challenge us,” as well as to “take the necessary personal and professional risks” to put changes into practice.

"Mark Laret's speech was an eloquent and clear call to action that has inspired the academic medical community," said AAMC President and CEO Darrell G. Kirch, MD.In his own address immediately following Laret’s, Kirch called for academic medical institutions to cultivate a new style of leadership — collaborative leaders who inspire others “to work hard, prepare for difficult situations and learn from failure.”

Kirch encouraged AAMC members to see leadership “not through a one-way lens of hierarchy, but rather as a relationship among equally committed individuals.”

The AAMC represents the interests of 135 U.S. and 17 Canadian accredited medical schools, and nearly 400 major teaching hospitals and health systems, before Congress, federal regulatory agencies and the executive branch on a wide range of health care issues. AAMC medical schools train 70 percent of all resident physicians, and AAMC member hospitals account for nearly one-quarter of all hospital admissions. They also provide nearly half of all hospital charity care nationwide.

Photo by Cindy Chew