Organizational, financial, and environmental factors influencing deans' tenure.

At a time when continuity of leadership in medical schools is most crucial, the tenures of deans continue to decrease. In the present study of factors influencing the tenures of 382 U.S. medical school deans from 1985 to 1994, the authors focused on issues that were likely to have had a greater impact on deans' tenures in recent years. They assumed that longer tenures are associated with less complex organizational factors and more stable environmental factors. Conversely, they assumed that deans and their tenures are adversely affected by an institution's declining financial health, a complex organizational structure, and a changing clinical marketplace where there is rapid growth of managed care. The authors compared the relationships between these factors and the length of deans' tenures during the ten-year period studied. Among the most important findings were the fact that schools that were less healthy financially, that had the same owner as the primary teaching hospital, and that had smaller numbers of faculty tended to have shorter dean's tenures and higher turnovers of deans. While the reason for shorter tenures of deans at schools that are less financially healthy is understandable, the effect of common ownership of the school and teaching hospital is less obvious, but perhaps the greater preoccupation of deans with the clinical enterprise in that circumstance is a significant constraint. The authors hope that the insights from their findings will be useful to future candidates for deanships in their negotiations with university officials and will help all parties reach more explicit agreements on such issues as expectations for financial performance of the medical school and the roles and relationships of the dean and the teaching hospital director.

Sustaining the development of primary care in academic medicine. Working Group on Sustaining the Development of Academic Primary Care. Association of American Medical Colleges.

This article is the report of the Working Group on Sustaining the Development of Academic Primary Care, one of the six subgroups of the Advisory Panel on the Mission and Organization of Medical Schools (APMOMS) sponsored by the Association of American Medical Colleges (AAMC). To begin, the group draws a distinction between primary care and generalism. Primary care is a core domain of health care and, in the context of emerging integrated systems, will increasingly be a multidisciplinary shared function. Non-subspecialized physicians, or "generalists," are a key element in the provision of primary care, but do not act alone. Core competencies for primary care are central to the education of all physicians. Therefore, irrespective of workforce goals for generalist physicians, primary care should have a strong, central position in the medical school so that graduates can receive a sound general medical education and can be prepared for any specialty and for lifelong learning in an evolving health care system. For primary care to achieve that position, medical schools must integrate primary care into their missions, strategic plans, operation, organization, academic administrative structures, curriculum development, faculty development (both school- and community-based), resource development, alliances with appropriate clinical services networks, financial policy, and evaluation and educational monitoring systems. The group briefly describes the elements of those changes and also proposes ways that the AAMC and medical school leaders could promote the central role of primary care in medical schools.

The volume and mix of inpatient services provided by academic medical centers.

This is the first in a series of AAMC Papers that analyze the clinical spectrum of patients treated in the nation's teaching hospitals. As stated in the separate Introduction, "The Transformation of Data into Knowledge," subsequent papers will examine trends in the provision of care to the indigent and make comparisons of quality of care among teaching and non-teaching hospitals. These analyses, carried out by the AAMC's Center for the Assessment and Management of Change in Academic Medicine (CAMCAM), are made possible by a reorganization of the AAMC's information infrastructure, in which many formerly separate databases have been linked. The Introduction concludes with a description of specific AAMC-CAMCAM initiatives that are being planned. This initial analysis examines the volume and mix of clinical services provided by AMCs, examines trends in these services over time, and compares services provided at different AMCs, in different markets, and between AMCs and non-teaching hospitals. Data from a variety of sources were used in these secondary analyses. The American Hospital Association's Annual Survey of Hospitals database was used to analyze volumes of inpatient services provided in AMCs and other hospitals. The AAMC's Clinical-Administrative Data Service database was used to analyze the volume and mix of clinical services provided in individual AMCs. The Agency for Health Care Policy and Research's Nationwide Inpatient Sample was used to compare the mix of clinical services provided in AMCs and other hospitals. Volumes of inpatient services in AMCs changed little between 1991 and 1994 and totaled six million hospitalizations, 41 million inpatient days, and two million inpatient surgeries in 1994. The mix of inpatient services in AMCs also showed little variation over time among individual AMCs, in markets with both high and low managed care penetrations, between public and private AMCs, or between AMCs and non-teaching hospitals, with the ten most frequent diagnoses accounting for significant proportions of total services. In contrast, several specialized services were much more likely to be offered and provided by AMCs. Despite rapid change in the health care environment, the volume and mix of clinical services provided by AMCs have been relatively stable. Implications for hospital planners, service chiefs and administrators, medical educators, clinical investigators, and health policymakers are discussed.

Comments on the AAMC policy statement recommending strategies for increasing the production of generalist physicians.

The United States has a physician specialty imbalance, primarily a shortage of generalists (defined as family physicians, general internists, and general pediatricians) relative to other specialists. In recent years, the rising costs of health care, the expansion of managed care, and problems of access to care have accentuated the critical role that generalists must play in a cost-effective, accessible health care system. Despite numerous public and private initiatives designed to address the supply of generalist physicians, the ratio of generalists to specialists has been decreasing. Although the factors contributing to the shrinking proportion of generalists are many and are often outside the control of educators, there is evidence that medical schools can play a major role in influencing specialty choice. Recognizing the need to address the specialty imbalance in this country, the Association of American Medical Colleges (AAMC) appointed the Generalist Physician Task Force to develop a statement suggesting actions that the AAMC and its constituents could take to foster a greater representation of generalist physicians in the United States. The task force produced an Executive Summary, published as an AAMC policy statement in early 1993, that contained recommended strategies for medical schools, graduate medical education, and the practice environment. The authors of the present article critique these recommendations, provide a background and rationale for each of them, and give suggestions about how some of the recommendations might be implemented. While they are in general agreement with the AAMC policy statement, they feel the recommended strategies fall short of the need. They maintain that the AAMC statement represents an admirable but cautious approach to a daunting problem, and that the time is past when cautious approaches will suffice. The authors conclude with the hope that bolder initiatives will emerge from the new AAMC Office of Generalist Physician Programs.