FSEC hears talk on medical education in managed-care era

John Wright, interim vice president for clinical affairs and dean of the UB medical school, brought that message to the Faculty Senate Executive Committee on March 5 at a joint meeting held with the medical school's Faculty Council Steering Committee.

Wright presented what he called the "idyllic model" of medical education vs. "the Buffalo scene and how it relates to the challenges of managed care and our situation."

A typical, arguably idyllic, academic health-center environment, Wright said, "is represented by a single focus for faculty practice, usually in some physical juxtaposition to the medical school itself." Clinical faculty are able to engage in scholarly interaction and collaboration among themselves and with their basic-science faculty colleagues. Medical students from each of the four years learn in the same environment, often from each other. And residents receive their training in each discipline at a single site.

In a typical academic health-care environment, he added, the medical school is affiliated with other institutions as needed and desirable.

The hospital understands, indeed is part of, the academic environment and shares common goals with the medical school," Wright said. "These institutions are admittedly expensive because of this shared mission, but reimbursement, tied to patient care, has traditionally been adjusted for this expense and applied to the teaching mission."

However, "in our environment, we must operate in a consortium of nine hospitals," eight of which are geographically distant from the medical school, he noted. "Although all have professed an academic commitment," the hospitals are academic medical centers "in name only. The clinical departments are consequently sited in multiple locations, without a critical mass at any one site, and contact with the basic science faculty proves to be sporadic at best."

As a result, clinical responsibilities often are so extensive that scholarship becomes compromised, according to Wright. "There is an odd mix of faculty at each site, with volunteer, geographic and strict full-time faculty working side-by-side, with varying degrees of state support, or non-support, some with tenure and some without." Funding for faculty comes from various sources, "including university or state support, hospital salary or contract funds and clinical practice income. For those tenured geographic full-time faculty who receive little or no state support, tenure is for title only."

Because medical students are scattered among the various hospitals, teaching can be "inefficient" and it is difficult to hold "interdisciplinary teaching conferences capable of reaching a wide range of students." Post-graduate work also is complicated, Wright said, "by the necessity for program duplication in multiple sites, which not only presents a 'critical mass' problem, but also results in an unnecessarily large number of residents in order to accommodate both service and education.

"Although education is the primary, and according to the accrediting boards the only, objective in the residency programs, make no mistake about it, residents provide service that is relatively cheap insofar as the hospitals are concerned," he said.

There are positive aspects to UB's model of medical school education, however, he said. "The breadth of clinical experience for our students is enhanced and the medical school is not fiscally responsible for a clinical enterprise that is often financially marginal at best and...associated with a significant annual deficit.

"In these turbulent times," Wright said, some hospitals have begun to question their educational mission, which puts the faculty "in an uncomfortable position...in which they have seemingly little or no control over their immediate environments or programs."

But at some hospitals, "the medical staff acts more as a group and seems more willing to accept directives and therefore move in a single direction. I would submit this reflects the presence of the university as an integral part of the department structure more than perhaps any other factor," he said.

"In this era of managed care, and the need to function as a group, this may be a previously unrecognized 'value' that the university can bring to the table."

Managed care is growing in Western New York, and the medical school needs to be aware of "what is happening nationally and how will it affect Buffalo."

As managed care becomes more prevalent, Buffalo may be at an advantage because the area has one of the lowest medical costs in the country, even though Western New Yorkers also overutilize medical services by 25 percent.

But there are a number of issues that will need to be addressed, Wright said, such as faculty support within hospitals, for administration, quality assurance and continuing medical education programs.

"Faculty practice within institutions and within the community-at-large will be an issue," particularly in relation to perceived competition with volunteer faculty, Wright said. "The town-gown issue will be alive and well in Buffalo."

Other issues of concern, he noted, are the relevance of the university-practice plan to the development of centers of excellence at UB, undergraduate and postgraduate medical-teaching programs, research programs that could be in competion for managed-care dollars, and the departmental structure within this new health-care system and the changes at UB that could result.

There also are global issues that will need to be examined, Wright said, such as concerns about oversupply in the physician work force. These concerns affect not only the region, but the entire country.

In other business, chair Claude Welch asked the FSEC how best to follow up on the Report of the Task Force on Women, and what role the Faculty Senate should take in any action plans.

Bernice Noble, who co-chaired the effort, said she would "urge people to think of things sooner rather than later." She encouraged the group to pick one issue as a main priority "and get on it.

"I think nothing is going to be enacted or change" unless we push it, she added.

Jack Meacham, professor of psychology, suggested that the FSEC invite Senior Vice President Robert Wagner and Sinette Denson, acting director of the Equal Opportunity/Affirmative Action Office, to discuss where the university's EO/AA plan and the Report on the Task Force on Women would intersect.

"I don't want to be here 20 years from now (still) talking about the status of women," he said.