303
OBSTACLES TO COLLEGIALITY IN THE ACADEMIC HEALTH CENTER* ROGER JAMES BULGER, M.D. President Association of Academic Health Centers
RUTH ELLEN BULGER, PH.D. Director Division of Health Sciences Policy Institute of Medicine Washington, D.C.
"The unexamined life is not worth living" Socrates, quoted by Plato, The Apology
TN ATTEMPTING TO UNDERSTAND the obstacles to collegiality within a medical school, a full-blown academic health center with several health professional schools, or a university one cannot escape the need to understand societal and cultural elements that describe the particularly American experience from which our academic institutions have emerged. Habits of the Heart, by Robert Bellah and colleagues,' is to the America of the 1990s as The Lonely Crowd, by David Riesman, was to the America of the 1950s; that is, Habits of the Heart seeks to understand the particular searches for individual meanings characteristic of Americans in the postmodern age. The major thread that runs through Bellah and his coauthors' work is the American search for a sense of community, of connectedness, and of meaning for life. The authors point out that Americans need to reach common understandings about the appropriate sharing of economic resources based "on conceptions of a substantively just society,"2 The authors look to our moral traditions for resources to think about these issues. They draw upon three major historical trends embedded in our nation's earliest years: the Biblical construction, exemplified by the search for a just and compassionate society to be shared with one's neighbors as personified by John Winthrop, first governor of Massachusetts; the utilitarian, individualistic, "God helps those who help themselves"3 motif * Presented as part of a Symposium on Academic Collegiality in American Medicine held by the Foundation for Neurosurgical Research at Camp Topridge, New York, September 7-9, 1990. Address for reprint requests: Assocation of Academic Health Centers, 1400 16th Street N.W., Suite 410, Washington, D. C. 20036
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BULGE AN- R. F. .J. BULGER R. R~~~~~. AND -II7E E. BULGER
personified by Benjamin Franklin; and the Republican commitment "of a self-governing society of relative equals, in which all participate,"' best articulated by Thomas Jefferson. Alexis de Tocqueville, in 1835, worried for the fledgling nation about the naive individualism born of Benjamin Franklin, but finding expression throughout the American frontier-an individualism that led people to believe that with their acres of land, their families and small sets of friends, and their guns, they had no need of any other human or social structure. If this tendency for isolation got the upper hand in America over the tendencies to community flowing out of the biblical and republican ideas, he felt that the great democratic experiment might break apart and fail. In America, the scales ofjustice as expressed through equity and liberty, as well as through individual freedoms, are balanced differently than in most other western democracies. In America we tilt inevitably more towards individual freedom than we do to equity. To a significant extent, our national meaning has been rooted in an expanding frontier, a limitless hope for improvement, a firm belief that each generation will be materially better than the last, and that our inventiveness and productivity are infinite. During recent decades, one after another of these self-conceptions, myths, and unifying ideas have been shattered or significantly discredited. Nuclear plant disasters, the Challenger tragedy, and our sense of loss of human control even over medically-related technologies have all contributed to our uncertainties. We are not first in the world in all ways; science has not brought us to Utopia; our children are not going to be better off than we are and they do not seem to want to propagate the race with much enthusiasm; and living longer is not a guaranteed good thing, especially when so many are frightened at the discomfort and expense with which they might die. Our patriotism, our family structures and allegiances, our biblical language, and our unifying ideas have all been seriously weakened. As H. Tristam Engelhardt points out, we no longer have a canonical, content-full set of values to which we all subscribe, leading him to believe that consensus building and negotiation concerning pluralistic, competing values will be one of our most important communal tasks.5 Carol Gilligan's path-breaking book, In a Different Voice: Psychological Theory and Women's Development, shows how the two sexes have been conditioned toward different values and behaviors and how the dominant voice has created societal values that unfairly restrict a subset of our population.' How the new language of the different voices, based on responsibility and caring, will be integrated with the dominant voice's concern for rights and justice is yet to be played out. Our sensitivities have been similarly raised Bull. N.Y. Acad. Med.
OBSTACLES
OBSTACLES
305
by the voices of various racial and ethnic minorities, soon to become majorities for large parts of our nation. Grafted on to all these uncertainties, each with their own implications for collegiality when placed in academic health centers, are such universityspecific factors as: physical and intellectual separation of the medical center from its parent university; incredible growth in power and influence of successful academic health centers due to their physical and fiscal size; the enormous post World War II investment in biomedical research via the National Institutes of Health, largely given to the medical schools in conformance with principles enunciated by Vannevar Bush;7 the big dollars, big business fall-out of that research effort and the great increase in incomes from clinical practice; the enormous success of reductionist biology leading to specialized scientific fields that then have corresponding difficulties in interdisciplinary communication; specialized science that has led to specialized techniques that in turn have led to specialized practitioners who relate more to their specialty colleagues across the nation than to their medical center colleagues across the hall; the explosion in the availability of clinical dollars and research dollars reflected by the explosion of a seven-fold increase in full time medical school faculty members during the past few decades; and the role of our medical schools in technology transfer; the drive for patients, market share, and technology development, to be one of the economic winners rather than one of the losers. Each of these in turn may adversely affect the environment for open communication among scientists. The overall impact of this success can encourage insatiable greed to run amok, facilitated by the currently fashionable sociopolitical emphasis on entrepreneurial behavior and the drive to utilize medical centers as economic engines with which to positively affect local economies. Add to all this the growing importance to the medical and health enterprise of the social sciences and nontraditional biomedical sciences (such as epidemiology and biostatistics) and the subsequent highlighting of the paradigm clash between the molecularly-oriented, reductionist, biomedical model and the population-based, epidemiologic model, and it is not hard to appreciate that collegiality at the medical school level, not to mention the health science center-wide level, is in for some tough sledding. Complicating these considerations even further are the overwhelming time demands made upon our faculties. How do clinical faculty members balance the requirements of the modern highly competitive research laboratory with the demands of increased service for income production as well as service to the medically underserved, at the same time maintaining close personal Vol. 68, No. 2, March-April
I(A ovu
ANTDP TI CIFR R Z. F RI RTI C.FR IAIN" R I DUL,%JZJX IX. J. M. DL)J-%-Yr-lk
relationships with our student colleagues? To the extent that the triple-theater is dead, faculty members seem to be becoming mostly researchers or mostly teachers or mostly clinicians, or significantly involved with administrative matters or external community service. Faculty salaries have risen rapidly over the last decade. Such increases have been welcome but increase the pressure on those many faculty members supported partially or entirely by soft money that they must continually earn by medical practice or by obtaining research grants. In an increasingly competitive research environment, our colleagues become our competitors from whom we withhold our ideas and our hard-earned laboratory products. Greed replaces generosity and collegiality is diminished. Tensions inhibiting collegiality have been known to develop at many levels in academic health centers: between basic science and clinical faculty concerns such as the size of salaries in each of their areas and the amount of time available to them for research pursuits; among the various members within medical school departments and across the departments themselves over turf considerations; among medical school and university faculty members over relative salary size, time required to be spent teaching students, and over differences in opinions on university values; and between basic scientists in basic science departments and basic scientists in clinical departments over such issues as tenured and nontenured positions, access to teaching responsibilities, salary and fringe benefits, and independence in choice of research
topics. The pace of our work life continues to accelerate; letters are whipped out of our computers, sent by fax or electronic mail, and the reply comes back almost instantaneously, eliminating the time we used to have for measured reflection. As we sit at our computers, we tend to use electronic mail even to reach the person just across the hall or next door, again decreasing collegiality. The legal environment also impinges on our sense of colleagueship. As our actions are more frequently challenged by a litigious society, self evaluation among colleagues in activities such as clinical pathological conferences and morbidity/mortality conferences is increasingly abandoned. We react to questioning of our medical decisions with suspicion and fear. We are, in fact, being required by society to be more accountable for our actions not only with respect to medical liability, but relating to honesty in our scientific laboratories as well as our use of animals in research. State legislatures and boards of trustees are playing a more active role in our day to day activities, constricting our spheres of influence, and limiting our control over our professional lives. Bull. N.Y. Acad. Med.
OBSTACLES
307
Who are these colleagues? Other faculty members are obviously colleagues, but how do we balance colleagueship with competition over teaching and service loads and for resources and attention? Are the students our colleagues? Surely they are. Hippocrates even spoke of the relationship of physicians and learners, using terms such as parents, sons, and family.8 If they are our colleagues, how do our actions communicate colleagueship to them when they spend much of their first two years sitting in lecture halls as classes of 100-200 functioning as passive vessels responding to a parade of expert lecturers? Bulger proposed obligations in the area of faculty competence, communication skills, treating students with justice and caring, developing creativity and freedom from control.9 Finally, are our unknown neighbors our colleagues? It is easy to see our role with the patient in front of us, but what are our responsibilities to the faceless population, which in truth is composed of such individuals? The core challenge to collegiality at both a professionwide and universitywide level becomes a challenge to develop the basis for and the mechanisms by which to bring about a meaningful sense of community, a discovery and iteration of shared core values, and a behavior change based upon a perception of the importance of living up to those shared values, while maintaining what we have attained and consolidating the progress already made. Meeting such a challenge may require us to consider how we might reapportion our time to achieve such goals. It will require courage to question and to change the basic assumptions on which so many of our daily activities are based. REFERENCES 1. Bellah, R., Madsen, R., Sullivan, W. M., et al.: Habits of the Heart, Individualism and Commitment in American Life. New York, Harper and Row, 1985. 2. Ibid., p. 26. 3. Ibid., p. 32. 4. Ibid., p. 30. 5. Engelhardt, H.T., Jr.: Integrity, Humaneness, and Institutions in Secular Pluralist Societies. In: Integrity in Health Care Institutions, Bulger, R. E. and Reiser, S. J., editors. Iowa City, University of Iowa Press. In press. 6. Gilligan, C. In a Different Voice. Psychological Theory and Women's Development. Cambridge, MA, Harvard University Press, 1982. 7. Bush, V. Science, The Endless Frontier, A Report to the President on a Program for Postwar Scientific Research. Washington, D.C., Office of Scientific Research and Development (Reprinted by the National Science Foundation), 1980. 8. Selections from the Hippocratic Corpus. In: Ethics in Medicine. Historical Perspectives and Contemporary Concenrs, Reiser, Stanley J., Kyke, A. J., and Curran, W. J., editors. Cambridge, MA, Massachusetts Institute of Technology Press, 1989, p. 5. 9. Bulger R. E.: The need for an ethical code for teachers of the basic biomedical sciences. J. Med. Educ. 63:131-33, 1988.
Vol. 68, No. 2, March-April
OBSTACLES TO COLLEGIALITY IN THE ACADEMIC HEALTH CENTER* ROGER JAMES BULGER, M.D. President Association of Academic Health Centers
RUTH ELLEN BULGER, PH.D. Director Division of Health Sciences Policy Institute of Medicine Washington, D.C.
"The unexamined life is not worth living" Socrates, quoted by Plato, The Apology
TN ATTEMPTING TO UNDERSTAND the obstacles to collegiality within a medical school, a full-blown academic health center with several health professional schools, or a university one cannot escape the need to understand societal and cultural elements that describe the particularly American experience from which our academic institutions have emerged. Habits of the Heart, by Robert Bellah and colleagues,' is to the America of the 1990s as The Lonely Crowd, by David Riesman, was to the America of the 1950s; that is, Habits of the Heart seeks to understand the particular searches for individual meanings characteristic of Americans in the postmodern age. The major thread that runs through Bellah and his coauthors' work is the American search for a sense of community, of connectedness, and of meaning for life. The authors point out that Americans need to reach common understandings about the appropriate sharing of economic resources based "on conceptions of a substantively just society,"2 The authors look to our moral traditions for resources to think about these issues. They draw upon three major historical trends embedded in our nation's earliest years: the Biblical construction, exemplified by the search for a just and compassionate society to be shared with one's neighbors as personified by John Winthrop, first governor of Massachusetts; the utilitarian, individualistic, "God helps those who help themselves"3 motif * Presented as part of a Symposium on Academic Collegiality in American Medicine held by the Foundation for Neurosurgical Research at Camp Topridge, New York, September 7-9, 1990. Address for reprint requests: Assocation of Academic Health Centers, 1400 16th Street N.W., Suite 410, Washington, D. C. 20036
Vol. 68, No. 2, March-April
304304
BULGE AN- R. F. .J. BULGER R. R~~~~~. AND -II7E E. BULGER
personified by Benjamin Franklin; and the Republican commitment "of a self-governing society of relative equals, in which all participate,"' best articulated by Thomas Jefferson. Alexis de Tocqueville, in 1835, worried for the fledgling nation about the naive individualism born of Benjamin Franklin, but finding expression throughout the American frontier-an individualism that led people to believe that with their acres of land, their families and small sets of friends, and their guns, they had no need of any other human or social structure. If this tendency for isolation got the upper hand in America over the tendencies to community flowing out of the biblical and republican ideas, he felt that the great democratic experiment might break apart and fail. In America, the scales ofjustice as expressed through equity and liberty, as well as through individual freedoms, are balanced differently than in most other western democracies. In America we tilt inevitably more towards individual freedom than we do to equity. To a significant extent, our national meaning has been rooted in an expanding frontier, a limitless hope for improvement, a firm belief that each generation will be materially better than the last, and that our inventiveness and productivity are infinite. During recent decades, one after another of these self-conceptions, myths, and unifying ideas have been shattered or significantly discredited. Nuclear plant disasters, the Challenger tragedy, and our sense of loss of human control even over medically-related technologies have all contributed to our uncertainties. We are not first in the world in all ways; science has not brought us to Utopia; our children are not going to be better off than we are and they do not seem to want to propagate the race with much enthusiasm; and living longer is not a guaranteed good thing, especially when so many are frightened at the discomfort and expense with which they might die. Our patriotism, our family structures and allegiances, our biblical language, and our unifying ideas have all been seriously weakened. As H. Tristam Engelhardt points out, we no longer have a canonical, content-full set of values to which we all subscribe, leading him to believe that consensus building and negotiation concerning pluralistic, competing values will be one of our most important communal tasks.5 Carol Gilligan's path-breaking book, In a Different Voice: Psychological Theory and Women's Development, shows how the two sexes have been conditioned toward different values and behaviors and how the dominant voice has created societal values that unfairly restrict a subset of our population.' How the new language of the different voices, based on responsibility and caring, will be integrated with the dominant voice's concern for rights and justice is yet to be played out. Our sensitivities have been similarly raised Bull. N.Y. Acad. Med.
OBSTACLES
OBSTACLES
305
by the voices of various racial and ethnic minorities, soon to become majorities for large parts of our nation. Grafted on to all these uncertainties, each with their own implications for collegiality when placed in academic health centers, are such universityspecific factors as: physical and intellectual separation of the medical center from its parent university; incredible growth in power and influence of successful academic health centers due to their physical and fiscal size; the enormous post World War II investment in biomedical research via the National Institutes of Health, largely given to the medical schools in conformance with principles enunciated by Vannevar Bush;7 the big dollars, big business fall-out of that research effort and the great increase in incomes from clinical practice; the enormous success of reductionist biology leading to specialized scientific fields that then have corresponding difficulties in interdisciplinary communication; specialized science that has led to specialized techniques that in turn have led to specialized practitioners who relate more to their specialty colleagues across the nation than to their medical center colleagues across the hall; the explosion in the availability of clinical dollars and research dollars reflected by the explosion of a seven-fold increase in full time medical school faculty members during the past few decades; and the role of our medical schools in technology transfer; the drive for patients, market share, and technology development, to be one of the economic winners rather than one of the losers. Each of these in turn may adversely affect the environment for open communication among scientists. The overall impact of this success can encourage insatiable greed to run amok, facilitated by the currently fashionable sociopolitical emphasis on entrepreneurial behavior and the drive to utilize medical centers as economic engines with which to positively affect local economies. Add to all this the growing importance to the medical and health enterprise of the social sciences and nontraditional biomedical sciences (such as epidemiology and biostatistics) and the subsequent highlighting of the paradigm clash between the molecularly-oriented, reductionist, biomedical model and the population-based, epidemiologic model, and it is not hard to appreciate that collegiality at the medical school level, not to mention the health science center-wide level, is in for some tough sledding. Complicating these considerations even further are the overwhelming time demands made upon our faculties. How do clinical faculty members balance the requirements of the modern highly competitive research laboratory with the demands of increased service for income production as well as service to the medically underserved, at the same time maintaining close personal Vol. 68, No. 2, March-April
I(A ovu
ANTDP TI CIFR R Z. F RI RTI C.FR IAIN" R I DUL,%JZJX IX. J. M. DL)J-%-Yr-lk
relationships with our student colleagues? To the extent that the triple-theater is dead, faculty members seem to be becoming mostly researchers or mostly teachers or mostly clinicians, or significantly involved with administrative matters or external community service. Faculty salaries have risen rapidly over the last decade. Such increases have been welcome but increase the pressure on those many faculty members supported partially or entirely by soft money that they must continually earn by medical practice or by obtaining research grants. In an increasingly competitive research environment, our colleagues become our competitors from whom we withhold our ideas and our hard-earned laboratory products. Greed replaces generosity and collegiality is diminished. Tensions inhibiting collegiality have been known to develop at many levels in academic health centers: between basic science and clinical faculty concerns such as the size of salaries in each of their areas and the amount of time available to them for research pursuits; among the various members within medical school departments and across the departments themselves over turf considerations; among medical school and university faculty members over relative salary size, time required to be spent teaching students, and over differences in opinions on university values; and between basic scientists in basic science departments and basic scientists in clinical departments over such issues as tenured and nontenured positions, access to teaching responsibilities, salary and fringe benefits, and independence in choice of research
topics. The pace of our work life continues to accelerate; letters are whipped out of our computers, sent by fax or electronic mail, and the reply comes back almost instantaneously, eliminating the time we used to have for measured reflection. As we sit at our computers, we tend to use electronic mail even to reach the person just across the hall or next door, again decreasing collegiality. The legal environment also impinges on our sense of colleagueship. As our actions are more frequently challenged by a litigious society, self evaluation among colleagues in activities such as clinical pathological conferences and morbidity/mortality conferences is increasingly abandoned. We react to questioning of our medical decisions with suspicion and fear. We are, in fact, being required by society to be more accountable for our actions not only with respect to medical liability, but relating to honesty in our scientific laboratories as well as our use of animals in research. State legislatures and boards of trustees are playing a more active role in our day to day activities, constricting our spheres of influence, and limiting our control over our professional lives. Bull. N.Y. Acad. Med.
OBSTACLES
307
Who are these colleagues? Other faculty members are obviously colleagues, but how do we balance colleagueship with competition over teaching and service loads and for resources and attention? Are the students our colleagues? Surely they are. Hippocrates even spoke of the relationship of physicians and learners, using terms such as parents, sons, and family.8 If they are our colleagues, how do our actions communicate colleagueship to them when they spend much of their first two years sitting in lecture halls as classes of 100-200 functioning as passive vessels responding to a parade of expert lecturers? Bulger proposed obligations in the area of faculty competence, communication skills, treating students with justice and caring, developing creativity and freedom from control.9 Finally, are our unknown neighbors our colleagues? It is easy to see our role with the patient in front of us, but what are our responsibilities to the faceless population, which in truth is composed of such individuals? The core challenge to collegiality at both a professionwide and universitywide level becomes a challenge to develop the basis for and the mechanisms by which to bring about a meaningful sense of community, a discovery and iteration of shared core values, and a behavior change based upon a perception of the importance of living up to those shared values, while maintaining what we have attained and consolidating the progress already made. Meeting such a challenge may require us to consider how we might reapportion our time to achieve such goals. It will require courage to question and to change the basic assumptions on which so many of our daily activities are based. REFERENCES 1. Bellah, R., Madsen, R., Sullivan, W. M., et al.: Habits of the Heart, Individualism and Commitment in American Life. New York, Harper and Row, 1985. 2. Ibid., p. 26. 3. Ibid., p. 32. 4. Ibid., p. 30. 5. Engelhardt, H.T., Jr.: Integrity, Humaneness, and Institutions in Secular Pluralist Societies. In: Integrity in Health Care Institutions, Bulger, R. E. and Reiser, S. J., editors. Iowa City, University of Iowa Press. In press. 6. Gilligan, C. In a Different Voice. Psychological Theory and Women's Development. Cambridge, MA, Harvard University Press, 1982. 7. Bush, V. Science, The Endless Frontier, A Report to the President on a Program for Postwar Scientific Research. Washington, D.C., Office of Scientific Research and Development (Reprinted by the National Science Foundation), 1980. 8. Selections from the Hippocratic Corpus. In: Ethics in Medicine. Historical Perspectives and Contemporary Concenrs, Reiser, Stanley J., Kyke, A. J., and Curran, W. J., editors. Cambridge, MA, Massachusetts Institute of Technology Press, 1989, p. 5. 9. Bulger R. E.: The need for an ethical code for teachers of the basic biomedical sciences. J. Med. Educ. 63:131-33, 1988.
Vol. 68, No. 2, March-April
