Dystopia in the School of Medicine
Clinical service demand endanger physician education


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Conflict in the Academic Life
A lover's complaint
By Pamela Hall
October/November 2001 Academic Exchange


In the October/November 2001 issue of the Academic Exchange, Associate Professor of Philosophy Pamela Hall outlined characteristics of academic utopia and dystopia and seemed to conclude that Emory had not yet become a dystopia. Dr. Hall’s utopian university fosters the “intellectual community” by supporting and rewarding teaching, research, and service. This idealized university recognizes that these three tasks are equally important and usually complementary but may occasionally be in conflict. A dystopian university fails to recognize these potential conflicts and demands that faculty vigorously pursue excellence in all three categories simultaneously. In Dr. Hall’s words, faculty at this institution “will be seen as producers, and the [university’s] goal is
to press them to produce as much as possible.” Dr. Hall might be
surprised to learn that some of us already endure the dystopia she fears.

Five years ago, life in my part of the School of Medicine was utopian: the clinical service obligation was reasonable, allowing us enough time to teach our students and residents using the case-based method popularized long ago by Sir William Osler. On a busy clinical day, I may have reviewed one hundred x-rays with my students, a workload that was nearly perfect for combining teaching with clinical care. In addition, one day a week we had no clinical duties and could prepare lectures and pursue our research interests.

That idyllic time is gone. The absolute worst day I have experienced in academic medicine occurred about one year ago when I was responsible for covering the Grady Memorial Hospital emergency room, the mammography service, and the orthopedic radiology service simultaneously. On that occasion, I reviewed x-rays on about 250 patients, some of whom were among the sickest and most severely injured people in the city. I apologized to the resident helping me with the orthopedic radio-graphs, explaining that in this situation, I needed to concentrate on getting the clinical work done carefully but expeditiously and would have little or no time for teaching. Since that time, I have had several days that were even busier, but somehow less depressing since one can get used to or endure nearly anything.

My department tracks our clinical service output using something called an RVU, or relative value unit. For each chest x-ray I read, I get 0.8 RVU; for each CAT scan I get a few more; and so on. The latest RVU figures show that the average member of my department is now about 10 percent more productive than the average private practitioner according to the Medical Group Management Association. My own RVUs are 20 percent higher than those of my private practice colleagues. This is a terrific example of the faculty as producers, complete with a technique for quantifying productivity.

The School of Medicine enrolls some of the brightest, hardest working, and most eager students in the country. As director of the fourth-year medical student radiology clerkship, I feel extraordinarily lucky to be involved in educating these future doctors. As our clinical load has increased, however, I have had to cut my teaching time in half. In fact, during one particularly brutal two-week period, I had virtually no contact with the medical students. The high clinical workload has almost completely killed the joy of teaching for many of us. Sometimes I catch myself rushing through a lecture or a small group discussion because I know that while I am busy teaching, the clinical work is piling up. Some departments are even more overwhelmed by clinical duties than my own, and some faculty members have begun turning medical students away.

Let me rephrase that last statement for emphasis. Some faculty members now refuse to teach medical students because they simply do not have the time. Even for those of you who regard the School of Medicine as a glorified trade school, this should be shocking news. Keep in mind that about 50 percent of physicians practicing in Georgia receive at least part of their medical education at Emory. Chances are good that if you have a mammogram, are involved in a car accident, or end up in an intensive care unit in this city, I will have helped train the doctors involved in your care.

I wish research in the School of Medicine were merely fetishized, as Dr. Hall puts it. Instead, this vital activity is reduced to numbers—in some cases meaningless ones. The administration charts the progress of the medical school in terms of grant dollars obtained from the federal government. The objective of the research is almost irrelevant; the important thing is to capture lots of fat awards. The School of Medicine’s goal is to move from position number 18 in federal grant support to somewhere in the top ten of research universities. This is hardly a visionary goal, but it fits beautifully with the dystopian view of faculty as producers.

Is the situation at the School of Medicine irretrievably bleak? Not yet. Emory remains blessed with outstanding facilities, learning opportunities, and first-rate teachers. Education is the only activity that is unique to medical schools; private industry maintains a vigorous research agenda, and community hospitals can take care of patients more efficiently than academic medical centers. We have just entered Dr. Hall’s dystopia, and it remains to be seen whether the increasing demands of clinical service and research destroy the other core mission of the School of Medicine, the education of physicians.