Pursuing Excellence in Healthcare: Preserving America's Academic Medical Centers

  • Arthur M. Feldman
Productivity Press, 2009 336 pp., hardcover, $49.95 1439816573 | ISBN: 1-439-81657-3

Pursuing Excellence in Healthcare: Preserving America's Academic Medical Centers is a thoughtful book presenting an overview of the major challenges presently facing Academic Medical Centers (AMCs) and offering recommendations to both institutions and policy makers. In his book, Feldman argues that preserving AMCs is crucial to our society for providing excellent patient care, teaching future physicians and leading scientific research to ultimately improve care. He articulates the “grave challenges” facing AMCs today and poses an “audacious” question: “how can AMCs compete, survive and continue to fulfill their societal missions in a highly competitive and hostile marketplace?”

To answer this question, he draws on literature from mainstream business applied to the business of medicine and his own interviews with leaders from a variety of AMCs. He describes specific examples of how a particular AMC approached a problem and whether it was successful or not. For example, he describes different structures for organizing the relationships between the hospital, medical school, physician practice plan and university. In this analysis, using specific examples from multiple AMC structures, Feldman concludes that the “most effective means of attaining the core mission of providing outstanding patient care can be achieved by the integration” of these four components. Feldman further concludes, on the basis of his research, that the guiding principle for the success of AMCs must be to make the provision of outstanding clinical care the most important mission—a radical notion for many AMCs, which place the mission of research ahead of patient care and teaching.

Feldman lays out a series of recommendations for each of four spheres of action: developing an integrated structure, pursuing and supporting disease-related research, educating the healthcare workforce and focusing attention on the business of medicine.

In a thoughtful and organized approach, Feldman describes the present challenges faced by AMCs in each of these spheres, presents examples of alternative strategies used and recommends preferred approaches based on his observations. For example, in the section on structure, he strongly favors the development of integrated clinical service lines to improve patient care. He believes that the traditional departments in AMCs have created barriers to effective care.

One of the strengths of the book is the comprehensive overview of the challenges facing AMCs. These include the “broken pipeline” of AMC scientists (related to the high likelihood that junior scientists will leave their research career paths), the teaching of medical professionalism and the business aspects of AMCs. Feldman is particularly effective in bringing to life examples of how different AMCs approach similar situations, such as the various types of arrangements AMCs are developing with medical schools across the world, including Duke's collaboration with the National University of Singapore and Weill Cornell Medical College's creation of a medical school in Qatar.

One of the issues that Feldman raises is that the US has 'have' and 'have-not' AMCs. The 'haves' have large endowments, and, even in a competitive market, they can take risks and invest in new endeavors. In contrast, the 'have-not' AMCs often have a crucial role in providing patient care to vulnerable populations in their communities. Sixty percent of the care of uninsured patients is provided by the 126 AMCs, and many of these are have-not institutions. Feldman makes an important case that society cannot afford these institutions to fail and that at present there is a lack of federal government oversight of AMCs to address this problem. He makes useful recommendations for policy solutions regarding this concern by, for example, calling for the need for the federal government to support some AMCs that provide services for the underinsured or uninsured, particularly where the state governments cannot support the AMCs.

By virtue of the breadth of the book, some areas are covered in less depth. The chapter on medical professionalism raises major and uncomfortable problems, such as clinicians' inability or unwillingness to intervene when they know a colleague is not competent. Feldman recommends developing a “culture of professionalism” in the AMC, but he does not provide details about how to achieve this ambitious goal.

Recommendations in most chapters include those that can be implemented by individual AMCs and policy-level strategies that would need federal or state plans. The practical implementation of strategies at an individual AMC seem feasible, but it is less clear how the policy-level recommendations might be moved forward. Although the Association of American Medical Colleges might lobby for some of the required changes to support AMCs, more federal oversight is clearly needed. It would therefore be useful for legislators to read the book and consider some of Feldman's recommendations.

I think the most radical notion in the book is Feldman's consistent statement that the pursuit of excellent patient care must drive decisions in AMCs. I wish this were the case, but, in my experience, decisions are often made with money and reputation in mind. Feldman's book should help challenge AMCs to consider their approaches in a variety of areas crucial to their futures and, perhaps, to adopt some 'best practices' offered in Feldman's recommendations.