Korn D
Office of the President, Association of American Medical Colleges, Washington, D.C., USA.
Acad Med. 1996 Oct;71(10):1033-43. doi: 10.1097/00001888-199610000-00008.
Academic medicine is entering an era of profound, unsettling change resulting not simply from the drastic transformation of the health care marketplace but more fundamentally from the chronic, growing gap between academic medicine's seemingly insatiable demand for total resources and the supply of resources that society is willing to provide. To examine this problem, the author reviews the major factors that have shaped the development of academic medical centers (AMCs) since World War II and are now the roots of their vulnerability. The first was the major federal investment in university-based programs of science research and education that began in the 1940s; the second was the enactment in the 1960s of the Medicare/Medicaid legislation that established federal responsibility for the support of graduate medical education. After describing important characteristics (e.g., number of faculty, number of students, dollars spent on research) of the growth and accomplishment that resulted from this massive infusion of federal funds over the last few decades, the author discusses several adverse consequences, such as the de-emphasis on education in favor of research and clinical service delivery and the serious disjunction between the internal labor markets of the AMCs and the external labor markets of the real world that AMCs' graduates enter. The author then analyzes the severe challenges being faced by academic medicine in research, education, and clinical practice in the emerging resource-limited environment. Of particular concern are the fate of the clinical investigator and the future of clinical research. The author concludes with a list of four feasible strategic options for AMCs (e.g., "build one's own system") and an extensive list of what he believes AMCs will do to respond to the stresses now upon them (e.g., capitalize on unique strengths rather than trying to compete in all areas). He concludes that it will take courage for AMCs to preserve their core values in the new era, but that this can be done if AMCs craft new adaptive structures that are better attuned to the new environment and not wedded to one that is vanishing.
学术医学正进入一个深刻且令人不安的变革时代，这不仅源于医疗保健市场的急剧转型，更根本的原因是学术医学对全部资源看似无法满足的需求与社会愿意提供的资源供应之间长期且不断扩大的差距。为审视这一问题，作者回顾了自二战以来塑造学术医疗中心（AMC）发展的主要因素，而这些因素如今正是其脆弱性的根源。第一个因素是始于20世纪40年代的联邦政府对基于大学的科研与教育项目的重大投资；第二个因素是20世纪60年代颁布的医疗保险/医疗补助立法，该立法确立了联邦政府对研究生医学教育支持的责任。在描述了过去几十年这种大规模联邦资金注入所带来的增长与成就的重要特征（如教职员工数量、学生数量、科研经费支出）之后，作者讨论了一些不利后果，比如对教育的忽视转而青睐科研和临床服务提供，以及学术医疗中心的内部劳动力市场与学术医疗中心毕业生所进入的现实世界外部劳动力市场之间严重脱节。作者接着分析了在新兴的资源有限环境下学术医学在科研、教育和临床实践中所面临的严峻挑战。特别令人担忧的是临床研究者的命运和临床研究的未来。作者最后列出了学术医疗中心的四个可行战略选择（如“构建自己的体系”），以及一长串他认为学术医疗中心为应对当前所面临的压力将会采取的措施（如利用独特优势而非试图在所有领域展开竞争）。他总结道，学术医疗中心在新时代要坚守其核心价值观需要勇气，但如果学术医疗中心精心打造更适应新环境且不执着于正在消失的旧环境的新型适应性结构，这是可以做到的。
