The University of Alabama at Birmingham Medical School and the University of Alabama at Birmingham Health System are collaborating in a plan they call “AMC21” to become the preferred “Academic Medical Center for the 21st century”, according to a story in today’s issue (November 3, 2011) of the Birmingham News. From the article, it sounds mostly like an expansion of their research efforts, or more pointedly, of their efforts to lasso NIH research dollars. Which is all fine and good, to a point.
But what is the purpose of a medical center and college? Does striving to be considered an elite medical college and a leader in health care research comport with its purpose?
The purpose of an organization that provides health care has to resolve to helping people get well or to helping them manage incurable diseases and conditions. Simple as that. Hospitals and medical centers like UAB’s exist to treat patients whose maladies are too complicated, or the treatments too capital-intensive, to undertake in out-patient clinics and doctor’s offices. In-grown toenails are generally best treated by the primary care physician. Bone marrow transplants need full-time, intensively-focused care. If the medical center is to treat patients, the focus has got to be on the clinical treatment and well-being of the patients.
It seems that a great deal of focus on patient care is lost when doctors try to become researchers instead of clinicians, as my son’s two bone marrow transplants at a leading teaching and research hospital (eight years apart) bear ample witness. The transplant doctors in both cases only saw patients on a rotation that allowed several weeks of time between patient-care duties, ostensibly to pursue their research prerogatives. Each time the rotation changed, the first several days were spent educating the new doctor on rotation as to the particular issues my son faced. And it wasn’t as if the research they were performing seemed to enhance their ability to diagnose and treat his symptoms. During the first transplant, it took a good four weeks for the doctors to diagnose post-transplant-lymphoproliferative disorder, which is a rather common affliction of whole organ transplantees. It’s not as common in bone marrow transplants, but one has to wonder, if the focus had been on the patient, might the diagnosis have been more timely? As it was, he very nearly died from the lag in diagnosis time. Once they figured out what he had, treating the disease was rather straight-forward.
In his second transplant, I learned first hand that knowing how to get one’s papers published in medical journals does not necessarily a good clinician make. Time and again, I would hear explanations about my son’s condition, particularly regarding his kidney and bladder functions, that made no sense. If his bladder was bleeding because of a virus that he had, then why did it bleed the same, no matter the observed level of the virus? The ability to cite journals in which one’s research has been published matters precious little when simple cause and effect relationships in the clinic can not be grasped. If A appears without B simultaneously appearing, A can not be causing B, or vice versa. If they appear together, one might be causing the other, but correlation is not causation; it is only evidence that causation might be present. This is simple logic that somehow didn’t make it from the lab to the bedside. In other instances, the unit failed to do the simple stuff, like correctly managing platelet levels, that could have saved my son a great deal of misery and pain. There’s not much glamour in properly managing platelet levels, as the research on the relationship between platelet levels and bleeding is now over half a century old, but sticking to the knitting of good medicine requires that it be properly done.
I attribute the failures of the bone marrow transplant unit in part to its focus on research over clinical practice (I should have known better after the first time). It sometimes felt as if I had been defrauded by their having agreed to treat my son when it was clear they had no intention of making his care a singular focus of their efforts. The half-million or so dollars expended in my son’s care (each transplant) was paid to have doctors focused on his well-being, not on getting their research published in a medical journal. No man can dutifully serve two masters.
To make matters worse, the transplant unit in which my son was treated was only a children’s auxiliary to the main, adult bone marrow transplant unit at the medical center’s main hospital. Though the medical center had overall responsibility for the children’s auxiliary, located only about six blocks away, to my knowledge it never exercised any managerial or professional oversight. I never saw a doctor from the main transplant unit. It appeared they didn’t even share expertise and research. When a complication developed with my son’s liver functioning, one that is far more common in adults than children, but not so uncommon in second transplants, the condition was improperly diagnosed by the doctor on rotation, or at least was until he bothered to pick up the phone and call the main transplant unit and plead for help.
It seems to me that successful organizations singularly focus on being good at whatever it is they do. In the hospital/medical center context, a choice has to be made. Either the focus may be on delivering excellence in patient care, or it may be on delivering excellence in expanding the universe of medical knowledge. Both functions may be accomplished under the same umbrella organization, but at the operational level, they need to be separate. Doctors are not demigods. They are subject to the same human limitations as the rest of us; they can and will serve only one master. It is either the patient or it is the science (specifically the scientific angling for research dollars).
If a medical college and center wishes to continue treating patients while it embarks on a push to become an elite academic and research organization, it owes it to the patients to segregate the functions so that treating physicians get paid by how well they treat patients, not by how many journal articles they publish, or research dollars they garner. It can still have researchers, and the researchers can collaborate with the treating physicians, but patient care has to be the priority whenever they agree to treat them.