(The FASEB Journal. 1998;12:621-624.)
© 1998 FASEB
What Role Will Chairs of Discipline-Based Subjects Play in the Evolving Medical School of the Future?
Donald A. Fischmana
a Department of Cell Biology and Anatomy, Cornell University Medical College, New York, New York 10021, USA
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INTRODUCTION
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Before discussing the future role of chairs in discipline-based departments, it seems appropriate to address the concerns and problems facing such departments, since these considerations will predicate the functions of their chairs. Widespread concerns are now evident in the departments of many American universities, especially those termed `research universities'; nowhere are these concerns more tartly discussed than in medical schools, particularly in clinical departments buffeted by the financial strains of health care reform and the `discipline-based' basic science departments such as anatomy, biochemistry, physiology, microbiology, and pharmacology. It is the concerns of the latter departments—discipline-based basic sciences—that I address here.
Figure 1
illustrates the central issues, and I will discuss each in turn, moving clockwise around the wheel.
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Figure 1. The wheel of worry: major concerns of chairs attending to the basic science departments of medical schools in the United States.
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INTEGRATED MEDICAL SCHOOL TEACHING PROGRAMS
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Most medical colleges in the nation are in the midst of curriculum reform or have already completed such a reform. The majority of these revisions entails a centralization of curriculum authority and cross-departmental integration of subject matter. In short, there is a loss of departmental control of the basic science courses and a greater focus on clinical relevance, often disguised as `'oblem-based learning'. In my view, it would be unwise of the discipline-based departments to hinder or oppose this trend; its momentum is too great and, frankly, such integration is long overdue. It eliminates significant redundancy between courses and fills important gaps that have been omitted in the past. Departments must attend to the central issue, which is not control of the courses but rather what subject matter is included in them. Content should be the focus of the basic science faculty, not the format of the courses or their link to clinical material. I recognize that many Ph.D.-trained faculty feel uneasy with the clinical subject matter, but I suggest that these same faculty members should welcome the opportunity to broaden their own educational background; it might even have a salutary effect on grant funding in the coming years. This said, I recommend that discipline-based departments concentrate on the subject matter of the integrated courses, insist that high standards of excellence be maintained in such courses, but not fight a rearguard action in which the departments appear reactionary or ultraconservative.
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INTERDISCIPLINARY GRADUATE PROGRAMS
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Many of the most successful graduate schools in the nation have been shifting to integrated programs that span or cross departmental boundaries, which has resulted in open admissions and integrated curricula. Many of the best applicants to graduate programs in the biomedical and biological sciences are attracted by an open admissions policy in which students are not locked into single graduate programs in their first year of study. Independent students want the chance to begin their graduate careers in a less restricted manner, i.e., by deferring final program selection until late in their first year or early in the second year of study. This permits the trainees greater latitude in selecting research areas and Ph.D. mentors. As a consequence of these shifts, there has been the loss or decline of departmental control of graduate training, often with a change in program titles. For example, graduate training in anatomy may disappear and be replaced by training in cell biology, developmental biology, or neuroscience; molecular biology programs may be created without a formal medical school department possessing this title. So the names and focus of graduate programs may not be synchronous with the medical college departments.
Is this bad? I'm not sure. But the trend is clear and the pace is increasing. For graduate schools to compete for the best students, they must present attractive graduate opportunities that are flexible, integrated, and exciting. `Public relations' is a fact that cannot be ignored. The essence of a fine graduate program is the quality of both students and faculty. A school with a strong faculty that is incapable of attracting good students because of rigid departmental boundaries is not going to have a successful graduate program or a happy faculty. Medical school departments cannot afford to dig in and fight to rigidly control the graduate programs. Change must take place to attract the best students; generally, this involves integration and flexible training programs. This is the way we all do our research; why not do the same in our graduate programs?
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INADEQUATE HARD MONEY
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For many years research-intensive private medical schools in the U.S. have expected faculty to recover a fraction of their full-time salaries in proportion to the time they devote to research. This usually came from National Institutes of Health (NIH) grant support. As competition for NIH support has intensified over the past decade, particularly in areas distal from molecular genetics, traditional discipline-based departments have been severely pressured, weakening staff morale and diminishing their attractiveness to graduate students. With the demise of discipline-based Study Sections, e.g., physiology, this unease has deepened. Although the situation had been particularly intense at private schools, that is no longer the case; increasingly, faculty at state university medical schools have been expected to regain higher percentages of their salaries from grants. Salary recoveries in excess of 50% are not uncommon, and I do not believe that the situation is going to change unless one or more of the following developments occurs: 1) an increase in federal grant support; 2) an increase in medical college endowment monies allocated for salary support; 3) more foundation support (e.g., Howard Hughes Medical Institute); 4) increased industrial support; and 5) increased allocation of clinical dollars for basic science research. Space precludes a full discussion of this topic, but optimistic prospects for increased NIH support over the next 5 years are quite encouraging and should alleviate much of the stress now felt by faculty in discipline-based departments. It is unrealistic to anticipate a significant increase in endowment allocations for the basic science department, but chairs should work toward modest increments. Foundation support might increase, but not tremendously, and I am skeptical about major increases in industrial support. Finally, it is very unlikely that clinical revenues will increase in the future; the reverse is more than likely. Unless federal grant support for the basic sciences increases in the future, the stability and permanence of such departments will be uncertain.
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UNREALISTIC DEANS
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Deans of medical colleges are generally recruited with the expectation that they will strengthen research, modernize education, improve patient care, increase health care reimbursements, and enlarge private fundraising. However desirable, these expectations may be unrealistic, thus explaining the short tenure of most deans. Clearly, none of us want to blunt the high hopes or aspirations of our institutions, but the severity and complexity of these issues may preclude their timely solution. This has often led to an enormous expansion of dean's offices while faculties see shrinking academic departments, which increase teaching responsibilities without commensurate remuneration. This has led to dangerous skepticism between faculty and administrators that may have severe consequences. The increasing size and complexity of modern medical centers is a double-edged sword. Critical mass is essential for both research and tertiary health care delivery, but the current appetite for money is frightening. Most basic science faculty feel distanced from central administrators and suspect (quite rightly) that most of their attention is focused on clinical issues, primarily health care reimbursement. Open and meaningful discussions between faculty and deans concerning research and education are infrequent and usually unsatisfactory. Faculty feel they are being asked to do more teaching, often in areas in which they are poorly trained, while being asked to increase their extramural salary support. This necessitates an increasing flow of grant submissions and less time for thoughtful research. Space utilization is coming under increasing scrutiny, often with each square foot of research space being assigned a dollar value. Universities clearly have to optimize space utilization: it is a valuable resource. But despite many assurances to the contrary, most faculty believe that indirect cost recoveries are not being used to benefit their research but are disappearing in an ever-expanding dean's office. Is there a solution? Again, I am not sure. Clear and honest communication between the dean's office and faculty is essential. The aspirations of both parties must be acknowledged and addressed, but that becomes increasingly difficult as medical schools enlarge and diversify. Faculties are so dispersed and out of direct contact with one another that institutional bonds are fraying severely. Thus, the isolation felt by basic scientists is common in the modern medical center, possibly the natural consequence of increased size and diversity. I have no simple solutions: most deans and faculty muddle through, with nostalgic memories of the `good old days'. I see no rainbows with pots of gold on the horizon.
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SINUSOIDAL WAXING AND WANING OF DEPARTMENTS
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In a U.S. medical school, monies typically are invested in a department when a new chairperson is recruited. The sums invested at that time can be quite extensive—often many millions of dollars. Although this clearly has enormous impact on the department and school for the next 5–10 years, it is just as often the case that sustained support of that department dries up rapidly. Thus, research-oriented faculty are recruited in significant numbers for the first 5 years of a new chair's tenure, but as they reach mid-career with successful research programs, the institution's attention has shifted to other problem areas and the faculty and chair are left to fend for themselves. Although this may be understandable, it is short-sighted and self-defeating because many of the best members faculty members become unhappy, search for other positions, and foster a mood of discontent. Institutions must sustain, as well as seed, departments. The tradition of feast and famine is stupid; it inevitably leads to the sinusoidal waxing and waning of departments that seem to be the predictable fate of our basic sciences. While this might also be true of the clinical departments, in reality they depend very little on the dean's office for most of their support; clinical revenues and private support are a valuable buffer for those departments, usually unavailable to the basic sciences. It would be wise for deans' offices to plan for the annual banking of $100,000 to $200,000 per year by the basic science departments, which could be used for periodic reinfusions of their programs. Instead, chairs must go `hat in hand' to their deans for such infusions, often unsuccessfully. The short-sighted planning by most institutions is surprising indeed.
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UNREALISTIC START-UP PACKAGES
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Faculty recruitment typically requires substantial start-up packages, generally in the range of $500,000–750,000 for junior appointments. While this often includes a significant fraction of the appointee's salary, the sums are nevertheless very large and usually beyond the reach of most chairs. And then we continue the aforementioned hat-in-hand visit to the dean's office. The best young candidates are being recruited by many institutions, and despite the large number of available postdoctoral fellows the same names appear surprisingly often at the top of most search committee lists. Although competition is clearly a positive feature of the U.S. system, the sums now on the table are often backbreaking. The only answer is wise planning, prudent investment policy, and tough promotion procedures.
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SALARY RECOVERY
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In addition to the previous discussion, the issue of salary recovery is a severe one and not likely to go away. Also, different policies in different departments can become a problem within an institution. Uniform policies on this score are advisable because they would minimize the suspicion of favoritism or inequality that often pervades medical colleges. I suspect that salary recoveries in the range of 50% will be a reasonable target in most basic science departments, providing that NIH monies remain available.
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CLINICAL PRESSURES
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This is too large an issue to discuss in this brief article. Suffice it to say that the insecurity of clinician-scien~tists may be even more pervasive than that in the basic sciences. The pressures to see an ever-increasing number of patients, to carry an even greater teaching burden for pre- and postdoctoral students, and the intense competition for federal research funds have dampened the enthusiasm of most medical college graduates for entering academic careers in the clinical-scientist track. I have no crystal ball here and will duck the problem.
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OUTMODED FACILITIES AND EQUIPMENT
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With the intense financial pressures on most dean's offices, there has been a deferral of infrastructure repairs at many medical centers. Physical plants have been deteriorating as monies are used for short-term needs. This is having a disastrous effect on many institutions and must be redressed. The same is true of core facilities needed to sustain modern research. Until these core facilities are built and monies allocated for their subsidy, modern research programs will not be competitive. This is especially true of animal centers, which are essential for biomedical research and cannot be expected to cover their expenses from user fees. The cost of mouse colonies, for example, must be subsidized, but those monies have to come from sources also needed for start-up funds, bridge funds, library support, etc. Again, planning is essential but rarely occurs in an open and forthright manner. Faculty are often not included in long-range decisions that have a major impact on their research and educational programs. The obvious result is discontent and unease among the faculty. It can and should be avoided.
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PRESSURES TO CREATE NEW `AU COURANT' DEPARTMENTS
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Medical colleges are continually faced with the pressure to create new departments, both basic and clinical. The plethora of clinical departments in most medical schools, often numbering about 18–20, is obvious and disconcerting. Meetings of most chairpersons evolve into discussions of clinical reimbursements and the tensions between hospital and medical college administrators. Rarely are educational or research issues addressed. While the multiplication of clinical departments is occurring, most medical colleges have kept very tight reign on the growth in the number of basic science departments, usually retaining anatomy/cell biology, biochemistry, microbiology, physiology/biophysics, pharmacology, pathology (sometimes grouped with the clinical departments), and public health. Most schools would acknowledge the need to create departments of genetics and neurobiology as well, but usually this is limited by available endowment monies. As such, there continues the refrain about merging or renaming basic science departments to increase their attractiveness and competitiveness. At the same time, deans continue to test the waters about eliminating basic science departments altogether while creating a basic biomedical institute or center, with divisions akin to a department of medicine.
I have no enthusiasm for such a model. The size of the total unit would be in the range of 100 faculty members, and the essence of collegial units that most faculty find in departments would disappear. Once departments grow to more than 20, there is usually a falloff in faculty interaction and connectedness. Despite the professed reductions in administrative costs, I am not persuaded that this model would be successful or welcomed by many basic science faculty.
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ROLE OF CHAIRPERSONS IN THE DISCIPLINE-BASED DEPARTMENTS
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Chairs of the discipline-based departments are as bewildered as their faculty in this chaotic period of changing health care delivery, educational reform, and uncertain funding. Although most would prefer to emulate the Asian metaphor of bamboo—bending but not breaking in a strong wind—most feel like brittle twigs, fragile in the current winds of change. A central question is how much proactivity is called for or is advisable by chairs and their faculty at this time. Clearly, passivity is unappealing and defeatist. But how can we identify what is important to preserve within current departmental structure and what can be eliminated or repackaged? It is over this issue that most of us part ways. Very few basic scientists would advocate eliminating their departments, but I suggest there would be very little agreement about how much graduate program organization should be departmentally based, how much medical and graduate teaching should be controlled by medical school departments, and which departmental names should be preserved or eliminated.
I close by suggesting that until we as basic scientists reach some consensus on these questions, the situation will drift or be decided by administrators with agendas that differ from our own.
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FOOTNOTES
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1 Correspondence: Department of Cell Biology and Anatomy, Cornell University Medical College, 1300 York Ave., New York, NY 10021, USA. E-mail: fisch{at}mail.med.cornell.edu 
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INTRODUCTION
INTEGRATED MEDICAL SCHOOL...
