The Universityʼs (and Medical Schoolʼs?) Crisis of Purpose

“The University's Crisis of Purpose” is the title of a recent essay in the New York Times Magazine (6 Sept 2009) by Dr. Drew Gilpin Faust, President of Harvard. She describes how the economic downturn has underscored the fragility of the broader purposes of the university beyond just creating a competitive workforce. “Higher education is not about results in the next quarter but about discoveries that may take—and last—decades or even centuries. Neither the abiding questions of humanistic inquiry nor the winding path of scientific research that leads ultimately to innovation and discovery can be neatly fitted within a predictable budget and timetable,” she wrote. In effect, she is lamenting that the core goals of higher education are becoming commodities with the focus on training rather than inquiry for its own sake. She points out that business “is now by far the most popular undergraduate major.” The essay certainly points out the problems; a solution offered by Dr. Faust is for government to provide more support, as it did with the GI Bill after World War II. But my own sensibilities resonated much more with a response to the essay published in the magazine two weeks later (20 Sept 2009) from an emeritus professor of languages, Dr. Michael Shapiro. Dr. Shapiro agrees that there are economic causes for the troubles in American universities, but he believes the essay “does not comprehend the three main reasons that commodification has also been allowed to pervert higher education: (1) the professionalization of university administrations, resulting in hypertrophying hordes of overpaid managers (alias chancellors, deans et al); (2) departmental autonomy, whereby (typically small) teaching units are allowed to make personnel and curricular decisions immune to substantive scrutiny by outsiders; (3) the tenure system, which has become the last refuge of academic scoundrels and malingerers, guaranteeing them not only lifetime employment but a stranglehold on the appointment and promotion of junior faculty. If we are ever to live up to Cardinal Newman's justly celebrated vision in ‘The Idea of a University,’ it is these malignancies that must be rooted out first.” It appears that Dr. Shapiro has very strong feelings about this issue. My own reaction is colored by the fact that for most of my professional life I have been part of only one aspect of university life, the medical school, which certainly differs from a college of liberal arts. But when one considers the diversity of basic functions, the similarities of the problems are still greater than the differences. In fact, one may ask if there were also a crisis of purpose in medical schools and whether any of Dr. Faust's and Dr. Shapiro's concerns about universities in general also apply to medical schools. First, Some Basics Colleges and graduate programs in the liberal arts provide a broad education in the arts, language, history, and the rest to provide a strong foundation for living the life of an educated person. It is hoped that the student will leave with an appreciation of the cultural span of human history with its amazing accomplishments and failures and an improved ability to think and judge wisely. This education is not immediately “practical” in the usual sense, but at its best it provides an invaluable base for any future activity. Professional schools, such as law, nursing, pharmacy and medicine, prepare students to profess certain values and apply a body of knowledge; they are taught to represent the best interests of a patient or client and to assume responsibility for their medical or legal needs. The standards used are part of an evolving body of knowledge, which is continually shaped and modified by research, experience, and social evolution. The state recognizes the importance and seriousness of these activities by requiring that aspirants possess a basic fund of knowledge and practice in a legal-ethical manner. But professional schools are also sources of new knowledge acquired by systematic study and original research. The amount and quality of such innovative activity is balanced by training in the pragmatic professional skills. This balance varies widely among medical schools with some focused far more on research and others more on the practice of the profession. At their best, medical schools teach by example with balanced and high-quality scientific innovation and medical practice. At their worst, medical schools are simply narrowly focused trade schools for physicians or scientists whose fund of knowledge will peter out in five years leaving them susceptible to every little trend proffered by pharmaceutical detail men or to following the false trails in the scientific movements of the time. Basic Science Now back to the initial issues. Dr. Faust's concern for the survival of a liberal education has no exact parallel in a professional school, but the role of education in modern basic sciences in medical schools comes close. For many students, “getting through” basic science is an unpleasant but necessary hurdle. Relatively few will become competitive scientists, but without a basic understanding of genetics, microbiology, wound-healing and the rest, the student is likely to become a tradesman instead of a professional. But the role of economics also resonates in medical schools, though in opposite directions. For Dr. Faust, it is too little money for liberal education, which cannot support itself financially. In medicine it is the 600-pound gorilla of too much money “on the table” for doctors, pharmaceutical companies, so-called non-profit hospitals, and all the other feeders at the trough. This has led to a dearth of primary care doctors, an expansion of specialists, sub-specialists and sub-sub-specialists, all of whom earn very high incomes. This in turn has led to the active recruitment of primary care doctors from areas like sub-Saharan Africa that suffer a severe shortage of doctors; this practice has been called unethical or even criminal (Lancet 2008;371:685–88). Reimbursement for primary care doctors remains low while leaders wring their hands about their decline, but do nothing. Social evolution, changes in work-hour expectations of trainees, and huge debts for medical graduates also play a role in this transformation, so economics is shaping the profession of medicine, like it or not. Concerns Also Apply in Medical School? Do Dr. Shapiro's concerns also apply in medical school? In my view the answer is most definitely affirmative. In many schools there is a large array of deans, associate deans, assistant deans, associate chairmen, and the rest; it is mind-boggling. I don't know if they are all needed; the only sure thing is that they will spend more than half of their time sitting in committee meetings with one another. The autonomy of chairmen in most schools is a carryover from the medieval university system in which there was a single professor of a department who was usually the smartest and best physician or scientist; he was the professor, not a professor. Remnants of that model remained in the US as recently as the 1950s and persist today in some countries. But chairmen have largely become business managers whose success is measured largely in grant dollars and clinical revenue. They oversee an archaic organizational model that is increasingly being made irrelevant (or obstructionist) by multidisciplinary specialty programs in cardiology, neurology-neurosurgery, and oncology, and by freestanding facilities in cardiology, oncology, orthopedics, ophthalmology, and others. These more-focused efforts allow a greater concentration of expertise that can provide a broader educational experience and, with a nod to the times, a greater market share. Tenure System Dr. Shapiro's third point, the tenure system, is a no-brainer for me: tenure is inappropriate in professional schools. There is brave and principled talk about the importance of productivity in medical schools, but many faculty members in their 40s are given lifetime employment, irrespective of future productivity. This does not make sense. The traditional justification for tenure, freedom of speech and inquiry in controversial areas, has little relevance in professional schools. My preference is a renewable contract system with a length of three to five years, depending on rank. The Flexner Report written by Abraham Flexner and funded by the Carnegie Foundation was published in 1910. It was an exhaustive study of the state of medical education in the US and Canada, which, in a word, was terrible. It recommended sweeping changes and higher standards for medical schools, curricula, admissions policy, and oversight. The many medical trade schools were forced out of business. and the quality of education improved dramatically. The result was that medicine became, in fact, a profession. It is not too soon to think of another Flexner Report type of examination of medical schools as we approach its 100th anniversary year. Although things are not as bad as in 1910, medical schools have not adapted very well to the secular evolution of the past 60 years and the dominance of specialty training. The fraying of the social contract between physicians and the public, the endless stream of information (much of it wrong) in the public domain, and the flood of dollars into the business of medicine have perverted the profession. Computers and electronic medical records won't solve these issues; a return to first principles may.

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