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The recent Beyond Flexner postings and social mission articles have revived interest in Academic Medicine's Season of Accountability and Social Responsibility by William T. Butler, M.D. Dr. Butler gave this address to AAMC in 1990 and expected a response - one that never came.

The following are predominantly Dr. Butler's words with an update regarding the lack of progress regarding his calls to action.


Public Concerns About the Overall Health Care System

Dr. Butler declared that academic medicine had entered a new and stormy "season" of accountability and social responsibility, due to public concerns about the overall health care system. His recommendations are followed by comments regarding academic medicine addressing these concerns or not.
  • Public concerns have continued. There has been no progress in this area. The political arena has been a distraction, but the concerns continue. The same types of headlines listed not only are seen in the media headlines, but also across social media and numerous Business, Health Info Tech, and other journals and magazines.Medicine has lost respect and physicians have lost substantial ability to shape health care design. 
  • Academic designs have made matters worse for those who deliver basic health access. The partnership between managed care and accountability researchers resulted in micromanagement. This movement has added countless billions in additional health care costs based on assumptions and lack of evidence basis for health outcomes improvement. 
  • Worst of all is that the design changes have made it more difficult for the team members that deliver the care. Some physicians cry out, often those older who experienced much better environments, but not associations or academic designers.
Butler then reviews earlier seasons of academic medicine and the responses. He recommends how the AAMC can achieve several near-term solutions to pressing demands of the current season, such as the needs to manage academic medical centers more efficiently and to restore public confidence in the integrity of biomedical research.
  • Efficiency and confidence are lagging still. Academic centers push for more lines of revenue and fight to keep the highest reimbursement in each line - designs that they largely shaped and maintain. 
  • 1100 zip codes in 1% of the land area have top concentrations of physicians at 45% of physicians in places with 10% of the population. Over half of health spending is transferred to these settings making it difficult for half of the nation to receive even the basic care.
  • The graduate medical education design results in only 6.5% of residency positions found in 2621 lowest physician concentration counties with 40% of the US population. 
  • The expansion of GME is a primary example of the problems of academic medicine - lack of efficiency, training failure, and continued promotion of funding that widens disparities in dollars, workforce, and access. 
  • Residents in their fellowship years are paid only $60,000 and have small levels of benefits but often generate as much as subspecialty physicians paid $400,000 or more with some of the most lucrative benefit packages. More residents at these fellowship
Next, Butler focuses on proposals for academic medicine to provide leadership, through the AAMC, in two major areas: preparing more generalist physicians, and assuring greater access to health care for those who live in underserved urban and rural areas. Butler flat out states that generalists are the cornerstone of the medical profession.
  • Generalists have substantially failed due to academic medicine and academic influences that prevent true health care reform - more support for cognitive, basic, office services. 
  • Generalists and general specialties are shrinking as a function of US academic medicine, primarily because generalists, general specialties, and health access are prevented by the designs that academic medicine continues to shape.
Butler describes models of existing, successful programs.
  • The WAMI model looked good because it existed when the financial design for primary care was better 1965 to 1980. Since that time the model and other training models are limited by the financial design and the inherent suppression of generalists - particularly family medicine. 
  • The models that Butler promoted in the article were limited to only a small influence regarding solutions for underserved rural or urban practices. 
  • The financial model prevents any MD DO NP or PA training solution. 
  • The Deans Lies and the GME lies continue across MD DO and NP. No promises of improvements in primary care, health access, and care where needed should be made until academic medicine promotes true payment reform - more fuel for the generalists and general specialties.
The author concludes by proposing to create a "National System of Regional Medical Care." He urges the AAMC to continue its leadership by designating a task force to examine how such a regional system could be established within this decade.
  • States used to do statewide and regional planning, but this is largely left up to the largest systems and practices that control the health care dollars. 
  • The regional plan failed to progress.
  • Regional primary care officers in positions above hospitals could actually help to hold hospitals and hospitalists accountable for not coordinating care with primary care offices.
Most of the school and program successes we still revere are really about the one period of time with substantially improved finances - a time when the US steadily sent more dollars to lowest physician concentration counties. This was due to early Medicare and Medicaid 1965 to 1980. An improvement in the financial design shaped improvements in workforce and in access. The rush for schools, programs, special incentives, and pipelines to claim credit obscures the obvious reason for improvement.

Dollars injected into the care of those poor and elderly were specific to lowest physician concentration counties then as now, if we chose to do so. The original designs are not the same and the dollars are unlikely to go where needed as determined by designs from the 1980s to the present.

There are those who can point to "their program" or curricula as successful, but a rearrangement of the deck chairs type of success is failing 200 million people as will more easily be seen in 2040. As is often said it is amazing what can be accomplished if no one cares about who gets the credit but it is also true that those who claim credit falsely distract from the investments of time, talent, and treasure that do make the difference.

We are already a decade too late in workforce improvements specific to these counties to be in place by the 2040s. True reforms specific to most Americans by 2050 seem even more distant.

Care for most Americans left behind requires an entirely different financial design. This is the only way that the traditional health professional education design will to work for MD DO NP and PA. 

Anyone who promotes anything other than major financial reform as a solution is giving false hope. Health care interventions that do not improve patient outcomes and can worsen them are condemned, for good reason. The same should be true for those who promote any solution for health access that does not substantially improve the financial design.
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Data is often collected, processed, and promoted for dramatic impact. Dialing for dollars is very lucrative when it comes to health care. The controversies dominate our attention  as health care eats its way through our budgets, our employer budgets, our state budgets, and the federal budget. Physician salary data is a popular attraction. This data is often used to claim that physicians seek careers associated with higher salaries. The payment design shapes much more than physician salaries and in turn shapes those in our nation that win and those that lose - by national design.

Data from Medscape
The payment design has long favored procedural-technical services over office-based/cognitive/basic services. The highest paid physicians perform procedures that are paid at highest rates. Other highest paid physicians are those that perform higher volumes of higher paid procedures. These highest rates have been determined by academic, hospital, and physician association representatives that have dominated payment panels. The favor is returned as highest payments work well for academic institutions, largest systems, and associations.

Not surprisingly, the highest paid and highest volume services are the easiest to overutilize. Knee surgeries, cosmetic procedures, cardiac stents, prostate surgeries, tonsillectomies, and skin procedures are big business. Dr. Otis Brawley first came to my attention in his talks about too much done. He learned from hospital CEOs how various screening tests were reliable for harvesting a set amount of dollars in areas such as prostate surgery.

In a cruel irony, the tide has turned against unnecessary procedures and higher volume. This has also been applied to those lowest on the scale. As noted by various experts, higher volume of lowest paid office services has not broken the bank. But higher volume is castigated. Sadly, those paid least and limited to office services have had little choice other than to try to increase the volume. As costs of delivery have been forced higher, there are no good choices. In office based practice, the decisions can lead to fewer team members and lesser paid team members - a short term fix with cascades of consequences.

Brave New World for the Procedurally Focused

At the top of the scale can be seen those who have been able to separate from hospitals and systems, thus providing some competition for higher salaries. Surgical centers involving orthopedic and other procedures have done well for orthopedists and others establishing such centers. Orthopedic surgeons fresh out of fellowships get paid the same as the orthopedists nearing retirement.

The fact of the matter is that the national design for payment shapes winners and losers. Winners are indicated previously. Those most procedural, technical, subspecialized, and centralized are most organized for best payment and profit. Those less organized, not the biggest, not centralized, not academic, office-based, cognitive, and basic have had lesser payments. The consequences of lesser payment are many:
  • Lower salaries for those lower on the scale is just one consequence. Salaries are higher for those generating more under the payment design.
  • Team members working for those generating lesser payment are fewer and have more different tasks. They often follow the pay gradient to better support. The most specialized physicians can hire and support the most specialized team members who do much of the work. Public health and Community Health Centers are lowest on the scale. Academic and private primary care can pay better. More specialized practices and hospitals raise the ante. The most specialized can pay best. Stable team members, continuity, more team members, and more experienced team members follow the dollar gradient.
  • Nurse practitioners and physician assistants have followed this pay gradient following the physician example and adding more different specialties and subspecialties with more added to each new career type. This results in fewer and fewer remaining in primary care, especially in family practice.
  • Care where needed is compromised by design. About 90% of the services where needed (rural, underserved, 2621 lowest concentration counties) are generalist and general specialty services.  Primary care, mental health, and general specialty services are stagnant to declining where 40% of Americans are found. The workforce is aging - another indicator of lack of replacement and other consequences.
  • Paying the least for these basic services means sending the least dollars to these lower concentration settings where 40 -  50% of Americans are found. The designs for payment actually create the shortages that are seen. Team members in these areas face the most complex populations and have the least support - by design. 
  • With fewer dollars shipped to settings that already have lowest health, education, and economic outcomes - outcomes worsen as disparities widen.
  • The academic centers that train MD DO NP and PA graduates benefit by having shortages such that they can generate more interest for funding more graduates - who still cannot go where needed because of payment design. 
There really is no reason for the designers to change the design. It serves them very well. Those who do the studies and the reports shape the design. They also give the press releases and engage the media.

Most Americans lose in the design in a number of ways. They are the least likely to become physicians at 3 to 1 against. Even those that become physicians are least likely to become the physicians that shape the design. The designs are shaped by those far away, most exclusive, and most different than most Americans. 

Medscape and other information brokers do very well at capturing and selling our attention. Often the way the information is presented paints a certain impression. Not surprisingly the picture that is painted hides more than is shown.
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