Academic health centres have historically treated patients with the most complex of diseases, served as training grounds to teach the next generations of physicians and fostered an innovative environment for research and discovery. The physicians who hold faculty positions at these institutions have long understood how these key academic goals are critical to serve their patient community effectively. Recent healthcare reforms, however, have led many academic health centres to recruit physicians without these same academic expectations and to partner with non-faculty physicians at other health systems. There has been limited transparency in regard to the expertise among the physicians and the academic faculty within these larger entities. Such lack of transparency may lead to confusion among patients regarding the qualifications of who is actually treating them. This could threaten the ethical principles of patient autonomy, benevolence and non-maleficence as patients risk making uninformed decisions that might lead to poorer outcomes. Furthermore, this lack of transparency unjustly devalues the achievements of physician faculty members as well as potentially the university they represent. In this paper, it is suggested that academic health centres have an obligation to foster total transparency regarding what if any role a physician has at a university or medical school when university or other academic monikers are used at a hospital.
- applied and professional ethics
- health care economics
- informed consent
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Academic health centres (AHCs) are a unique healthcare provider as they are typically associated with medical schools. Appointments to an AHC encompass duties to further the multiple missions of an academic health system, which include, teaching, research and service. Moreover, funding for AHC is a mixture of clinical reimbursements, research funding, government appropriations and endowments.
Economic stress from (1) the restructuring of payments associated with Medicare and Accountable Care Organisations (ACOs), (2) the Affordable Care Act (ACA), (3) expenses associated with purchasing and maintaining new technologies, (4) decreased extramural funding research support, (5) reduced government appropriations and (6) a plethora of other financial challenges have forced many AHCs to restructure in order to remain competitive.1 This has resulted in several AHCs recruiting numerous physicians to solely increase clinical revenue and may have no or limited academic expectations. This has resulted in a blurring of the academic and clinical roles for many AHC physicians. In addition, numerous AHCs have aligned or merged their respective systems with non-AHCs, sharing different practice mandates within a single or allied health system.1 2 For patients and their referring physicians, such changes make it difficult to identify academic experts and navigate patients to optimal care. This paper explores the benefits and obligations of a modern AHC to identify academic physicians where academic and non-academic physicians are indecipherable. In contrast, it is suggested herein that, in regard to academic faculty tenets, a lack of transparency devalues the academic faculty members and weakens the academic institution’s fulfilment of its core values.
AHCs and their changing pressures
AHCs are founded on three fundamental goals: (1) high-quality patient care, (2) education of physicians and medical students and (3) proactive research. AHCs have historically provided a disproportionate share of the care for the uninsured and sickest of patients while also serving as the tertiary healthcare centre for all patients within their respective regions. They receive a large fraction of hospital transfer patients and function as a major safety net for patients, many initially treated at other hospitals. Furthermore, AHCs treat a higher proportion of patients with multiple comorbidities, poorer compliance rates with care and who frequently require readmission for exacerbations and complications of their acute and chronic illnesses. Such higher intensity and complexity of care has led AHCs to not only develop the capacity and expertise to treat the sickest patients but also the ability to better salvage patients from complications of therapy. It has been well demonstrated for complicated conditions such as cancers, severe burns and advanced heart surgery that better outcomes can be obtained at high volume or university centres. Moreover, this complex patient care environment has historically proven to be an outstanding training ground for physicians of various specialties and has served as the main source for clinical medical research undertakings.1 3 4
Medicare payment restructuring, the formation of ACOs and the ACA have resulted in a refocusing on healthcare costs and value-based medicine.1 2 5 Although these changes have the capacity to prevent the continued excessive consumption of National GDP financial resources into healthcare, this restructuring of medical payments has overlooked the essential role of academic physicians within AHCs. The more complex patient mix, as well as critical teaching and research activities, performed by academic physicians, contributes significantly to the increased costs associated with care at an AHC, placing them in a very precarious spot whereby their core missions will be non-remunerable in this new reimbursement system. In response, and to remain viable financial entities, AHCs have needed to proactively adapt to these changing circumstances. Nevertheless, despite such changes, the core missions of excellent patient care, teaching and research remain the fundamental values of AHCs that should guide both the faculty and the university or medical school.1
The transforming workforce composition of AHCs
University and medical school AHCs may be structured either as a wholly owned or closely affiliated but independent financial enterprises linked to a medical school or university.2 Alternatively, some AHCs have accepted more loose affiliations lending their name/brand to institutions without clear changes in many of the services provided. All of these activities may be linked to pressures to increase clinical activities, remain financially solvent and function as ACOs. As well, many AHCs and their collaborators have extended services both within their historical communities and to new markets outside of these regions. In order to accommodate such expanded healthcare services, AHCs have needed, in addition to increasing their geographic hospital and clinic footprint, to recruit and retain additional physicians and expand facilities.2 6 Frequently, the AHCs, rather than the respective medical school or university, may employ these additional physicians, with an expectation that such adjunct physicians place a heavy emphasis on clinical activities with few or no academic duties such as teaching or research.2 This lack of academic activity may disqualify the physician from a regular medical school or university faculty appointment, even when in some instances salaries for such positions may be identical or exceed those individuals with medical school appointments.7
Currently, there is no uniformity throughout the country regarding academic titles or appointments for the different faculty working within an AHC and its affiliated hospitals.5 In some AHCs, physicians may be designated as regular, visiting or voluntary faculty or receive no associated faculty status with AHC employment.6 8 The California University System, for example, has identified all physicians as faculty working within the system but stratified the faculty into multiple categories, of which only a few are eligible to participate in regular faculty activities such as the Faculty Senate and others being equivalent to limited contract employees for as little as 2 years.8–10 Another example includes the University of Michigan, which like many other large health systems covering a large geographic region, appoints faculty via various tracks, including tenure earning and clinical tracks for physicians. The clinical track faculty positions include titles of ‘instructor’ to ‘clinical professor’. The university also provides a plethora of ‘adjunct/visiting’ titles, as well as associated titles such as ‘clinical lecturer’.11 12 Minimal to no teaching or research expectations exist for many of these positions. As another example, the Columbia University Medical Center (CUMC) provides various titles that are separated into full-time and part-time faculty. Of the full-time faculty, those that primarily perform research are tenured or on the tenure track receive a ‘unmodified’ title, such as ‘professor of surgery’, while the faculty that have a variety of activities such as education, public health intervention and clinical care receive a modified title that ends with ‘at CUMC’, which implies a non-tenured track.13
Other AHCs that have developed collaborations or networks that offer services in concert with other health systems while providing their AHC name and various degrees of direct or indirect patient care services without specifically employing the collaborating physicians appear to have encouraged these physicians to represent themselves as AHC physicians. One such example is University of Texas MD Anderson Cancer Center, which has formed a network of affiliations with numerous community hospital systems across the country including Community Health Network in Indiana, DCH Regional Medical Center in Alabama, The Queen’s Medical Center in Hawaii and several others throughout the country.14 These hospitals are labelled as ‘certified members’ of the MD Anderson Cancer Network that employ ‘participating physicians’, labelled by the lapel pin they wear while working with patients.14 15 These titles may be misleading to patients and referring physicians who are seeking a higher level of cancer care because they risk implying that the participating physicians have equivalent expertise with those hired by and working for the University of Texas MD Anderson Cancer Center. In actuality, these certified members’ connections to the MD Anderson Cancer Center are limited to the use of its ‘clinical intellectual property’ including up-to-date research and bimonthly teleconferencing with the expert faculty at the University of Texas MD Anderson Cancer Center in order to better care for patients.15 16 To make matters even more confusing, there are two other types of membership specified on the MD Anderson Cancer Center website, namely ‘associate’ and ‘partner’, The three types of membership are designated by their ‘level of clinical integration’, but it is unclear as to what this exactly means.17
In other AHCs, academic titles are simply not provided. For instance, Partners HealthCare, which was founded by two Harvard Medical School-affiliated teaching hospitals, Massachusetts General Hospital and Brigham and Women’s Hospital, allows patients to search for available providers, but does not provide any form of academic titles of those doctors on their web pages. It does, however, provide the hospitals with which the doctors are affiliated, but without providing clear academic titles; this risks patients choosing a physician based on location convenience rather than a physician’s expertise.18 19
As AHCs have expanded in these different directions, the total number of regular academic faculty may have remained stable or even grown. The fraction of true academic faculty within these expanding AHCs, however, has in many cases may have shrunk. Furthermore, without a clear, uniform way to appreciate the details of the financial and academic arrangements between the physician, the AHC, the university or medical school and other networks, a patient seeking care at an AHC for a specific problem may find it difficult to locate the expert he or she requires. As a result of this lack of transparency, a patient may come to the conclusion that all AHC-monikered physicians have equivalent expertise, regardless of whether they are world expert, regular university or medical school faculty, leading the patient to make choices based on convenience and availability regardless of where the physicians practice.
Herein, it is suggested that faculty roles and clinical expertise be transparent and that it is problematic from a number of perspectives when transparency does not occur. The potential implications of the changing AHC arrangements regarding faculty from an ethical perspective are examined. Such arrangements can not only harm the physician–patient relationship but also increase the risk of patients making misinformed decisions regarding care. This can subsequently result in causing patients emotional or physical harms. In addition, it is argued that lack of transparency disempowers faculty, the associated medical school and university, as well as hinders the achievement of the stated AHC goals.
The impact of lack of transparency on the physician–patient relationship and the principles of beneficence and non-maleficence
Fundamentally, providing effective medical care relies on the intrinsic fiduciary relationship between a physician and a patient. The patient is dependent on the physician’s knowledge and character and assumes that she will uphold the principles of patient autonomy, beneficence and non-maleficence as a means of carrying out what is truly in the patient’s best interest.20 21 Thus, if a patient requires a specific type of physician such as a well-known family physician or a nationally recognised subspecialist for a specific problem, the health system and referring physician have a moral obligation to transparently assist in providing access to such specialists certainly if available within the system and arguably even if available at a competing institution. It is well recognised that in order for this effective distribution of care to occur, the physician–patient relationship must be based on complete honesty, confidence and trust.22
In order to earn and keep a patient’s trust and establish a favourable physician–patient relationship, a physician must demonstrate that she is honest and truly seeks what is in the patient’s best interest. This is achieved through active and open communication with the patient regarding their concerns and possible treatment options. For instance, if a local surgeon feels that a patient’s tumour be best managed under an expert at an AHC, then it would be most appropriate to transparently disclose this option to the patient, because it shows that the physician truly cares about the patient’s well-being and seeks what is best for the patient. The patient depends on this integrity and sincerity in order to trust the physician’s professional counsel and act according to her recommendations. In this particular example, acting on the physician’s recommendations could lead the patient to a more favourable outcome, which exemplifies the physician’s moral obligation and professional duty to patients.21–26
In the same fashion, it is the health system’s ethical responsibility to provide clarity in identifying experts in their system so that both the patient and the referring physician can make an accurate, informed decision as to which treatment path is best to take. An AHC that fails to provide transparent means to identify academic experts among their physicians fosters a system that puts patients at risk of making misinformed decisions in choosing a physician leading them to fall short of receiving the quality of care that leads to the best potential outcome. This misguidance could cause physical or emotional harm for the patient, which would not only cause them harm but also injure the patient’s trust in the referring physician, and via a halo effect, harm the patient’s trust in the entire AHC.23 Furthermore, the harm caused by this lack of transparency would violate the physician’s and AHC’s duty to uphold the essential ethical principles of benevolence and non-maleficence.
Therefore, when patients place their trust in a physician or health system, it would be an infringement of the fiduciary relationship for both physicians and AHCs to not provide the transparency to suggest and guide patients to the experts they are seeking, particularly if such care may represent the chance for superior outcomes.21 23–26 Without total transparency, the physician and the institution are at risk of committing an unfortunate but very tangible injustice by sacrificing the ethical principles of beneficence and non-maleficence, because they are failing to uphold what is in patient’s best interest, and harm is being brought about as a result.20–24
The implications on a patient’s right to autonomy
Patients have the right to make their own decisions when it comes to their healthcare.27 Decades ago, physicians made most medical decisions via a paternalistic approach where they served as experts that chose what they felt to be the greatest good for their patients without much open discussion with them. This archaic method had its shortcomings because physicians, despite their good intentions, were often unable to see the emotional or socioeconomical factors that played crucial roles in the patient’s condition.28 For example, an oncologist may decide that the optimal treatment for his patient with a seminoma be radiation therapy and paternalistically decides to proceed with this plan without learning that the patient fears becoming infertile as a result from the treatment. Had open communication occurred between the two, this fear could have been addressed, and other treatment options discussed. As a result of this dialogue, the physician–patient relationship would have been strengthened and the emotional harm of fear as well as the possible physical harm of infertility might have been avoided.27
Today, autonomy has shifted from the physician to the patient, and most final medical decisions have fallen into the hands of the patient with guidance from the physician on which treatment plan would be in the patient’s best interest.28 The physician provides the patient information that can facilitate patient participation in making medical decisions. In this manner, the physician acknowledges patient autonomy by respecting the patient’s right to informed consent, which allows the patient to partner in his or her own care.20 27 The patient retains control while trusting the physician’s knowledge and honesty to properly guide him so that the patient can make an informed decision on what he feels is the best treatment. This open communication enables a higher level of trust to develop between the patient and the physician. Furthermore, studies have shown that most patients want to understand and participate in their healthcare decisions, and when this method is fostered, patients have increased trust of their physicians.20 25
A patient’s autonomy, however, is limited on his decision-making capacity, so in order for this principle to be upheld, it is essential that he is provided access to the necessary knowledge to make an autonomous decision that accurately pursues his goal. This can only be achieved via optimising transparency.20 27 29 When there is a lack of transparency, a patient’s autonomy is undermined, as he no longer has the capacity to choose what is truly best for him because he lacks the necessary understanding. Without this information, a patient may result in picking a treatment path that is physically or emotionally harmful that could have otherwise been preventable.20
An AHC can promote patient autonomy by fostering transparency in regard to its expertise. This expertise is commonly measured with two metrics: case volume and individual outcomes. Patients may benefit from knowing the amount of AHC’s cases as well as the outcomes of these cases. While an AHC’s high case volume leads to better outcomes, as mentioned previously, the metric of individual outcomes examined by itself can be misleading as it can be confounded by case complexity.4 If an AHC receives numerous referrals for complicated cases with associated risks for a poor outcome, then a patient may assume that the physicians associated with the AHC lack expertise. Rather than giving in to the temptation to hide such outcomes, it is in a AHCs best interest to remain transparent in regard to the complexity of such cases. Doing so will provide patients with the most accurate expectations for their care and will promote a sense of trust with the AHC and its physicians.26
Thus, physicians and AHCs have a critical responsibility to be transparent regarding the exact roles and expertise of the physician faculty so that a patient can properly identify the certain experience he or she requires. Only through this methodology can a patient retain his or her right to autonomy and make an informed decision. Hence, referring physicians and their corresponding healthcare institutions must honestly and openly provide transparency regarding the roles, titles and expertise of academic experts for the sake of respecting the moral principle of patient autonomy.
Lack of transparency disempowers faculty and the university
The patient is not the only one who suffers from a lack of transparency, the physician faculty of the medical school is afflicted by it as well. When an AHC hires physicians with little to no academic expectations and fails to transparently distinguish physicians, the academic expert’s contributions are devalued amidst the company of these additional physicians who share the same moniker of the AHC. Patients and referring physicians searching for an academic expert would find difficulty in distinguishing one physician’s expertise from another, and all physicians would be blurred together regardless of their duties. As a result, being a physician faculty member under the name of a well-known and respected academic institution suffers a loss in its worth, and the faculty member is disadvantaged, when compared with non-academic affiliate physicians who practice under the same AHC brand. Under this system, the merits of performing academic duties such as research, education and clinical care are disincentivised. This is both a disservice and an injustice to the university faculty members who have devoted their careers in achieving their academic titles and laurels, fulfilling the primary AHC goals and representing the strength and name of the university.
A lack of transparency is also not in the best interest of the university. The university’s name is misrepresented when numerous adjunct physicians who have little or no academic duties are muddled with the academic faculty. The ratio of an AHC’s academic output to physicians plummets, creating an apparent loss in academic force of the university. Furthermore, all three of the stated AHC goals are at risk for failing when transparency does not occur, as the faculty members who achieve these goals are diluted. Without proper distinction of their expertise, physicians who have represented the university and served the community in their positions for years may suffer a loss of perceived importance and influence, which could negatively impact work incentive and productivity.30 In the worst scenario, research and education efforts from the long-standing faculty members could dwindle, and patient care as a whole could be damaged due to the long-term consequences of weakened emphasis on research and education. Such shortcomings run the risk of numerous implications for the university such as loss in government funding, confidence and trust from patients and respect from the community, all of which, weaken the university academic mission.
Providing transparency, however, communicates to the faculty members a sense of respect and appreciation. Their specific expertise can be clearly recognised by all, and the hard work resulting in their publications, grants, titles, and duties come to light. They can perform their duties at their fullest potential and adequately serve the university, local community and society as a whole by optimally fulfilling the goals of patient care, education and research.30 The university flourishes from having a strong academic representation, and the patients have the potential for better outcomes being able to identify the experts they require. In short, transparency in regard to physician expertise at an AHC is morally and practically necessary in order to achieve the greatest good for all parties.
Proposals for solutions to the lack of transparency
A variety of solutions ought to be emphasised for the widespread lack of transparency. The first proposed solution is that physicians make a consistent and conscious effort to remain honest in their practice regarding their own expertise as well as the expertise of other physicians. Not only should they maintain integrity in their own work but also actively strive to promote it among their peers as a core mission of the very foundation of their medical vocation. Doing as such on a daily basis is a small but obligatory step that must be made to combat this lack of transparency and begin to reverse its negative effects. In addition to the regular practice of honesty, AHCs that do not provide academic titles ought to publicly do so on their own web pages. This would serve as the most straightforward method to allow patients and referring physicians alike to clearly identify certain academic experts amidst the vast array of providers that share the same university name.
A uniform methodology of displaying the hierarchy of academic titles throughout all US AHCs would be ideal, but would be significantly difficult to implement given that it would most likely require national legislature or at the very least a legally binding agreement between all AHCs throughout the nation, which would be a massive undertaking. This could be championed and/or mandated through membership of the Association of Academic Health Centres. More realistically, individual universities could mandate accurate academic titles for their physician faculty and defining these titles for laypersons, namely, the academic roles and responsibilities associated with each title. This simple and clean method would achieve a significant improvement in transparency, enabling clear and proper recognition for the faculty and university as well as optimising patient autonomy in choosing a physician.
For the AHCs that are affiliated with other health systems to varying degrees, it is critical to explicitly define the affiliation as well as the types or degrees of membership. Clear, detailed and honest explanations regarding the level of integration with the AHC should be displayed publicly on web pages and other media. This will serve as a means to avoid confusion among physicians and patients alike, which will ultimately lead to a better quality of care. While these suggestions serve mainly as starting points, AHCs must challenge themselves to remain resilient in their promotion and maintenance of transparency throughout the years to come despite what pressures the future may hold.
Benefits of Medicare and the ACA on patient care despite the effect on transparency
Despite the changes that AHCs have made to adjust to the aforementioned financial pressures, Medicare and the ACA’s focus on preventative care have benefits for patients that ought to be stated. For decades, Medicare has aided elderly and disabled Americans with accessing and paying for their healthcare. The ACA has improved the effectiveness of Medicare in numerous ways such as covering preventative care services without sharing the cost with the patient as well as making prescription-drug coverage cheaper. The ACA has also made efforts to increase the quality of healthcare for patients by creating incentives for hospital systems to better coordinate care of chronic disease management, reduce the number of hospital-acquired infections and readmissions and control expenses through the formation of ACOs. It is through this focus on preventative care at increased quality and decreased cost that ultimately lead to better outcomes for patients, which is a goal shared with AHCs.3 31 32 Given these substantial benefits as well as the common goal of better patient outcomes, it is all the more imperative for AHCs to adapt to the pressures brought about by the national changes without sacrificing their ethical obligation of transparency. By following the proposals of solutions mentioned above, AHCs are better able to achieve their common goal with the ACA.
The financial pressures from healthcare reform have inevitably forced changes on AHCs resulting in the recruitment of numerous additional physicians with little or no academic expectations. The true academic faculty and their merits have become blurred among the new members due to a lack of transparency in regard to their respective expertise. This ambiguity has several ethical implications such as failing to uphold the principles of benevolence, non-maleficence and patient autonomy, the possible physical and emotional harm for the patient and the impediment in achieving the AHC goals of excellent patient care, education and research. Furthermore, the faculty and university are disempowered, which is an injustice and disservice to the academic faculty members and the patients for which they care. Thus, physicians and the AHCs they represent have a moral obligation to foster transparency in regard to the academic undertakings and expertise of the entire faculty. Doing so guarantees that the three aforementioned ethical principles are respected and the potential of a better outcome for the patient remains available. It also clearly distinguishes the merits and titles of physician faculty members and empowers them to continue to fulfil the AHC missions. Via the adoption of transparency, the university name is protected from misrepresentation, and the university’s academic influence remains robust. For all these stated reasons, there can be no justified excuse in withholding transparency. Solutions to combat this lack of transparency have been proposed, and the importance of Medicare and the ACA’s to increase quality have been emphasised in order to give additional rationale to promote honesty despite the financial challenges. Providing clarity in disclosing its expertise is not only an AHC’s ethical obligation but is also the faculty member’s and patient’s right. This, along with the plethora of benefits that emerge from fostering transparency, AHCs should make removing the injustice of lacking total transparency among all physicians and healthcare systems a top priority.
Contributors All the authors contributed to the idea, drafting the manuscript, editing and approval of the final manuscript.
Funding This study was funded by Eli Lilly Fund.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement There is no unpublished data from this study.
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