I have been studying or working in medical schools since
1972. I have seen many changes in that time and not all of it is good. In fact
many of the changes I have seen have been for the worse. Among those things
that have occurred to the detriment of medical schools in general and mine in
particular has been the corporatization of medical schools. Many would suggest
that what I am calling medical school corporatization represents a long overdue
application of sound business principles and professional management to the
operation of medical schools. However, I have seen over and over again, that in
reality the major effect of such corporatization has been the distortion and
abandonment of long standing academic
values which have allowed education and scholarship to thrive. They have often
been replaced with inflexible rule-driven bureaucratic organization driven by
the apparent need to control.
Among the reasons that this corporatization has taken place
is because of the relationship between medical schools and hospitals.
Educational institutions generally have a collegial style of operation with a
relatively flat hierarchy. Hospitals, in contrast, seem to be dominated by
highly vertical hierarchies with strongly bureaucratic inclinations. Moreover the educational institutions in
these partnerships are generally much smaller than the clinical institutions
and the result is dominance of the hierarchical culture at the expense of the
collegial academic culture. The values
of education, scholarship and collegiality are threatened and replaced by the
values, or in fact lack of values, which spring from bureaucracy.
In this type of organization the line academic
organizational hierarchy is diminished and becomes dominated by the support
staff hierarchy. Let me clarify what I mean by this. An academic medical
organization engages in education, scholarship, and clinical services. These
are the domain of the faculty who actually perform these functions. They
account for most of the organizational output and, along with philanthropy, are
the basis of most organizational revenue. These activities require support
systems such as human resources, information technology, and all the units that
support the business on the institution. By any reasonable assessment these are
support systems for education, scholarship and clinical care which form the
actual mission of the institution. But the support systems grow
disproportionately in the hierarchy and require a proliferation of
vice-presidential level bureaucrats. This drives proliferation of corporate
hierarchy and consolidates power within the organization. Eventually this
drives the transformation of governing boards into bodies dominated by business
people at the expense of educational, research, and medical expertise.
The end result is corporate bureaucrats who become more
powerful than deans and department chairs. The shift in power and values
becomes permanently institutionalized and the organization is diminished. It is
time for both faculty and accrediting organizations to stand up to this
insidious trend and reverse it.
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