TENSIONS WITHIN THE ACADEMIC HEALTH-CENTER

A variety of forces are converging to unbalance the internal environme nt of the academic health center, and the dean of the medical school s its uneasily in the resulting vortex of conflicting needs and demands. For example, the introduction of Medicare in 1965 profoundly changed the size and complexity of medical school departments and greatly stim ulated the growth of hospitals. More stresses have come from rising he alth care expectations of the public; the replacement of fee-for-servi ce indemnity health care by managed care and vertically integrated hea lth care systems; the proliferation of academic specialties and subspe cialties; and the recent growth in the academic medical center, which is seen as a threat to the academic integrity of the university. Withi n the medical school there are tensions between basic and clinical res earch, between education and research, between education and clinical practice, and between the dean and department chairs over allocation o f resources. Perhaps the most complex tensions exist between the medic al school dean and the academic hospital director. The overarching ten sion in the academic health center results from striving to balance th e need to fulfill academic goals with the need to fill hospital beds t o maintain financial solvency. This tension will not lessen so long as there is no common vision for the academic health center as a whole, and will probably increase with the forthcoming changes in health care reform. The dean and the hospital director must forge a strong allian ce, and the hospital must realize that for its continuing success, it must support the academic program. Academic health centers will surviv e, but only those centers where the medical school, the teaching hospi tal, and the faculty practice plan are integrated will thrive.