Family medicine in the academic medical enterprise: Issues of resource dependence, culture, and professionalization

Abstract

The healthcare marketplace is rapidly changing how we finance medical education, how we train physicians, and the interrelationships within an academic institution. This case study examined the historical development of the Department of Family and Community Medicine and the impact of growing financial constraints on the training of medical students and residents, the clinical practice, faculty workload, and departmental organization. The theoretical frameworks of resource dependence, culture, and professionalization theory were employed to understand how different groups within the context of an academic health center co-exist to meet the core missions of teaching, research, and service. Data collection was conducted over a two-year period and utilized the triangulation of interviews, document analysis, and participant observation methods. The study's findings indicated that the Department of Family and Community Medicine continually faced the challenge of being a primary care department in an academic medical culture that placed more emphasis on specialized care and specialty departments. Over a period of time, the Department went from a profit-center to a cost-center where faculty's ability to teach and conduct research revolved around the success or failure of the clinical care enterprise. Faculty productivity was increasingly emphasized and its definition was dependent on the healthcare marketplace and the availability of resources. The competitive health care market encroached on faculty workload and manifested itself in part through the loss of a major patient care contract, the receivership of the Department, and the splitting of the Department and its resources. During the period of time analyzed, the department was in a no-win situation because the success of the department was determined by more powerful coalitions that had decision making ability and controlled the necessary resources. The department's power lay in the provision of teaching resources and its alignment with the state's goal of training primary care physicians to work in rural and underserved communities. Conflict arose as departments tried to defend and protect their declining resources and jurisdictions. The study findings emphasized the importance of understanding departmental jurisdictions and how resource allocation decisions are made in the context of the academic setting and culture.