Striking a nerve. Apparently, Orac takes exception to I said a few days ago:

Dr. Kevin’s comment revealed a common misconception of what it is really like to work in academic medical centers that is common among physicians in private practice . . . If you’re in academia for any length of time, you become aware that many private practitioners appear to have some sort of stereotypical picture of us academicians sitting in our “ivory towers” sipping lattes, thinking deep thoughts, reading journals, doing seemingly arcane experiments, and not having to deal with the reality or nitty-gritty of the “real world” of taking care of patients . . . Indeed, I have news for Dr. Kevin: Medical academicians have been operating in the “real world” for at least a decade now. It began back in the 1980′s, when HMOs and managed care rose to become the dominant means of paying for health care, and accelerated throughout the 1990′s. Before then, it was quite possible for clinical departments to build up impressive surpluses from clinical revenue that they could devote to research because it was generally accepted that academic institutions were more expensive and less efficient because of their research and teaching missions, and insurers and the government were willing to pay extra. However, as the bottom line became more and more important, as insurers and third party payers ceased to differentiate between academic and nonacademic health care providers, the financial squeeze became more and more pronounced. Worse, because of our research and teaching missions, it is almost impossible for academic medical centers to operate as efficiently as private medical centers, putting them at a competitive disadvantage for managed care contracts, as I’ve been learning from the prolonged discussions of finances and contracts that dominate nearly every Department of Surgery faculty meeting at my institution. Add to that the responsibility as tertiary care centers to accept and care for the sickest (and therefore often less profitable) patients and the frequently high rate of uninsured patients cared for in university medical centers, and it becomes clear that the “ivory tower” of academic medicine is something that has all but faded into legend.

No offense meant. I sympathize with the plight of the academic physician – with the continual dual pressures of research funding and the financial “bottom-line”. It just seems that many of the suggestions proposed by our “leaders in academia” seem so impractical that one can’t help but to feel that academic physicians are out of touch with the real world.

Orac gives a final word.

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  • mchebert

    I agree with you, Kevin. I just finished residency in 2001 and, though academics certainly work hard, I also have the strong impression that they are out of touch with the “real world.” Even when an academic has an active clinical practice, the organization he is with is so large and bureaucratic that he does not face the same situations and decisions a doc in private practice does.

    Academics don’t have to discipline employees, worry about salary structure, choose hospitals to apply for prividges for, decide on managed care contracts, deal with partnership issues, or deal with patient access issues (like having to treat RA yourself because there isn’t a rheumatologist within 100 miles).

    These differences in experience do make pronouncements of academics seem out of touch.

    I want to note too that I have started a blog on my experiences and opinions formed as a primary care physician. I am at

  • Michael Rack, MD

    “Academics don’t have to discipline employees… or deal with patient access issues (like having to treat RA yourself because there isn’t a rheumatologist within 100 miles).”
    patient access can be a problem in academia. For example, at the U of MS, dermatology is not available. Some academic centers are limiting access to hepatitis c clinics. Access to specialty care is especially problematic for the many uninsured and Medicaid patients that academic primary care docs see.
    “don’t have to worry about salary structure”
    salary structure is very complex in academics- there is the “base salary” from the medical school, often a stipend from the hospital for being a medical director of a unit,and profit sharing within the department for money received for clinical services. Researchers get additional money from those activities.

  • Anonymous

    You’re right, but … as an academic I’ve had to:
    … fight for over a year with crazy unions/bureaucracy to get an incompetent administrative employee ‘fired’ … (actually, just transfered, with an increase in salary … although the problems are continuing … looks like another raise/transfer is in order)
    … fight for 8 months (and counting) to get a replacement hired
    … lose two good candidates for the above position when the bureauracy couldn’t process their offers in a timely manner
    … watch the billing dept collect less and less on services each year due to mismanagement
    … watch the billing dept collect less and less each year due to our clinic becoming one of the only in the area that takes medicaid … because we can’t refuse

    I think the ivory tower is supposed to ‘isolate us from the real world’, it’s getting pretty tarnished … and that’s all aside from issues with shrinking research dollars for basic science, increased teaching responsibilities, and decreased lab time.

    I would say six of one, half a dozen of the other …

  • Anonymous

    I would agree with Kevin. I would agree with Orac. My wife and I practice the same medical specialty, my wife in the “ivory tower” while I slog it out in the community. I make about 50% more in salary and when I am not working I truly am off the clock. On the other hand, she gets a guaranteed salary, money and time for CME, sick days, etc. However she is never truly off, she is always preparing lectures, developing curriculum, sitting on committees while doing a fair share of clinical work. She love it, I would hate it.

    Agree with 8:55 anon. It is six of one or half a dozen of the other.

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