“Academic medicine” refers to a way of practicing as a physician that remains inside of the hierarchy of medical education. The education of physicians (“medical education”) occurs in two basic stages. In medical school, college graduates graduate as physicians; in residency, medical school graduates emerge as eligible for board certification. During both stages, trainees work in a hierarchy of students, residents, post-residency trainees (“fellows”), and physicians who have completed training (“attending” physicians).
One or both of these stages is traditionally done in a setting known as “academic medicine,” although other models exist and this is a simplified view. Academic medicine describes the environment formed by a medical school and one or more residency programs at one or more clinical sites, staffed by a combination of administrative staff and physicians, and divided into departments (e.g. the Department of Pediatrics, etc.). Physicians who choose to remain in academia usually do so out of interest in research or teaching, distinguishing them from their colleagues in the community who are devoted to patient care.
Funding for academic medicine comes from payments for patient care (provided in the course of education at the hospital and clinics), student tuition, research funding from government entities or private foundations, and federal subsidies for residency training (Barzansky 2002, Huron Consulting 2015, Congressional Research Service 2018). Academic medicine often coalesces into partnerships between two entities: (1) a medical school handling research and educational income and (2) a hospital that handles clinical income from medical care provided in the process of teaching physicians (Bongiorni 2017).
The medical community at large is paying attention to burnout and toxicity in academia (Shah et al 2019, Rosenthal 2020) related to difficulties with research funding, equitable representation, and work-life balance (Druss 2005, Seritan 2010, Vickers 2020). At their worst, departments can commit fraud, violate rules for trainee work hour limits, overtly abuse trainees, and depersonalize physicians, other professionals, and patients (Wilson 2020, Jenner 2019, Grabinski 2020). The community of academic medicine needs a systematic approach to running a department well.
“Ethics” is the study of acting rightly (Fieser). Medicine, education, and research are all inherently normative (Singer 2001, Higgings 2016, Mulvenna 2017). Thus, while there might be debate about the legitimacy of ethics entering into organizational function in other spheres (Goodpaster 2007), there is little debate about the role of ethics in academic medicine. In fact, some have openly called for more ethical behavior in academic medicine, specifically regarding trainee treatment and equity among junior, female, and underrepresented minority employees (Faunce 2004, Fins 2013).
But what “ethical” or “ethics” means is extremely important in order to achieve a well-run, employee-friendly, pleasant and productive department. This is a difficult subject to broach in academic medicine, as generational, cultural, and even moral differences divide academic physicians. It is easy to become overwhelmed and dismiss the idea that an “ethical department” can be systematically described.
This piece presumes the contrary. Academic medicine rests on three “cornerstone activities”—clinical medicine, education, and research. If the optimal practice of these three activities can be articulated, so can the optimal practice of academic medicine. The nature of clinical medicine as a profession is dynamic, but also defined: medicine is based on human beings, who have matured in their social and moral understanding over the centuries, but have not changed physiologically much. The nature of education is similarly dynamic, but defined: the art of teaching has matured, but the need to pass on information and habituate intellectual and mechanical skills is unchanged. Research, perhaps, has undergone the most significant evolution over the centuries, but is reaching a maturity surrounding the objective need to ethically investigate clinical questions. If the three cornerstone activities of academic medicine are dynamic but defined, then this paper proposes that the organizational efforts connected with academic medicine can also be defined, if dynamic.
Given a firm starting point, then, the objective of this work is to outline the ethical foundation for an ideal department in academic medicine, stated in general terms so that it can be applied to various specialties and situations.
Although principlism has weaknesses and, in fact, for decades has been aching for replacement or buttressing (Humanism in Medicine 2008), it has a long history in academic medicine as a basic ethical framework that works well in pluralistic systems. As a result, this piece will aim to define a principlist framework for a proposed ideal department. Correctly prioritizing principles is also key, as it helps resolve disputes between values that are not equivalent.
The first principle that motivates any organization should be more than simple profit, but should be a something that this organization wants to do that others cannot, hereafter called a “mission” (Goodpaster 2007, p. 122). For most departments in academic medicine, this mission will likely be threefold, based on the cornerstone activities:
This piece does not aim to develop a specific mission statement for every department in academic medicine, this threefold mission orients the ethical framework of the ideal department.
These three cornerstones are prioritized intentionally. Priorities are important and inevitable; principlism was originally built without prioritizing between principles (Beauchamp and Childress 2019, p. ix), but priorities were then added based on value judgments, which then led to disagreements over the priorities (Kekewich 2011). One way to avoid nonprioritization or poor quality prioritization is to look to something objective about the cornerstone activities.
Clinical care not only provides the majority of funds for most departments, but it has historical, philosophical, and logical pride of place among them. After all, what is medicine without patient care? Education and research come next, in order as they descend from clinical care. Education is prioritized second, even though it is not highly lucrative in time or money, because the profession has a duty to sustain itself, noted as long ago as the time of Hippocratic Oath (Hippocrates). Education is a direct extension of patient care: education allows physicians to directly contribute to the care of future patients. Research comes last, even though for some departments this is a primary source of money and prestige (and thus, a draw for students, faculty, patients, and more research collaborators). Research is also an extension of clinical medicine, but a more indirect one: research is an attempt to improve care for future patients. Basing the department’s priorities on the definitions of these cornerstone activities allows for a balanced approach that doesn’t shift based on value judgments; individual department members are free to have personal priorities, but the department as a whole has priorities founded in unmoving fact about the practice of academic medicine.
The department’s mission should make room for the cornerstone activities, but must also be openly tempered by something beyond pure achievement. “Profit is a good servant, but makes a poor master,” and business ethics is familiar with the disaster that simplifying a mission into a drive for profit or prestige leads to: tunnel vision, rationalization, ethical blindness, and eventually scandal (Naughton 2014, p. 17, Goodpaster 2007). In medicine, excessive demands for profit and prestige lead to cynicism and vicious cycles of exhaustion (Leiter 2009). A balanced pursuit of the mission respects persons, including employees and the patients they serve, more than profit or prestige. But how is a vague “respect for persons” to be carried out? Besides the three cornerstones of the ideal department’s mission, the department should codify respect for multiple groups of people and clarify how it shall protect each population.
Based on a long history of prioritizing the most vulnerable populations, this piece prioritizes patients most highly among the many groups vulnerable to abuse in the power structure that any department represents. Patients’ conditions place them at a unique disadvantage during all three cornerstone activities of any department (their own medical treatment, education utilizing them as lessons, and research including them as subjects). Thus, the highest respect must be given to patients, and extending to their loved ones at the bedside, and their presence elsewhere, such as on social media.
Depending on the department’s locale and makeup, other vulnerable populations must also be protected, such as trainees, department members with extraordinary needs (e.g. for any amount of medical or mental health exception), or persons with ordinary yet highly-valued needs (e.g. the balance between work and family, or other personal accomplishments that do not directly serve the department). Ultimately, all persons that the department encounters, including very privileged ones, are worthy of respect, and the happiness and work-life balance of all employees impacts productivity (Bataineh 2019, Bellet 2019), and may improve patient safety and satisfaction (Lu 2018).
Many readers, especially those who have been in the trenches of academic medicine for one or more decades, may be tempted to scoff at this point. This ideal is not possible, there is too little time and money, too many regulations and complexities, and too much greed and drama for excellence in these three cornerstone activities and true respect of persons to coexist. This piece begs to disagree, from a business ethics perspective.
Organizations can create and continue cultures that balance respect for persons with the impartial achievement of the department’s mission (Goodpaster 2007, p. 76). Here, “culture” is defined as a set of corporate habits that motivate action. There is a well-documented history of such companies, with many in healthcare (Murphy and Enderle 1995, c.f. Goodpaster 2007 ch. 5). Two things are essential to these organizations: first, people (leaders and followers) who acknowledge the role of ethics and care about acting ethically, and second, a culture (not simply the sum of individuals’ beliefs) that balances achievement of goals with respect for persons.
A leader who can maintain an ethically ideal department is recognizable by two behaviors that match, and arguably make, the ideals of their department. First, the leader shows “a high degree of objectivity about themselves and their organization” and a “strong commitment ‘to perceive and interpret reality’ in the context of openness and honesty” (Murphy and Enderle 1995, p. 125). This is related to the department’s mission, grounded in reality.
Second, the leader acknowledges that their organization and people are at their best when aiming at a mission above profit or prestige (Murphy and Enderle 1995, p. 119). They have respect for persons, described in literature as “an uncommon concern for how their decisions affect others” and an “unusual degree of ‘motivation’ and ‘emotional strength’” (Murphy and Enderle 1995, p. 125). As a result, they make sacrifices for the sake of acting ethically, since “[e]thics pays in the long run, but can be financially costly in the short term” and sometimes requires “paying a price” (Murphy and Enderle 1995, p. 119). This leader sets an example of aiming at the department’s mission, but retaining respect for persons in doing so.
Most persons involved with academic medicine have significant leadership qualities at the bedside and/or the lab. However, not everyone can be a leader in every setting, so some physicians and even some non-physicians will have leadership over other physicians, non-physicians, and trainees. These latter we will call “followers.” What is expected of the followers in an ideal department in academic medicine, and what can they expect?
Followers are expected to recognize the department’s mission’s priorities, and emulate the principle of respect for persons. In turn, they can expect the department to pursue the mission as it applies to their interests and goals, and they can expect the department to respect them. Followers should expect to help detect and resolve clashes between the espoused values and the lived reality of the department (c.f. Goodpaster 2007, p. 152). They can also expect that they may not always “fit” with the departmental culture in small ways, since they are recipients of this culture, parts of which may be discordant with their personal preferences (c.f. Goodpaster 2007, p. 197). Followers should expect open communication about culture during hiring, reasonable tolerance during inculcation, and benefits from it long-term (c.f. Goodpaster 2007, p. 198).
The culture of the ideal department in academic medicine is one that immaterially drives its members, who are of diverse belief systems, toward its threefold mission with an enthusiasm tempered and enhanced by respect for persons. An intentional strategy outside of the moral principles shaping the culture is necessary.
Building an ethical culture begins with intentional communication about its two principles (its mission and respect for persons) so that leaders and followers alike act consistently with the organization’s values. This must be done with care, because inculcation of company culture cannot be too dogmatic, nor too permissive (Goodpaster 2007, 198-199). Too dogmatic, and there is no room for improvement or maturation; too permissive, and the culture dissipates among discordant values like excessive focus on profit or prestige.
The practical first step will differ based on the department. A near-ideal department can simply educate new hires on the culture and their role in it. Departments which have openly disrespected persons must demonstrate adherence to stated values (e.g. set aside funding for parental leave or fire longstanding perpetrators of abuse) before asking adherence of employees.
Two significant contributors to burnout are provider lack of control and low-level decision-making (Wiederhold 2018). Thus, an important set of structures will focus on optimizing and raising the control and decision-making available to providers at all levels. Some control will be in proportion to economic value to the department, such as the ability to take a sabbatical. But other opportunities for control will be available to all, such as the ability to request shifts and leave, or delegate low-level tasks. This involves money prioritized to coordinators as well as a commitment to timely handling of requests and transparency about delays. As much as possible, administrative support should handle matters like licensing, credentialing, renewal of memberships, facilitating required trainings, reimbursements, and research and regulatory paperwork, so that physicians can dedicate their time to achieving the clinical, educational, and research work that they are employed by the department to do.
Physicians feel at home in departments that function as true communities. Departments, especially those with several divisions or training programs, or who are spread over multiple sites, face a continual threat to community, leading to cynicism.
Leadership of the ideal department actively seeks to rebuild community. Communication between individual department members, such in mentorship, is good; communication within parts or the whole of the department, such as at noon conferences or division meetings, is better. Using meetings as occasions of community requires attention to detail. Can attendees easily come? (Is it available virtually, is it at a decent time for those with morning cases or who are post-call?) Do attendees enjoy the meeting? (Are topics interesting and not always negative, are there refreshments, are enough people similar to them attending?) Do attendees emerge more unified after the meeting? (Did they create something together like an algorithm or plan, or learn something about each other like whose birthdays happen this month?) This attention to detail is not wasted, but a key initiative to building and sustaining culture.
Positive reinforcement is a positive tool for organizations with shared missions, and formalizing culture into ceremonies and recognition is a powerful tool that the department should leverage. Physicians who feel unrewarded are at higher risk of burnout (Wiederhold 2018), so the department can consider patient-centered, financial, and symbolic rewards in regularly-scheduled ceremonies, to reinforce its culture (Goodpaster 2007, p. 161).
Processes for quality improvement (QI) and conflict resolution should be written into departmental policy. Grand rounds, mortality and morbidity conferences, and root cause analyses are traditional methods of clinical quality improvement. Other tools, such as the Caux Round Table Self-Assessment and Improvement Process (Goodpaster 2007, p. 143) or the Plan-Do-Study-Act cycle (Langley 2009), are optimized for nonclinical and semiclinical settings. Particular departments may use multiple tools or may fashion their own.
Any employee involved in quality improvement or conflict resolution should be discreetly informed, and his or her “side of the story” be elicited before any escalation or analysis occurs, in conformity with respect for persons. Any employee should be able to request conflict resolution or quality improvement, as all employees are contributors to the departmental culture. Completion of QI initiatives should be reported regularly either to appropriate managers or the entire department (depending on the nature of the matters) in ways that maximize cultural fit and minimize retribution or friction.
Annual reviews of all members of the department, including trainees, should begin with assessing the person’s cultural fit. By prioritizing this, leadership avoids the pitfalls of exaggerating relatively minor events or dismissing grave ethical failures. Promotions and hiring should be focused on individuals who actively contribute to the culture as expressed in its mission and respect for persons (Goodpaster 2007, p. 201). By intentionally providing constructive criticism, encouragement, promotions, and employment offers in accord with the mission and core values, department leadership strategically promotes the planned culture.
Academic medicine is sick—physicians and other professionals face high levels of burnout, disillusion, and dissatisfaction with their field and workplaces. Academic medicine, in particular, poses additional challenges, and physicians are leaving academia during the pandemic at increasing rates (Arnoff 2009). Academic medicine has huge potential as a meaningful workplace that is naturally focused on persons. A specific mission with an active plan to carry out and inculcate this mission could transform a department from a dehumanized rat-race through three mazes at once, to a pinnacle of human-centered care and excellence.
Aronoff D. M. (2009). And then there were none: the consequences of academia losing clinically excellent physicians. Clinical medicine & research, 7(4), 125–126. https://doi.org/10.3121/cmr.2009.878
Author unlisted. (2008). Principlism and the Future of Bioethics. In: Humanizing Modern Medicine. Philosophy and Medicine, vol 99. Springer, Dordrecht. https://doi.org/10.1007/978-1-4020-6797-6_13
Barzansky, Barbara. (2002). United States Medical School Financing: Beyond the Black Box. Medical Science Educator. 12;1:5-8. http://www.iamse.org/wp-content/uploads/2015/08/12_complete.pdf
Bataineh, K. adnan. (2019). Impact of work-life balance, happiness at work, on employee performance. International Business Research, 12(2), 99. https://doi.org/10.5539/ibr.v12n2p99
Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics. Oxford University Press.
Bellet, C., De Neve, J.-E., & Ward, G. (2019). Does employee happiness have an impact on productivity? SSRN Electronic Journal. https://doi.org/10.2139/ssrn.3470734
Bongiorni, Dante (2017). Management Structures of the Academic Medical Center [Masters thesis, University of Pittsburgh]. D-Scholarship Institutional Repository. https://d-scholarship.pitt.edu/31049/1/BongiorniD_%20MasterEssay_April_2017.pdf
Congressional Research Service. (2018.) Federal Support for Graduate Medical Education: An Overview. https://sgp.fas.org/crs/misc/R44376.pdf
Druss, B. G., & Marcus, S. C. (2005). Academic medicine: who is it for? Funding gap between clinical and basic science publications is growing. BMJ (Clinical research ed.), 330(7487), 360–364. https://doi.org/10.1136/bmj.330.7487.360-b
Hippocrates of Cos. (1923). The oath. Digital Loeb Classical Library. https://doi.org/10.4159/dlcl.hippocrates_cos-oath.1923
Faunce, T., Bolsin, S., & Chan, W. (2004.) Supporting whistleblowers in academic medicine: training and respecting the courage of professional conscience. Journal of Medical Ethics 30:40-43.
Fieser, James. Ethics. The Internet Encyclopedia of Philosophy, ISSN 2161-0002, https://iep.utm.edu/, Oct 20, 2021.
Fins, J., Pohl, B., & Doukas, D. (2013). In Praise of the Humanities in Academic Medicine: Values, Metrics, and Ethics in Uncertain Times. Cambridge Quarterly of Healthcare Ethics, 22(4), 355-364. doi:10.1017/S0963180113000200
Goodpaster, Kenneth E. (2007). Conscience and Corporate Culture. Blackwell Publishing.
Grabski, D. F., Goudreau, B. J., Gillen, J. R., Kirk, S., Novicoff, W. M., Smith, P. W., Schirmer, B., & Friel, C. M. (2020). Compliance with the Accreditation Council for Graduate Medical Education duty hours in a general surgery residency program: Challenges and solutions in a teaching hospital. Surgery, 167(2), 302–307. https://doi.org/10.1016/j.surg.2019.05.029
Higgins, C. & Jo, K. (2016). Ethics and Education. obo in Education. doi: 10.1093/obo/9780199756810-0142
Huron Consulting Group. (2015). Academic Medicine Investment in Medical Research. American Association of Medical Colleges. https://store.aamc.org/academic-medicine-investment-in-medical-research-summary-and-technical-reports.html
Jenner, S., Djermester, P., Prügl, J., Kurmeyer, C., & Oertelt-Prigione, S. (2019). Prevalence of Sexual Harassment in Academic Medicine. JAMA internal medicine, 179(1), 108–111. https://doi.org/10.1001/jamainternmed.2018.4859
Kekewich, M. (2011). Introduction. Ethical Assessment: Open versus Restricted Access and Optimal Use of Solvent/ Detergent-Treated Human Plasma (Octaplas): Pilot Project [Internet]. Retrieved October 22, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK362093/
Leiter, M. P., Frank, E., & Matheson, T. J. (2009). Demands, values, and burnout: relevance for physicians. Canadian Family Physician, 55(12), 1224-1225.
Lu, D. W., Weygandt, P. L., Pinchbeck, C., & Strout, T. D. (2018). Emergency medicine trainee burnout is associated with lower patients’ satisfaction with their emergency department care. AEM Education and Training, 2(2), 86–90. https://doi.org/10.1002/aet2.10094
Mulvenna, M., Boger, J. & Bond, R. (2017). Ethical by Design: A Manifesto. Proceedings of the European Conference on Cognitive Ergonomics. Association for Computing Machinery, New York, NY, USA, 51–54. DOI:https://doi.org/10.1145/3121283.3121300
Oliver, D. (2019). David Oliver: Does doctors’ admin take up too much time? BMJ, l6381. https://doi.org/10.1136/bmj.l6381
Rosenthal S. L. (2020). Preventing Burnout Among Academic Medicine Leaders: Experiencing Leadership Flow. JAMA pediatrics, 174(7), 636–638. https://doi.org/10.1001/jamapediatrics.2020.0287
Seritan, A. L., Iosif, A. M., Hyvonen, S., Lan, M. F., Boyum, K., & Hilty, D. (2010). Gender differences in faculty development: a faculty needs survey. Academic Psychiatry, 34(2), 136–140. https://doi.org/10.1176/appi.ap.34.2.136
Shah, D. T., Williams, V. N., Thorndyke, L. E., Marsh, E. E., Sonnino, R. E., Block, S. M., & Viggiano, T. R. (2018). Restoring Faculty Vitality in Academic Medicine When Burnout Threatens. Academic medicine : journal of the Association of American Medical Colleges*, 93(7), 979–984. https://doi.org/10.1097/ACM.0000000000002013
Singer, P. A., Pellegrino, E. D., & Siegler, M. (2001). Clinical ethics revisited. BMC medical ethics, 2, E1. https://doi.org/10.1186/1472-6939-2-1
Vickers, S. M., & Ruffin, J. (2020). Recognizing and Addressing the Disparities in Research Funding for Underrepresented Minorities and Women. Annals of surgery, 272(1), 30–31. https://doi.org/10.1097/SLA.0000000000003933
Wiederhold, B. K., Cipresso, P., Pizzioli, D., Wiederhold, M., & Riva, G. (2018). Intervention for physician burnout: A systematic review. Open Medicine, 13(1), 253–263. https://doi.org/10.1515/med-2018-0039
Wilson, P. (2020). Academic Fraud: Solving the crisis in modern academia. Exchanges: The Interdisciplinary Research Journal, 7(3), 14-44. https://doi.org/10.31273/eirj.v7i3.546
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