Society for Pediatric Research Presidential Address 2002: First Principles

The thesis of this presidential address is that we in academic pediatrics have lost our way. The old structures and ways of doing business do not appear to work anymore. To reflect this, I have entitled this talk “First Principles.” I believe that we must return to the reason for our existence to rebuild and reorganize academic pediatrics. We in academic pediatrics exist to improve health care for children of the future. To accomplish this mission requires research, clinical care and education, the so-called “threecornered stool” (Fig. 1). This, in my opinion, is the first principle and the focus of my presentation. The three-cornered stool of academic medicine is supported by three legs. If any leg is removed, the stool collapses. Although research, clinical care, and education can be carried out in isolation, I believe that we must undertake all three simultaneously to train future leaders and practitioners, provide the best medical care to children, and ensure that pediatrics in the future is even better than pediatrics in the present. In addition, the three-legged stool must be supported on a platform of advocacy for children and children’s health at local, national, and international levels. Although the underlying principles remain the same, a number of major recent revolutions have impacted our institutions. The style of health care and clinical practice has changed. Much of this change is related to reimbursement, and much of the jargon of academic medicine has changed as a result. Medical centers (and their leadership) are often immersed in issues of the bottom line rather than the missions associated with the three-cornered stool. There have also been a number of technologic revolutions: in information systems; biotechnology, including genetics and genomics; imaging; and other technology-driven disciplines. In addition, the “practice of science” has dramatically changed. Science today is more expensive and fast moving than ever and involves collaboration of individuals with different training and experience. Therefore, many of the old paradigms of academic medicine, including the “rugged individualism” upon which tenure systems are based, are less applicable today. We must devise new models to accommodate changes in methodologies and approaches to scientific endeavor. The rapid growth of academic medicine since the end of World War II has far-reaching effects. Any industry that had undergone the immense growth that we have experienced during the course of my career would be facing numerous problems. By whatever metrics are applied, we have grown dramatically. Whether measured by dollars flowing into the system, including tuition, grants and contracts, patient care dollars, government subventions, etc.; dollars flowing out, including personnel costs, purchase of goods and services, interest costs, etc.; the number of people involved in various entities as trainees, faculty, employees; or lastly, the extramural budget at National Institutes of Health, academic medicine has experienced phenomenal growth in the last 30 years. One example is the National Institutes of Health budget (Fig. 2), which more than doubled during the 1990s. I contend that any industry with this magnitude of growth would be dealing with problems of resource allocation. So, how should we remodel ourselves in the year 2002? At present, there are two extreme organizational models in American academic pediatrics: the large children’s hospitals and the smaller university services. Children’s hospitals have obvious strengths, including a dedicated board, an independent administration, large-scale fundraising, and the size and robust nature of their enterprise. They do, however, in my opinion, also have weaknesses. There is a tendency to become intellectually isolated, complacent, and lose perspective as a result of the limited interaction with their university and broader medical center community. On the other hand, the university services are highly interactive with their universities and carefully reviewed within the confines of academia. They compete with other university entities for resources, making it more difficult to become isolated intellectually or to escape peer review. At the same time, they also have their weaknesses, largely due to their small size and the lack of a dedicated board and administration. This results in fewer resources for the university model and a financial barrier to growth. These programs are typically small in size and thus do not generate large clinical incomes. Because there is no dedicated board or administration, leadership is often concerned with the issues of the larger organization rather than focusing on children’s services. Therefore, university children’s services are often last in line for both existing resources and fundraising because of the multiple needs of the larger medical center and university. So, what do small services need? They must garner a higher market share to increase program scale. This may be accomplished by outreach programs and linkages with community hospitals. They need to expand their Received June 20, 2002; accepted July 24, 2002. Correspondence: Alan M. Krensky, Department of Pediatrics, Stanford University, CCSR Building, Room 2105, Stanford, CA 94305-5164, U.S.A.; e-mail: Krensky@stanford.edu Presented at the 2002 Annual Meeting of the Pediatric Academic Societies, Baltimore, Maryland, U.S.A.