The reality of the healthcare marketplace and the medical school curriculum.

At the close of the 20 th century, fundamental changes in the American practice of medicine continue to occur at an increasingly rapid pace. In December 1999 President Clinton, in response to the report by the Institute of Medicine documenting an “unacceptable” rate of adverse patient outcomes, ordered federal healthcare agencies to evaluate and implement methods for reducing medical errors. Given that the federal government is the nation’s largest purchaser of healthcare services, such an action will force industry-wide reforms aimed at improving patient outcomes. Meanwhile, the uncoupling of the third-party payer system, through vehicles such as managed care organizations, has exposed the healthcare industry to the classic forces of a market economy. Frankly, it is remarkable, given the size of the industry, that it has been protected from market forces for as long as it has. We may expect the heretofore craft-based practice of medicine, now subject to the forces of a market economy, to evolve into a systems-driven industry through classic standardization of processes. Examples of this transition at the patient care level include the current emphasis on clinical pathways and disease management protocols, which not only incorporate the traditional elements of clinical care, but also feature organizational, managerial and financial indicators that are necessary for regulatory approval and financial stability. The second phase of cost efficiencies in the evolution of the healthcare service industry, currently upon us, is clinical integration. Unlike utilization review, its predecessor, which has been managed by non-physician healthcare leaders, this phase can be driven only by physicians. As the integral providers of patient care, it is incumbent upon physicians to integrate cost-containment measures with quality standards of patient care and thus create value in clinical outcomes. To date, medical schools have ignored organizational, leadership, financial, or outcomes issues in the curriculum of undergraduate medical education; given the current and future environment of the healthcare marketplace, this omission must be rectified. Although it should not be the charge of our medical schools to provide extensive curriculum and training in such areas, it is imperative that such topics are introduced and discussed with students throughout their undergraduate medical education to prepare them to practice in a changed economic environment. At the very least, every medical student should become familiar with the development and implementation of processes such as clinical pathways. The economic reality of the healthcare marketplace is simple: successful entities require capital and a profit margin in order to remain viable. Health care providers, large and small, have relied heavily on the third-party payer system, private and governmental, to subsidize their own inefficiencies and duplication of services. Given the progressive elimination of indemnity reimbursement plans and the Balanced Budget Act, American health care now finds itself at a major crossroads; only a dynamic, efficient organization with activitybased management initiatives in place, such as clinical care pathways and process improvements, will flourish. Increasingly, the centrality of physicians in the success of health care organizations is being recognized. However, in order to lead healthcare organizations, physicians need to play several vital roles. First, through understanding fundamental tools inherent to the business of private enterprise, physician leaders serve not only as the catalyst for positive change within their organization, but also as innovators for the industry-wide movement towards maximal efficiency and improved communication. In context, they will function as the liaison between their clinical physician counterparts and the traditional administrative management of the organization. Physicians, by training, are oriented to one-on-one decision-making; most do not appreciate the multilevel complexity and political realities of the modern healthcare organization. Furthermore, they certainly are even less inclined to work well with standard hospital management, who tend to rely strongly upon institutional planning, financial standards and outcomes measurements to assist with decision making. Physician leaders, on the other hand, must be equipped to negotiate between two vital goals which are often at odds: the quality of patient care and cost-efficiency measures. In conclusion, the undergraduate medical curriculum needs to introduce and reiterate the importance of topics such as healthcare economics, organizational behavior, leadership training, financial imperatives, and outcomes measures. Furthermore, faculty role models are necessary in order to model such behavior. Without such attention to the realities of the healthcare marketplace, we will continue the current failure to produce physician healthcare leaders. In the end, the real losers, both from a quality healthcare delivery standpoint and an economic perspective, will be the American public.