NEW CHALLENGES IN INTERNAL MEDICINE
0025-7125/92 $0.00
+ .20
ACADEMIC PURSUITS IN THE MULTISPECIALTY CLINIC Edward D. Frohlich, MD
From the earliest ages of formal medical education, the student of medicine developed the art of medical practice at the side of a respected preceptor. This concept of medical education persisted within schools of medicine that were established independently or as part of the larger university. However, this tried and established educational philosophy endured until early in the twentieth century when an increasingly greater scientific basis of education began to emerge. In the United States, under the renowned Abraham Flexner's leadership, undergraduate medical education standards were developed. The large number of schools of medicine that had appeared in prior years were markedly reduced, and a means for medical school accreditation was established and husbanded through the aegis of the American Medical Association. Associated with these standards for undergraduate medical education was the development of medical specialization and subspecialization, and organizations that developed provided the necessary standards for the practice of those specialties. Graduate medical education training programs were established in teaching hospitals, each program assuring that basic standards of education and practice were maintained by the oversight of residency review committees. Along with this maturation of undergraduate and graduate medical education, a new concept of medical practice emerged in the United States-the multispecialty medical clinic. This no longer involved the traditional concept of private medical practice or of the outpatient medical clinics long present in the university hospitals that provided medical care largely to the indigent populations under the supervision From Alton Ochsner Medical Foundation, New Orleans, Louisiana THE MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 5· SEPTEMBER 1992
1003
1004
FROHLICH
of full-time or voluntary medical faculty. In contrast, the large multispecialty clinics were developed to provide the "cutting edge" of medical care for the "fee for service" or "private" patient seeking the expertise of medical specialists committed to excellence in medical practice individually and collectively. But these specialized medical practitioners soon became less satisfied with their medical practice without the other intellectually satisfying necessities: education and research. Thus, the philosophical basis of academic medicine in the large multispecialty medical clinic became very similar to that of the schools of medicine throughout the world. However, there were certain subtle differences in this philosophy even though both institutions (medical school and multispecialty clinics) were firmly based upon the classical "three-legged stool" of academic medicine: education, research, and patient care. In the school of medicine, the primary mission is, by definition, medical education. Fundamental and clinical research are necessarily implicit in providing that complete educational experience since medical and scientific teachers of excellence must continually acquire and disseminate new medical knowledge. However, pursuit of these primary objectives of medical education and research is not possible without a secondary mission of patient care. As a result, patient care is a necessity for the medical school. This philosophy is somewhat different in the multispecialty medical clinic. Here, the primary purpose for the existence of this institution is to offer a new means for providing excellence in patient care. The primary academic objectives of the school of medicine only became a necessity for those clinic physicians who required the intellectual stimulation and satisfaction from providing their professional expertise in an educational ambience that was also associated with the generation or exposition of new knowledge (experiential or in the laboratory setting). Both of these later academic pursuits (i.e., education and research) could only be provided as the financial resources of these private institutions permitted. Thus, the multispecialty clinic could develop its academic and intellectual needs only to the extent that the clinic's resources could afford these secondary objectives. Today, most large medical multispecialty clinics have well-established and respected graduate medical education programs. The number of their training programs, however, depends upon the financial commitment of that clinic, its clinical patient base, and of course, the accreditation provided by the specific specialty boards. Many of these clinics also satisfy the professional and intellectual satisfaction by also becoming involved in undergraduate medical education. This usually is accomplished through the institution's formal association with schools of medicine in its geographical region. Only one large clinic in this country has its own medical school. The medical staffs of many of the larger medical clinics satisfy their needs for personal involvement in undergraduate medical education by lecturing or attending at outpatient facilities of the schools of medicine, or by teaching medical
ACADEMIC PURSUITS IN THE MULTISPECIALTY CLINIC
1005
students rotating through their own ambulatory care clinics and by interacting with their hospital patients. Thus, the extent of educational commitments assumed by the various large medical multispecialty clinics is variable depending upon the resources. In a similar fashion, so is the ability of the multispecialty clinic to pursue the various levels of medical research. Some staff members restrict research activities to prospective or retrospective analysis of personal or collective clinical experiences. Others engage in medical research through experiences with innovative forms of diagnosis and therapy that have been developed and pursued in their clinics. More recently, the large multispecialty clinic has entered into more fundamental aspects of practice research by exploiting their unique experiences in health care delivery through those areas of outcomes research, quality assurance, costlbenefit analysis, etc. Still others conduct investigational activities fundamentally grounded in research at the laboratory bench utilizing the breadth of techniques from molecular and cellular biology to more classical systems studies. But, much like the extent to which education is pursued in these institutions, so is the research effort dependent upon the available physical, financial, and other resources of the institution and the vigor with which it is also willing to obtain support from extramural sources. In the final analysis, the multispecialty clinic conducts its educational and research activities more variably than the school of medicine. The Alton Ochsner Medical Foundation was established by the staff of the Ochsner Clinic in order to satisfy their clinical needs to provide the excellence in medical care that their professional expertise demanded and also to satisfy the intellectual need to become intimately involved in education and research. This has been accomplished in the setting of a formal association with the schools of medicine and with other institutions of higher education in the region. Thus, in addition to its commitment to graduate and undergraduate medical education, our institution conducts its Alton Ochsner School of Allied Health Sciences (which comprises a vast array of accredited programs) and a Continuing Medical Education program that is responsible for a large number of varied intramural courses as well as extramural programs given at major national societal and organizational meetings. Each of these commitments to our Clinic staff is supported by a well-stocked medical library, computerized learning resources, and by editorial, photographic, audiovisual, and biostatistical services. These latter facilities are offered to the staff of our Clinic at two campuses, in New Orleans and Baton Rouge. The specific concepts relating to graduate medical education and research philosophies are discussed elsewhere in this issue by eminently respected members of our Clinic staff. In this issue of The Medical Clinics of North America, we have selected specific issues that we believe best represent the importance and values of the larger multispecialty medical clinics. We present that which we believe is innovative with respect to both primary and tertiary health care delivery. Ours is one of the few large clinics with its own health maintenance organization, and we discuss how this new development
1006
FROHLICH
in medical practice can satisfy current needs in medical education and research. We also present, in a variety of selected medical topics, new and controversial concepts in the practice of internal medicine. These articles are wide in scope, ranging from those issues concerned with the treatment of patients with hypertension and other diseases to the optimal selection of patients for a variety of organ transplantations, and to relating newer knowledge about the immune system to related diseases. Thus, while traditionally viewed as institutions that provide excellence in health care delivery, the larger multispecialty clinics must also be considered as major national academic resources. The medical and scientific staffs of our large multispecialty clinics also offer their collective knowledge and experiences to many of our national federal, voluntary health, and professional organizations. Their clinical expertise provides a valuable resource to those agencies developing innovative approaches to health care delivery. And, most importantly, the multispecialty clinic provides innovative tertiary health care regionally, nationally, and internationally. In this context, we are most proud to dedicate this issue to our founding physicians and, in particular, to Alton Ochsner who provided the guiding inspiration and source of strength in a continuing quest to secure these academic goals. Address reprint requests to Edward D. Frohlich, MD Alton Ochsner Medical Foundation 1516 Jefferson Highway New Orleans, LA 70121
0025-7125/92 $0.00
+ .20
ACADEMIC PURSUITS IN THE MULTISPECIALTY CLINIC Edward D. Frohlich, MD
From the earliest ages of formal medical education, the student of medicine developed the art of medical practice at the side of a respected preceptor. This concept of medical education persisted within schools of medicine that were established independently or as part of the larger university. However, this tried and established educational philosophy endured until early in the twentieth century when an increasingly greater scientific basis of education began to emerge. In the United States, under the renowned Abraham Flexner's leadership, undergraduate medical education standards were developed. The large number of schools of medicine that had appeared in prior years were markedly reduced, and a means for medical school accreditation was established and husbanded through the aegis of the American Medical Association. Associated with these standards for undergraduate medical education was the development of medical specialization and subspecialization, and organizations that developed provided the necessary standards for the practice of those specialties. Graduate medical education training programs were established in teaching hospitals, each program assuring that basic standards of education and practice were maintained by the oversight of residency review committees. Along with this maturation of undergraduate and graduate medical education, a new concept of medical practice emerged in the United States-the multispecialty medical clinic. This no longer involved the traditional concept of private medical practice or of the outpatient medical clinics long present in the university hospitals that provided medical care largely to the indigent populations under the supervision From Alton Ochsner Medical Foundation, New Orleans, Louisiana THE MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 5· SEPTEMBER 1992
1003
1004
FROHLICH
of full-time or voluntary medical faculty. In contrast, the large multispecialty clinics were developed to provide the "cutting edge" of medical care for the "fee for service" or "private" patient seeking the expertise of medical specialists committed to excellence in medical practice individually and collectively. But these specialized medical practitioners soon became less satisfied with their medical practice without the other intellectually satisfying necessities: education and research. Thus, the philosophical basis of academic medicine in the large multispecialty medical clinic became very similar to that of the schools of medicine throughout the world. However, there were certain subtle differences in this philosophy even though both institutions (medical school and multispecialty clinics) were firmly based upon the classical "three-legged stool" of academic medicine: education, research, and patient care. In the school of medicine, the primary mission is, by definition, medical education. Fundamental and clinical research are necessarily implicit in providing that complete educational experience since medical and scientific teachers of excellence must continually acquire and disseminate new medical knowledge. However, pursuit of these primary objectives of medical education and research is not possible without a secondary mission of patient care. As a result, patient care is a necessity for the medical school. This philosophy is somewhat different in the multispecialty medical clinic. Here, the primary purpose for the existence of this institution is to offer a new means for providing excellence in patient care. The primary academic objectives of the school of medicine only became a necessity for those clinic physicians who required the intellectual stimulation and satisfaction from providing their professional expertise in an educational ambience that was also associated with the generation or exposition of new knowledge (experiential or in the laboratory setting). Both of these later academic pursuits (i.e., education and research) could only be provided as the financial resources of these private institutions permitted. Thus, the multispecialty clinic could develop its academic and intellectual needs only to the extent that the clinic's resources could afford these secondary objectives. Today, most large medical multispecialty clinics have well-established and respected graduate medical education programs. The number of their training programs, however, depends upon the financial commitment of that clinic, its clinical patient base, and of course, the accreditation provided by the specific specialty boards. Many of these clinics also satisfy the professional and intellectual satisfaction by also becoming involved in undergraduate medical education. This usually is accomplished through the institution's formal association with schools of medicine in its geographical region. Only one large clinic in this country has its own medical school. The medical staffs of many of the larger medical clinics satisfy their needs for personal involvement in undergraduate medical education by lecturing or attending at outpatient facilities of the schools of medicine, or by teaching medical
ACADEMIC PURSUITS IN THE MULTISPECIALTY CLINIC
1005
students rotating through their own ambulatory care clinics and by interacting with their hospital patients. Thus, the extent of educational commitments assumed by the various large medical multispecialty clinics is variable depending upon the resources. In a similar fashion, so is the ability of the multispecialty clinic to pursue the various levels of medical research. Some staff members restrict research activities to prospective or retrospective analysis of personal or collective clinical experiences. Others engage in medical research through experiences with innovative forms of diagnosis and therapy that have been developed and pursued in their clinics. More recently, the large multispecialty clinic has entered into more fundamental aspects of practice research by exploiting their unique experiences in health care delivery through those areas of outcomes research, quality assurance, costlbenefit analysis, etc. Still others conduct investigational activities fundamentally grounded in research at the laboratory bench utilizing the breadth of techniques from molecular and cellular biology to more classical systems studies. But, much like the extent to which education is pursued in these institutions, so is the research effort dependent upon the available physical, financial, and other resources of the institution and the vigor with which it is also willing to obtain support from extramural sources. In the final analysis, the multispecialty clinic conducts its educational and research activities more variably than the school of medicine. The Alton Ochsner Medical Foundation was established by the staff of the Ochsner Clinic in order to satisfy their clinical needs to provide the excellence in medical care that their professional expertise demanded and also to satisfy the intellectual need to become intimately involved in education and research. This has been accomplished in the setting of a formal association with the schools of medicine and with other institutions of higher education in the region. Thus, in addition to its commitment to graduate and undergraduate medical education, our institution conducts its Alton Ochsner School of Allied Health Sciences (which comprises a vast array of accredited programs) and a Continuing Medical Education program that is responsible for a large number of varied intramural courses as well as extramural programs given at major national societal and organizational meetings. Each of these commitments to our Clinic staff is supported by a well-stocked medical library, computerized learning resources, and by editorial, photographic, audiovisual, and biostatistical services. These latter facilities are offered to the staff of our Clinic at two campuses, in New Orleans and Baton Rouge. The specific concepts relating to graduate medical education and research philosophies are discussed elsewhere in this issue by eminently respected members of our Clinic staff. In this issue of The Medical Clinics of North America, we have selected specific issues that we believe best represent the importance and values of the larger multispecialty medical clinics. We present that which we believe is innovative with respect to both primary and tertiary health care delivery. Ours is one of the few large clinics with its own health maintenance organization, and we discuss how this new development
1006
FROHLICH
in medical practice can satisfy current needs in medical education and research. We also present, in a variety of selected medical topics, new and controversial concepts in the practice of internal medicine. These articles are wide in scope, ranging from those issues concerned with the treatment of patients with hypertension and other diseases to the optimal selection of patients for a variety of organ transplantations, and to relating newer knowledge about the immune system to related diseases. Thus, while traditionally viewed as institutions that provide excellence in health care delivery, the larger multispecialty clinics must also be considered as major national academic resources. The medical and scientific staffs of our large multispecialty clinics also offer their collective knowledge and experiences to many of our national federal, voluntary health, and professional organizations. Their clinical expertise provides a valuable resource to those agencies developing innovative approaches to health care delivery. And, most importantly, the multispecialty clinic provides innovative tertiary health care regionally, nationally, and internationally. In this context, we are most proud to dedicate this issue to our founding physicians and, in particular, to Alton Ochsner who provided the guiding inspiration and source of strength in a continuing quest to secure these academic goals. Address reprint requests to Edward D. Frohlich, MD Alton Ochsner Medical Foundation 1516 Jefferson Highway New Orleans, LA 70121
