LEADERSHIP IN AN AGE OF UNCERTAINTY AND AUSTERITY

Jeffrey Borkan; Ardis Davis; Thomas Campbell; Richard Wender

doi:10.1370/afm.1326

Not in recent history have times for academic family medicine been so uncertain. As recently reported in the New England Journal of Medicine,¹ we are witnessing health care policy during an age of acute uncertainty, but long-term austerity.

We are facing a myriad of challenges that are posing a test for everyone in the discipline—whether chairs, residency directors, faculty, or trainees. Indeed, it is very difficult to determine which direction the wind is blowing and how to prepare for the next few years, let alone the next few decades. Below are enumerated but a few of the more common and extreme scenarios we are anticipating:

The fate of health care reform is unclear. The Accountable Care Act is under threat in the courts and in the political process. If it goes forward, there will be fundamental changes to Medicaid and Medicare that will influence patients, patients’ choice, and the institutions where they seek care
Clinical revenues may be severely curtailed. The rate of medical inflation is unsustainable and significant cuts may be on the near horizon, starting with Medicare’s sustainable growth rate (SGR)
How medical services are paid for is already undergoing profound alterations and more changes are virtually certain to be implemented. Some insurers, such as in Massachusetts, are considering paying less to high-spending hospitals, while bundled payments are being strongly considered
Graduate medical education funding is threatened and may be on the Congressional chopping block in the near future
NIH funding lines are extraordinarily low with no signs of improvement in the near future—or other sources to compensate for the drop
All institutions that support family medicine are under threat and many are in economic straits—whether hospitals, medical centers, or medical schools

What is clear is that budgets for departments and residencies in family medicine are likely to come under growing pressure in the next few years—and many have already, as we face the potential “perfect storm” of simultaneously reduced clinical, research, and educational funds for our academic units and for the organizations that host them.

The urge may be to hunker down and conservatively manage our scarce resources and our portfolio of programs—and take fewer risks. Paradoxically, this is clearly a time when we need to expand the primary care workforce, and when there appear to be bountiful opportunities for innovation, program expansion, and entrepreneurship. In addition, 10 years into the patient-centered medical home (PCMH) and residency reform efforts, we seem to be generally on the right course regarding practice transformation and student interest.

How are we to reconcile these opposing forces and plot the way forward? Although there is no single formula, some suggestions come to mind, including those learned from our colleagues in other professions and other countries:

Reaffirm one’s core values and goals; improving the health of the public is what academic medicine must be about
Act boldly, while watching finances, making sure “no money is left on the table” (careful billing, pursuing management in addition to fee for service fees, etc) and building reserves when possible
Examine other means of reaching our goals—especially if they are more fiscally sound
Speak with one voice and with a focused and repeated message to any and all who will hear us
Develop advocacy skills and use that power to educate legislators on what is at stake for the public. All of us in family medicine, whether we are faculty, residents, students, chairs, residency directors, or physicians in practice, need to understand how we can impact the process through advocacy. If each of us takes a student or resident along in an advocacy activity, we double the number of family medicine advocates
Invest in faculty development long term
Look for new opportunities and keep your fingers on the pulse of your hospital, medical center, and medical school
Canada—when faced with budget cuts and a decline in student interest in family medicine, they invested in family medicine education

As we plan programming for the fall 2011 meeting of the Association of Departments of Family Medicine and our 2012 winter meeting to follow, we will be working with our colleagues to help us all understand the vagaries of navigating through these times while staying above water and even seizing the unanticipated opportunities out there! As each of you look to the future, we encourage you to consider how to navigate the turbulent waters ahead, while moving the discipline and the health of the American public forward.