‘Swotting’ Departments: Issues and Challenges in Academic Family Medicine

The SWOT analysis, commonly used in business management, is a process for delineating the Strengths, Weaknesses, Opportunities, and Threats to an organization. Just as business has used the SWOT approach, academic programs can develop their own systems and organizations for effective support and analysis, since the health of academic family medicine has a major impact on the future of the discipline as a whole.

To this end, the Association of Departments of Family Medicine (ADFM) represents the academic organization of family medicine in the medical schools throughout the United States. The ADFM, formed in 1977, has more than 125 organizational members, which in turn represent several thousand faculty. The purpose of ADFM, as defined in its mission statement, is to “promote the philosophy and interests of family medicine in medical schools in the United States ...”. To accomplish this goal, ADFM provides a forum for informing and training members on innovative approaches to the missions of academic departments. It has recently developed a departmental consultation service to assist departments in identifying strengths and weaknesses and recommending solutions.

It is difficult to describe a typical family medicine department. If you have not visited a family medicine department in a while, you may be in for a surprise. Departments vary considerably in size, scope, and design, and have become increasingly complex entities in the last decade. What has not changed is the threefold mission of research, teaching, and clinical care. Most departments have responsibility for medical student clerkships in the third or early fourth year, offer residency training (often at several sites), promote scholarly activity, and play a significant role in the provision of primary care for their institutions.

In addition, a recent study indicated that a majority of departments also have major responsibility for the teaching of interdisciplinary courses in the first 2 years of medical school, and typically rely on more than 100 volunteer faculty in each program to accomplish the teaching load.¹

The majority of departments are also involved in training programs beyond the residency. More than half of departments provide fellowships in faculty development, geriatrics, sports medicine, or obstetrics in addition to an assortment of other fellowship offerings.¹ Many family medicine departments have a more complex academic mission, which may include academic community and preventive medicine activities.

The clinical role of departments varies as well. In addition to the core provision of primary care, it may include involvement in or management of primary care networks, university student health services, employee services, contractual activities with government entities (such as public health departments, correctional institutions, or mental health services); and special clinical services such as women’s health, HIV care, or sports medicine. Most academic departments also continue to have significant clinical activity in inpatient settings.

Along with medical student education, research is one of the core responsibilities of academic departments. There is some evidence that the productivity of research has increased in the past few decades, though in the opinion of some, not at the desired rate. Limitations have been attributed to a lack of trained researchers, insufficient support for areas of interest to family physicians, and insufficient opportunities for collaboration in smaller departments with competing missions. The recent emphasis on academic support of research by US Public Health Service grants may indicate a step towards improving this record in the future. In addition, departments have been active in the development of a number of practice-based research networks, which may facilitate greater collaboration and more opportunities to address relevant research questions.

There are several areas of concern. A recent study² of academic family medicine departments indicated that only 40% have financial reserves, down 14% from a similar study reported 3 years earlier.¹ The number of departments with an excess of debt remained the same (24%), but the number with neither debt nor reserves has increased (34% from 19%). Threats to the financial stability of departments include continuing financial difficulties of academic health centers, poor reimbursement for primary care, a disproportionate share of underserved and Medicaid patients, and the possibility of diminishing support for federal primary care educational funding.

Another related concern has been the apparent discordance between the perception of priorities of academic family medicine department chairs and the medical schools, universities, and academic health centers in which they reside. For example, while graduate education was the top priority cited by the chairs in one study (53%), only a small percentage of them believe this to be the highest priority of the other academic entities.¹ On the other hand, family medicine departments often find themselves as bridges between the academic and practice world, and in the best situations, as developers of new systems of care and of education that benefit both, and the patients most of all.

In the upcoming issues of Annals, ADFM will explore the areas of strength, delineate the inherent weaknesses, outline the opportunities, and exchange ideas on the threats facing academic family medicine in education, clinical care, and research. By highlighting programs that have developed innovative approaches and lasting solutions, we hope that we will stimulate positive discussion and dialogue.

• © 2003 Annals of Family Medicine, Inc.