See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/262010748

The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society

Chapter · February 2014

DOI: 10.1002/9781118410868.wbehibs317

CITATIONS READS

4 1,131

1 author:

Pavel V Ovseiko
University of Oxford
98 PUBLICATIONS   1,482 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Oxford BRC 'Partnerships for Health, Wealth and Innovation' View project

EULAR task force on gender equity in rheumatology View project

All content following this page was uploaded by Pavel V Ovseiko on 15 October 2017.

The user has requested enhancement of the downloaded file.

Medical Schools as
Professional Workplaces
PAVEL V. OVSEIKO AND ALASTAIR M. BUCHAN
University of Oxford, UK
Medical education and medical schools have
been around for centuries, but they origi-
nated differently in different countries. The
historical origins of medical schools and the
subsequent evolution of their missions are
integral to our understanding of the complex
environment in which modern medical
schools operate as professional workplaces.
In his classic comparative study of medical
education in Europe and North America,
Flexner (1925) distinguished between three
types of medical schools: (1) the clinical type,
(2) the university type, and (3) the proprie-
tary type.
The clinical type originated in France and
Great Britain, where medical schools grew
out of hospitals. Pre-clinical medical educa-
tion in universities existed in these countries
as early as medieval times, but, unlike
practice-based learning, pre-clinical medical
education was not obligatory for practice.
Hospital physicians and surgeons often
accepted students for training without any
university education, which was considered
desirable but not necessary. Effectively, stu-
dents were apprentices learning medicine or
surgery by watching and helping their mas-
ters at work. As the amount of knowledge
required to practice medicine and surgery
grew, those physicians and surgeons who
wanted to teach associated themselves with
universities, or organized hospital schools to
share teaching workload and to rotate their
apprentices through different activities.
The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, First Edition.
Edited by William C. Cockerham, Robert Dingwall, and Stella R. Quah.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
The university type originated in the nine-
teenth century predominantly in Germany
and Austria-Hungary, but also in Scandinavia,
the Netherlands, and Switzerland, where
medical schools broke away from practice-
based teaching in hospitals to develop
research-based teaching in universities.
Unlike hospitals, education and research in
universities were linked to the effect that the
promotion of university faculty depended on
their contribution to both research and edu-
cation. With the advent of pre-clinical and
experimental medical sciences, universities
established well-equipped hospital laborato-
ries and units headed by university profes-
sors. This not only led to great advances in
medical sciences in the nineteenth century,
especially in Germany, but also allowed uni-
versity professors to teach their students and
treat their patients using the latest scientific
knowledge and technology.
The proprietary type originated in the
nineteenth century in North America where,
historically, medical education was neither
embedded in hospitals, nor linked to univer-
sity teaching and research. Proprietary
schools were usually established by one or
more enterprising physicians or surgeons and
operated to make a profit for their owners. As
hospitals usually belonged to municipalities,
churches, or charities, proprietary medical
schools and hospitals had different owners
and therefore were not linked. Likewise, pro-
prietary medical schools were not linked to
universities. Lecturers often possessed lim-
ited knowledge themselves and the curricu-
lum was minimal. Moreover, proprietary
schools did not have research laboratories
and the faculty were not involved in research.
As a result, there were an excessive number of
2
medical schools in North America by the end
of the nineteenth century and they provided
low-quality education.
Despite their different historical origins
and separate development up until the begin-
ning of the twentieth century, the three dif-
ferent types of medical schools around the
world have been following convergent paths
ever since. This convergence coincided with
a  revolution in medical sciences and was
spurred by Flexner’s monumental report,
Medical Education in the United States and
Canada (Flexner and Pritchett 1910). In this
report, Flexner recommended that university
education in basic medical sciences should be
obligatory for medical practice, and that
medical schools should become part of uni-
versities with well-equipped research depart-
ments. As Flexner was convinced that future
advances in teaching and clinical practice
would come from science, he also recom-
mended that medical schools and hospitals
establish academic centers to pursue the
combined tripartite mission of research, edu-
cation, and patient care. The Flexner report
not only transformed medical education in
North America, but also influenced it around
the world.
Today, medical schools in most countries
around the world are part of universities and
have research and education facilities embed-
ded in their affiliated or owned teaching hos-
pitals. Academic physicians and scientists
employed by medical schools form the core
part of academic health centers (AHCs),
which are also known in different countries
as academic health science centers, academic
medical centers, and university medical cent-
ers. According to the US Institute of Medicine,
such centers are “a constellation of functions
and organizations committed to improving
the health of patients and populations
through the integration of their roles in
research, education, and patient care to pro-
duce the knowledge and evidence base that
become the foundation for both treating ill-
ness and improving health” (Kohn 2004).
Given that academic physicians and scientists
employed by medical schools work across the
university (academic enterprise) and the
teaching hospital (clinical enterprise), organ-
izational relationships and governance
arrangements of AHCs influence their ability
to fulfill the tripartite mission of academic
medicine.
Practitioners and scholars alike have tradi-
tionally focused on the integration of the aca-
demic and clinical enterprises and how
different models of organizational relation-
ships and governance arrangements could
improve the delivery of the tripartite mission.
The most extensive typology, by Weiner et al.
(2001), includes eight archetypical models
based on different values and configurations
of three dimensions: (1) high–low clinical
enterprise organization – that is, the degree to
which the clinical enterprise integrates pri-
mary care, hospital services, and insurance
functions; (2) high–low academic-clinical
enterprise integration – that is, the degree to
which the medical school integrates itself
with the clinical enterprise; and (3) high–low
authority position of the chief academic
officer – that is, the degree of authority of the
medical school dean or the university vice-
president for health affairs over the clinical
enterprise. Yet, it is possible to reduce the
variety of medical school–clinical enterprise
relationships to two prototypical models:
“(1) the fully integrated model, where academic,
clinical, and research functions report to one
person and one board of directors, and (2)
the split/splintered model, where the aca-
demic and clinical/health system operations
are managed by two or more individuals
reporting to the same or different governing
boards” (Wartman 2008).
In recent years, there has been a marked
change in the approach to the promotion of
academic–clinical integration in AHCs

around the world, with an emphasis on pro-
fessional leadership and voluntary collabora-
tion as opposed to bureaucratic control.
Previously, medical schools concentrated on
increasing academic control and increasing
the authority of the chief academic officer
through changes to governance structures, or
the acquisition and ownership of the affili-
ated teaching hospitals and faculty practice
plans. The latter allow medically qualified
faculty to practice their disciplines and use
the arising patient care revenue to support
research and education in medical schools. A
number of failed acquisitions of teaching hos-
pitals by medical schools and financial prob-
lems with running faculty plans in the United
States, as well as failed governance arrange-
ments that sought to increase academic con-
trol of teaching hospitals by medical schools
in Europe, have led medical schools to seek
better alignment with teaching hospitals
without changing ownership and accounta-
bility relationships.
The advocates of alignment emphasize
that, though long-lasting structural changes
to the ownership and governance structure
are hard to achieve, various alignment mech-
anisms can be used to improve academic–
clinical integration (Reece, Chrencik, and
Miller 2012). These include making joint
leadership and management appointments in
medical schools and teaching hospitals while
maintaining separate reporting relationships,
coordinating fund-raising efforts and creating
a joint investment fund, defining the common
measures of success, using organizational
structure to support collaboration, and trans-
forming organizational culture. For example,
there are AHCs on both sides of the Atlantic,
where hospital chiefs of clinical services are
also chairs of medical school departments.
Many US AHCs use balanced scorecards to
measure their success in research, education,
and patient care. Emerging AHCs in the Middle
East map their medical school departments
3
onto hospital service lines. In the Netherlands,
several universities and AHCs established clus-
ter structures known as the Medical Delta to
promote alignment across the whole cluster.
Similar to the evolution of the mission of
medical schools and their relationships
with  universities and teaching hospitals,
the  structure of medical schools has also
changed dramatically in modern times. Up
until the beginning of the twentieth century
most medical schools consisted of only two
major clinical departments – medicine and
surgery – but it is not uncommon today for
medical schools to have more than 20 clinical
departments as well as numerous pre-clinical
departments, divisions, research centers, and
institutes. At the beginning of the twentieth
century, medicine and surgery divided into a
larger number of disciplines, which formed
semi-autonomous departments within medi-
cal schools. In medicine new departments
arose in, among others, pathology, pediatrics,
radiology, psychiatry, neurology, and derma-
tology, while in surgery, new departments
emerged in obstetrics and gynecology,
anesthesiology, orthopedics, ophthalmology,
otorhinolaryngology, and neurosurgery
(Braunwald 2006). Also at around the same
time new pre-clinical disciplines, such as
biochemistry, microbiology, and pharmacol-
ogy, rapidly developed and became part of
the medical school’s departmental structure,
together with traditional pre-clinical disci-
plines such as anatomy and physiology.
The new departmental structure allowed fac-
ulty with similar training and interests to focus
on common research, teaching, and patient care
areas, make better use of space and equipment,
and identify and promote the next generation of
like-minded colleagues. In  countries where
medical schools had their own faculty practice
plans, clinical departments also controlled
income from patients and insurance companies
for services provided by their faculty members.
A small proportion of this income, known as
4
the dean’s tax, was allocated to the dean of the
medical school to support the medical school
and the university, and the rest of this income
was used by individual departments toward
their academic missions. Departments were
run by chairs, who had authority over income,
space, equipment, and faculty promotions.
Given that chairs were committed to the
advancement of their own departments and
had limited accountability to the medical
school, university, teaching hospital, and faculty
members, departments often operated like
independent fiefdoms. Inadvertently, this con-
tributed to the development of the “silo” men-
tality, whereby many members of the medical
school tended to focus wholly on their areas of
specialization, rather than collaborate with col-
leagues across the medical school. The adverse
effects of the silo mentality became evident
when faculty members in many medical schools
were high performers individually, but failed to
coordinate their activities and share resources
to accelerate performance for the whole of the
medical school and its clinical enterprise.
After World War II, both pre-clinical and
clinical disciplines experienced further spe-
cialization, which was accompanied by the
formation of divisions within departments.
New divisions mostly emerged around cer-
tain organ systems, such as cardiovascular or
musculoskeletal science, or certain diseases,
such as cancer. Divisions remained firmly
within the departmental structure, with
heads of division reporting to their depart-
mental chairs. Moreover, the departmental
structure was further strengthened thanks to
an unprecedented growth in departments’
research income from the state, charities, and
the biomedical industry. However, from the
1960s onward, the traditional departmental
structure was no longer able to support fully
the tripartite mission of academic medicine
due to a rapid growth of multidisciplinary
knowledge and technology. The subsequent
transformation of medical schools was largely
driven by the needs of research and patient
care, often without taking into consideration
the needs of teaching.
Several factors influenced the transforma-
tion of the traditional departmental structure.
First, cooperation between pre-clinical and
clinical departments resulted in the emer-
gence of new fields of knowledge and practice
such as neuroscience and immunology. They
became institutionalized as new multidiscipli-
nary centers or developed into full-fledged
departments. Second, great advances in tech-
nology led to the emergence of technological
platforms such as imaging and genomics
across the departmental structure. They either
established their own centers and institutes or
remained parts of different departments with
an overarching collaborative network or over-
sight committee arrangements. Third, a drive
to improve the quality of patient care in AHCs
through the adoption of service line manage-
ment, which focuses on particular patient ser-
vices and diseases, prompted structural
adjustments within many medical school
departments and hospital units. Last, funders
of biomedical research are increasingly
demanding that medical schools and AHCs
accelerate the translation of pre-clinical
discoveries into new treatments for patients.
This leads to the creation of new translational
biomedical research centers and institutes.
Finally, organizational culture has impor-
tant implications for medical schools as
professional workplaces. Over time, medi-
cal schools have developed distinctive val-
ues, ideas, beliefs, rules, and other elements
of organizational culture that set them apart
from other organizations. Results from a
recent study suggest that medical schools
have more entrepreneurial, team-oriented,
and rational cultures than teaching hospi-
tals, which tend to have more hierarchical
cultures (Ovseiko and Buchan 2012).
However, faculty members would prefer
significantly less hierarchical and more

entrepreneurial cultures to be developed
across the academic and clinical enterprises
in order to pursue the mission of academic
medicine more successfully. Another
important cultural issue is the relatively low
status of teaching in medical schools and
AHCs. It is sometimes viewed as a sub-
product of research and patient care. Very
few institutions measure the quality of
teaching and promote faculty on the basis of
their teaching excellence. Many scholars
believe that teaching has become the least
prestigious and most endangered mission of
academic medicine. Yet another important
issue is the underrepresentation of women,
especially in leadership positions. Although
in recent decades there have been signifi-
cant increases in the numbers of women
entering medical schools, they are still
underrepresented in tenured academic
positions and there are very few female
chairs of departments and deans of medical
schools. Profound cultural changes are
required in order to accelerate women’s
advancement and leadership in academic
medicine (Pololi 2010).
SEE ALSO: Health Professions and
Organization; Medical Knowledge; Medical
Research; Professional Work, Managing;
Professions and Professionalism
REFERENCES
Braunwald, Eugene. 2006. “Departments, Divi-
sions and Centers in the Evolution of Medical
Schools.” American Journal of Medicine 119(6):
457–462.
Flexner, Abraham. 1925. Medical Education. A
Comparative Study. New York: Macmillan.
Flexner, Abraham, and Pritchett, Henry S. 1910.
Medical Education in the United States and
Canada: A Report to the Carnegie Foundation
for the Advancement of Teaching. New York: Carn-
egie Foundation for the Advancement of Teaching.
View publication stats
5
Kohn, Linda T., ed. 2004. Academic Health Cent-
ers: Leading Change in the 21st Century. Institute
of Medicine Committee on the Roles of Academic
Health Centers in the 21st Century. Washington,
DC: National Academies Press.
Ovseiko, Pavel V., and Buchan, Alastair M. 2012.
“Organizational Culture in an Academic Health
Center: An Exploratory Study Using a Com-
peting Values Framework.” Academic Medicine
87(6): 709–718.
Pololi, Linda H. 2010. Changing the Culture of
Academic Medicine: Perspectives of Women
Faculty. Hanover, NH: Dartmouth College
Press.
Reece, E. Albert, Chrencik, Robert A., and Miller,
Edward D. 2012. “Fully Aligned Academic
Health Centers: A Model for 21st-Century Job
Creation and Sustainable Economic Growth.”
Academic Medicine 87(7): 982–987.
Wartman, Steven A. 2008. “Toward a Virtuous
Cycle: The Changing Face of Academic Health
Centers.” Academic Medicine 83(9): 797–799.
Weiner, Bryan J., Culbertson, Richard, Jones,
Robert F., and Dickler, Robert. 2001. “Organi-
zational Models for Medical School–Clinical
Enterprise Relationships.” Academic Medicine
76(2): 113–124.
FURTHER READING
Davies, Stephen M., Tawfik-Sukhor, Ali, and de
Jonge, Bob. 2010. “Structure, Governance and
Organizational Dynamics of University Medical
Centers in The Netherlands.” Academic Medi-
cine 85(6): 1091–1097.
Ovseiko, Pavel V., Davies, Stephen M., and
Buchan, Alastair M. 2010. “Organizational
Models of Emerging Academic Health Science
Centers in England.” Academic Medicine 85(8):
1282–1289.
Feldman, Arthur M. 2010. Pursuing Excellence
in Healthcare: Preserving America’s Academic
Medical Centers. New York: Productivity Press/
Taylor & Francis.
Wartman, Steven, ed. 2012. Confluence of Policy
and Leadership in Academic Health Science
Centers: A Professional and Personal Guide.
Abingdon, UK: Radcliffe Publishing.