LITERATURE SCANS
Review of ‘‘Preserving Surgical Academia in
the Centenary of the Flexnerian Academic
Health Center’’
KI Bland
Annals of Surgery 2011;254:393Y409
T
he academic health center (AHC) has come a long way
from its reformation in the early 1900s. It is not yet a perfect
system, and many problems must still be overcome to main-
tain the quality of surgical academia in the future. Some of
these problems, including funding and workload distribution, are
brought to attention so that solutions may be implemented. This is
important so that the integrity and mission of practicing physicians
and AHCs in the United States are maintained at a high level.
Today’s AHC can typically be viewed as a school of medicine
with its research activities and organized health care delivery sys-
tem. The author of this article focuses on how the AHC became what
it is today along with the current challenges that face medical edu-
cation. These problems are discussed in great length by the author
with some suggestions for academic leaders in all surgical special-
ties. Briefly, the modern AHC has evolved from its original structure
in the late 1800s to provide a more evidence-based approach with
the founding of the American Surgical Association by Dr. Samuel
Gross. The evidence-based philosophy took over the previous ho-
meopathic approach to surgery, which was roughly organized into 3
fields (gynecology, surgery, and otology/ophthalmology/laryngology).
Homeopathic medical schools were highly criticized for their be-
lief that diseases originated from natural orifices of the body and
therefore could be treated by operating on these orifices. The lack
of ‘‘scientific’’ teaching led to the closure of many homeopathic
medical schools in the early 1900s by the direction of Abraham
Flexner. This era marked the beginning of the allopathic approach to
medical education in addition to the requirement of a baccalaureate
degree for admission. These ‘‘new’’ medical schools were set up
with a full-time faculty and commitment to scientific research.
The transformation of the American AHC led to a mission fo-
cused on patient care, research, and education. The author of this
article emphasizes that high-quality patient care is the main goal,
with research and education being the means by which this goal is
accomplished. After World War II, the AHC experienced a large
period of growth and development, with the number of medical
schools doubling between 1935 and 2010. Enrollment has also
increased greatly with both native and international students. The
National Institutes of Health (NIH) has greatly contributed to the fi-
nancing of research and overall growth of AHCs. Although the
AHCs have successfully grown and multiplied, we still seem to have
a shortage of physicians to support our population. Lately, the AHCs
represent only 22% of the nation’s hospitals, and they have adopted
an important role to provide care to millions of the nation’s sickest
patients. The author states that even though faculty physicians make
up 20% of the workforce, they receive more than 40% of all trans-
ferred patients. To add to this stress, the AHC is financially hindered
by decreased reimbursements from Medicare patients and insurance
organizations. More financial problems are now seen on the side of
research, with less than 22% of grant submissions being funded by
the NIH. The Congressional Balanced Budget Act of 1997 has also
hobbled the AHC by limiting funds for postgraduate education. For
example, if an AHC wished to start a new residency program, then
it is responsible for these costs.
It is the author’s opinion that Congress must enlarge the NIH
budget to maintain the quality of medical research so that patient
1220 The Journal of Craniofacial Surgery
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
care will continue to be optimized. To further combat these financial
burdens, there has become an increasing dependence on the income
and growth of clinical practice and hospital revenue. This has not
been an easy transition because of decreased residency hours and the
increase in workload on attending physicians. It was also stressed in
this article that AHCs should focus on commodity services for both
financial and training proposes. One might consider why these
measures need to be taken when medical school tuition is constantly
on the rise along with greater allocation of taxes for health care. The
author clarifies the importance of transparency with these funds
among the medical school faculty so that financial trust is main-
tained, and budgeting concerns are avoided. The author goes further
to emphasize that teaching and research faculty satisfaction is im-
portant to enhance the departmental infrastructure and advance sur-
gical science.
Aside from overcoming financial issues, it is important for the
preservation of the AHC mission to maintain effective communi-
cation with the chairs, deans, chief executive officers, and trustees
of the entire system. The academic health system can be broken
down into 4 main components: the university, the school of medi-
cine, the university hospital, and the practice plan. If the commu-
nication within the health system is ineffective, then financial
viability is at stake in addition to multidisciplinary team support and
the ability to fulfill societal responsibilities of health care.
Overall, a successful surgical department must offer outstanding
care and performance at a competitive rate. Outstanding care is
supported by a strong research infrastructure, which needs to be
sustained financially. Continued emphasis on the recruitment of top
students is critical for the continuation of excellent surgical acade-
mia. Also, surgical training can be enhanced with the repeal of the
Balanced Budget Act of 1997. This will remove limits on the resi-
dent workforce and allow for adequate funding for the recruitment
in all surgical specialties. So that additional limits are not put into
place, it important that further reductions below the 80-hour work-
week are not considered to maintain the competency of the training
surgeon. Declining reimbursement, preservation of the curriculum,
reduction of research funding, and nonsurgical competition for re-
sources are only a few of the challenges facing surgical academia
today. These are not easy problems to solve, but it is important to
remember that medical education has faced tribulations in the past
and has already overcome many obstacles.
Colton McNichols, BS
Larry Hollier, MD, FACS
Baylor College of Medicine
Houston, TX
mcnichols.md@gmail.com
Review of ‘‘Force-Induced Craniosynostosis
in the Murine Sagittal Suture’’
A.J. Oppenheimer ST Rhee
SA Goldstein SR Buchman
Plast Reconstr Surg 2009;124:1840Y1848.
O
ppenheimer et al drill down in their ongoing investiga-
tion of the mechanotransductive pathways mediating
nonsyndromic craniosynostosis. The investigators har-
vested mouse sagittal sutures and loaded them into a
& Volume 23, Number 4, July 2012