This chapter uses the systems approach to analyze the impact of the evolving health care scene on the academic clinician. Such an analysis divides the organization and its activities into the following systems: technical, structural, psychosocial, cultural, and managerial. The US medical system, including its system of medical education, has evolved around a philosophy that every patient should be treated with every means available that might ameliorate the patient's condition. Implicit in this philosophy is the belief that "the doctor knows best" and that the role of society is to supply the funds necessary to support the work of physicians. The paradigm for this system was the traditional or monastic model of the AMC. It rested on an academic "stool" with the three legs of teaching, research, and patient care. Technical and structural subsystems challenges to the AMC may initially appear to be purely fiscal ones; however, their implications for the socio-technical systems of an academic teaching hospital are significant. To meet these financial challenges implicit in the new academic "stool" and to broaden the dean's "tax base," academic institutions are merging with non-academic institutions. The old-order monastic academic model, based on the three principles of teaching, research, and patient care, is deeply ingrained in many academicians who also resent their loss of the rewards encompassed by academic rank and prestige. The chapter concludes that if AMCs are to remain viable and capable of supporting their multifaceted mission, one must realign the reward systems to make them congruent.
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