Finally, An Ethical Framework for the Relationship Between Medical Schools and Teaching Hospitals

The excellent team of Frank A. Chervenak and Laurence B. McCullough have produced another pioneering article (unfortunately, available by subscription only. The full citation is Chervenak FA, McCullough LB. Responsibly managing the medical school - teaching hospital power relationship. Acad Med 2005; 80: 690.) They had previously written the first article to propose an ethical framework for the leaders of academic medical centers (see our post here.) The fact that this 2004 article was the first to ever discuss the need for such a framework was, of course, disturbing.
The new article is the first ever to propose an ethical framework for the relationship between medical schools and their teaching hospitals. From the introduction,

• "Finances are an increasingly contentious aspect of the relationship between medical schools and their teaching hospitals. Joint budget negotiations can be shaped by incomplete information and sometimes even misinformation, failure to consider enhancements to other services, strategic procrastination and strategic ambiguity in the process and substance of the negotiations, unfunded mandates for matters vital to the hospital, such as quality, and attempts by each party to shift costs toward and reimbursements away from the other party. Both parties are under mounting and relentless fiscal pressure, creating an environment in which each party increasingly tends to focus on protecting its organizational self-interest, especially its bottom line. As a result, both parties are at risk of acting solely on self-interest, thus losing sight of and failing to be guided by their co-fiduciary responsibility for excelllence in patient care, education, and research. This could result in ethically unacceptable organizational cultures and practices that could adversely affect the parties' ability to fulfill that responsbility."

Sound familiar to those in medical education? Their solution first is transparency:

• "Transparency means that both parties must be forthcoming about revenues, including collateral revenues, and actual and assigned costs."
• "Sharing this information routinely will allow a factually based, informed allocation of revenues and costs as they relate to the mission of excellence in clinical care, education, and research."
• "The justification of transparency in business ethics ultimately involves an appeal to rational self-interest in avoiding (mutual) exploitation in market exchanges."

Furthermore, the reason for transparency is not just based on business ethics:

• "An explicit appeal to the medical ethical concept of co-fiduciary responsibility provides a crucial, additional basis for such responsible management, because fulfilling co-fiduciary responsibility makes transparency obligatory, not just a matter of rational self-interest."

The article is worth reading in its entirety. I only hope that a few leaders of medical schools and teaching hospitals will take it to heart.