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The financial health of hospitals has been dismal. Insurance reimbursements no longer cover the actual cost of care. Every hospital struggles with operating losses and cost containment, and many hospitals are closing or considering merging with others.

As a result, the old definition of an “academic medical center” in which the medical school and the hospital are the same entity is dying. Many universities no longer want to own a hospital and its financial troubles. For example, Georgetown University, Harvard Medical School, Vanderbilt University and the University of Maryland, to name just a few, don’t own their own hospitals. Instead, the more appropriate term should be “academic medical affiliates.”

For clinical providers who had once solely been faculty members of a university, their paymaster becomes the hospital coffers and their affiliation with their respective academic institution is minimized -- in fact, it is sometimes only token in nature. This partnership may be good for universities who do not need to shelter a hospital’s financial troubles, but it comes at the cost of academic freedom of medical faculty members who no longer have the same university protections to their paychecks.

What is academic freedom? The standard of academic freedom was initially outlined in 1940 by the American Association of University Professors and the Association of American Colleges and Universities and is continually revised as this concept has been challenged. The AAUP currently uses language approved on June 12, 2009, by the University of Minnesota Board of Regents. “Academic freedom is the freedom to discuss all relevant matters in the classroom, to explore all avenues of scholarship, research, and creative expression, and to speak or write without institutional discipline or restraint on matters of public concern as well as on matters related to professional duties and the functioning of the University.” Continued protection of academic freedom in the medical field is crucial to protect our society’s overall well-being given the potential and powerful impediments the medical establishment can raise against progress.

The tension between the beliefs of health-care providers and the medical establishments in which they practice has existed for centuries. Historically, providers who were activists for change lost their livelihoods and sometimes their lives by disagreeing with the medical establishment. Medical students today understand the sanctity of learning from dissection in human anatomy classes, but in the Middle Ages, this was illegal. In 1847, Ignaz Semmelweis discovered hand washing could reduce deaths from infections during childbirth and was outraged that his findings were ignored. His colleagues and later his wife thought he was crazy, and he was eventually committed to an asylum, where he died.

For some physician activists who speak out, the risk of termination persists today. More modern-day examples are mental health professionals who disagreed with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders that until 1987 categorized homosexuality as a pathology. Today, there are providers employed by traditionally Catholic hospitals who cannot speak about a woman’s right to control her fertility. A physician who publishes about medically assisted suicide, genetic manipulation or selection, abortion, or anything else vaguely controversial may even be at risk of losing their job, depending on their alignment with their hospital’s administration.

So what should academic physician activists do today if the majority of their paycheck is controlled by a hospital that is affiliated with but not owned by the academic institution? I don’t have a good answer. The Minnesota language endorsed by the AAUP states, “Academic responsibility implies the faithful performance of professional duties and obligations, the recognition of the demands of the scholarly enterprise, and the candor to make it clear that when one is speaking on matters of public interest, one is not speaking for the institution.” This may be our best guidance. Do our jobs well and clearly state we speak as individual citizens and not on behalf of anyone else.

But in reality, without the implied expertise of our faculty titles accompanying our authorship, it is less likely that our opinions will be published. Separating our faculty titles from the affiliated hospital is almost impossible, as most hospitals still share the university’s name. And even if we are able to publish solely as a citizen, our employment is still unprotected. The First Amendment protects freedom of religion, expression, assembly and the right to petition, but not employment within the private sector.

Academic physicians should know their affiliated hospital, not the medical school itself, may be their paymaster. The paycheck that supports an academic physician’s public voice may not be protected by academic freedom. As academic institutions divorce their hospitals, academic physicians who speak out must carefully navigate their obligations and recognize their risk. For hospitals, we are employees before we are professors.

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