I recently participated in a small conference devoted to “physician alignment in the academic medical center.” The meeting was sponsored by a health care consulting firm, and drew about a dozen participants from around the country. The title refers to ways in which academic centers figure out how to work with their traditionally autonomous if not completely independent physicians to advance the institutional mission. An informal format allowed us to share (war) stories from our respective institutions and learn from each other. The ground rules included confidentiality (“what happens in Nashville stays in Nashville”), so I won’t disclose any specifics, but a few themes emerged that are worth sharing.

First, to no one’s great surprise, the old saw that “if you have seen one academic medical center, you’ve seen one academic medical center” still holds. There was great diversity among the represented institutions in organizational structures and in the financial arrangements between the parent institution and practicing physicians.

Second, everyone expressed uncertainty, if not outright anxiety, about the ability of current organizational models to assure success — however defined — in the years ahead. As one participant noted grimly, the three “businesses” of academic medical centers — clinical care, biomedical research, and medical education — are all “in recession” financially, so it is vital to rethink traditional structures. In the most striking example discussed that day, a medical school had sold its financially strapped faculty practice to a large independent multispecialty group practice, which then entered into a contractual arrangement with the school to provide clinical services. A radical move, for sure, and one which led to a deep-seated and ongoing culture clash.

Third, every institution was trying to figure out the best way to “engage” and “align” with community physicians. Strategies differed. Some were doing so “defensively” to lock in their existing base of referring physicians. Others were “offensively” trying to expand market share. The tactics of alignment differed too. Some were employing physicians on a large scale; others were “franchising the brand” of the academic center by providing independent practices with the hospital’s EMR and providing faculty status to community physicians.

The language around these efforts was interesting. The predominant explanation was that they were trying to balance their assets, by adding primary and community-based care to the traditional specialist-heavy roster of the academic center. The stated idea was that they could then continue to provide hospital based tertiary care, while simultaneously developing the capability to manage populations and participate in risk-based reimbursement schemes. Trouble is, a lot of the strategies looked less like that and more like trying to assure a steady stream of inpatients to “feed the beast” of the academic center.

I think it is fair to say that every academic medical center is struggling to figure out how to keep its doors open, while reimbursement for clinical care, which has always “floated” the teaching and research missions, declines. It also seems pretty clear that there is not going to be a single blueprint for achieving this, and that some institutions will fail in their attempts.

Ira Nash is a cardiologist who blogs at Auscultation.