From The Editor's Desk

This issue of The Ochsner Journal addresses challenges to the physician in carrying out a blend of obligations as professional, teacher, and investigator posed by the current environment of healthcare. The United States devotes a far greater portion of its resources to healthcare, measured both in absolute number of dollars and as a percentage of Gross Domestic Product, than do other nations, and those who view themselves as the payors of these costs are unhappy with the product, wish to limit their expenditures, and are demanding accountability from the delivery system, the educational establishment, and research endeavors. In this environment, a bottom-line orientation is imposed by corporate interests of both investor-owned and nonprofit hospital systems, by insurance companies and health plans, by the pharmaceutical industry, and by governmental and nongovernmental purchasers.

Kenneth Ludmerer, author of Learning To Heal and Time to Heal, describes the effect on the educational process of competing pressures for faculty time and energy and of heightened expectations for a structured content in postgraduate programs and decreased dependence on guild-apprenticeship models.

Bill Pinsky details the process of strategic planning undertaken at Ochsner to articulate mission-related objectives and goals in educational and research programs and to establish techniques to measure effectiveness and success in achieving these goals.

Arthur Garson, Jr., and Stephen A. Levin note the impact of recent trends, including reimbursement and resource constraints, on academic health centers and offer guidance how these institutions can fulfill their mission and avoid the fate of the dinosaurs to which they have been likened.

Bob Perillo emphasizes the importance of senior physicians serving as mentors and role models to trainees and of insisting on genuine educational content in residency and fellowship programs. LuAnn E. White, Marie Krousel-Wood, and Fran Mather point out the potential for improving educational opportunities for both postgraduate trainees and practicing physicians and for enhanced quality in patient care by taking advantage of advances in information technology and transfer.

It does require time to assimilate the information base of a specialty and develop the skills necessary to become a mature practitioner, and an excess of repetitive service chores hinders the process. The educational content of residency programs may not fare well in an era when work hours and time off are mandated by residency review committees or state educational commissions, when residents have been decreed to be employees rather than students by the National Labor Relations Board, and when economic pundits have pronounced that residents are paying the freight for their own education through foregone wages and service, and hence do not represent a cost to the academic medical center. It would be folly to advocate a return to the internship schedules of 36 hours on and 12 off, but the fact is that under that system almost half of the house staff were on hand during the evenings and weekends to share the work, and it was the rare shift that did not offer opportunity to read up on patients just admitted, to consult with senior residents on clinical problems, to oversee medical student workups—and still get some rest.

Teaching does take time and energy, but the process is often as beneficial to the teacher as to the students. We should be mindful of the promise in the Hippocratic Oath, “… to give a share of precepts and oral instruction and all the other learning to my sons… and to pupils who have signed the covenant and have taken an oath according to the medical law” (1).

The physician today faces conflicting pressures and often perverse incentives. As responsible citizens, physicians must participate in activities contributing to the improvement of the community, the betterment of public health, and the appropriate use of healthcare resources. The ethics and values of the profession mandate that in clinical care the responsibility of the physician to the patient is paramount. This obligation transcends the nature of the delivery system, the configuration of the practice, and the employment status of the physician in whatever forms they may assume in the 21^st century.

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Frank A. Riddick, Jr., President

• Ochsner Clinic and Alton Ochsner Medical Foundation