Commentary: The ivory tower
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OK, so the title of this commentary is “The ivory tower.”
If I changed it to “The town and gown syndrome,” it would ring a bell to you — although probably not for millennials.
Yeah, I know, they are not my favorite generation, but I digress.
An interesting history
The history of the town and gown syndrome is very interesting and — believe it or not — documentation of the first instances occurred in the 13th century.
Just to give you some perspective on the 13th century, historical events of that time included the end of the Crusades, the creation of the Magna Carta and Marco Polo exploring Asia by the Silk Road. Also, paper was invented in China and transmitted through Islamic Spain in the 13th century.
It’s amazing the history you can find in a matter of minutes today!
It makes sense that the founding of the first universities in the 13th century coincided with the initial occurrence of the town and gown syndrome.
As Robert J. Baker, MD, described in Archives of Surgery: “Throughout the more or less civilized parts of Central and Western Europe, these institutions proliferated, creating the environment for frequent outbreaks of violence and rioting among students, faculty and neighboring townspeople.”
It evidently took three or four centuries for communities to realize that having a university in their neighborhood was an economic and intellectual advantage. Hence, the violence and rioting finally stopped, according to Baker, except for a few Ivy League universities.
I have to admit I have not been able to document that the Ivy leagues didn’t stop!
Taking many forms
Baker’s commentary described several types of town and gown syndromes.
The first is the intramural conflict. This involves the full- and part-time faculty in a university vs. the basic scientists who have no connection to clinical medicine.
This manifests itself when it comes time for faculty appointments and promotions between the two groups. Discussions don’t lead to rioting as they did in the 13th century, but they certainly result in what one could call “lively” debates. Ring a bell to any readers?
The second type is one that my generation certainly is familiar with. That’s the environment that involves the teaching university faculty vs. the community hospital faculty.
“Community physicians don’t know what they are doing” was a common statement.
I experienced this in my early career, although — in retrospect — it really didn’t make sense.
Today, I think you all would agree there is an attempt to develop strong relationships between academic centers and community hospitals — especially in the cancer field, where 80% of care is delivered in the community hospital setting.
This relationship is probably best demonstrated by the consortium status between NCI-designated cancer centers and community hospitals in our country.
Our own community cancer center has a unique 12-year agreement with The Wistar Institute, an NCI-designated basic cancer center. These types of relationships have just taken several centuries to get here!
The third type of town and gown syndrome is probably more relevant today.
It comes down to the issue that many community hospitals in the United States have accredited residency programs in many specialties. This is similar to the intramural conflict described above between clinicians and research-oriented scientists, and centers around paid faculty in a community-hospital setting working together with physicians in private practice.
Taking time to teach in any specialty usually means the attending physician will be seeing fewer patients.
For a salaried physician in a community hospital, that may not make a major dent in one’s pocket as opposed to a private practice physician.
On the other hand, in the present era of relative value units (RVUs), this becomes very relevant — even with salaried physicians. If your compensation plan has a component of productivity with RVUs and, at the same time, you are teaching, then your patient volume will be affected because of the time element (seeing fewer patients).
This is also not a 13th century issue, but an issue in 2024.
It certainly can be justified to stipend a program director and associate program director or lower their RVU target, but what about the remaining teaching faculty, whether salaried/employed or private practice? What is the answer there?
Frankly, the solution to this financial issue between employed and private practice physicians in the community setting is a separate discussion.
The key question
So, is it fair to say that the town and gown syndrome — or the ivory tower — no longer exists in the 21st century, or is it still present in medicine?
I leave that answer and discussion up to you. Shoot me an email if this commentary touched a nerve!
Stay safe.
References:
- Baker RJ. Arch Surg. 1991;doi:10.1001/archsurg.1991.01410270025002.
- Bloom JM. Papermaking: The Historical Diffusion of an Ancient Technique. In: Jöns H, Meusburger P, Heffernan M (eds). Mobilities of Knowledge. Knowledge and Space, vol 10. Springer, Cham; 2017.
- Gibson R. 13th century: 7 historical events that took place in the 13th century. Available at: https://historycolored.com/articles/8577/7-historical-events-that-took-place-in-the-13th-century/. Published Jan. 9, 2022. Accessed Feb. 10, 2024.
- Wescoe WC. JAMA. 1963:doi:10.1001/jama.1963.63710080019011.
For more information:
Nicholas J. Petrelli, MD, FACS, is Bank of America endowed medical director of ChristianaCare’s Helen F. Graham Cancer Center & Research Institute and associate director of translational research at Wistar Cancer Institute. He also serves as Associate Medical Editor for Surgical Oncology for Healio | HemOnc Today. He can be reached at npetrelli@christianacare.org.
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