Medicolegal Issues

Town & Gown


Centers of academia and learning have been physically located within urban communities since the time of the ancient Greeks. During the Middle Ages, church-supported universities were established in Italian cities, in Paris, and in Britain at Oxford. Typically, the university community resided in a sequestered segment of the city. As a result of financial endowment and protection granted by the Church, they were largely independent of civil laws and regulations.

In the Middle Ages, students and teachers wore gowns over their attire for warmth in the drafty libraries as well as to identify themselves as scholars; hence the distinction of “town,” a term referring to the townspeople, from “gown,” the people associated with the university.1 For a host of reasons, the traditional relationship between the local community and associated centers of academia has been one of suspicion and hostility.

Establishing Alliances

Over the years, better communication and cooperation between the academic communities and their host cities has eased some of these tensions and—in some cases—has resulted in positive and cordial relationships. Some academic institutions endeavor to contribute to the general community by providing access to evening study events and lectures and by inviting the community to participate in fine arts performances.

These overtures are welcome, but it is important to recognize the potential for universities to exert a dominating influence within a community. The impact of a university on the local community can vary, depending on the size and reputation of the university as well as the size of the town. A large, powerful university has a more profound influence when it is located in a moderate-size city (one with a population less than 250,000) than if it is located in a major metropolitan community. In this situation, the onus is upon the university to recognize its position with respect to the local community and its obligation to contribute to the general societal good.

Most universities recognize the value of establishing strong alliances and trusting relationships with their host communities. Located in Gainesville, Fla., a city with a population of 186,000, the University of Florida is a large university with a major medical school and a 576-bed teaching hospital. In response to community concerns about neighborhood issues, the university’s president appointed a University of Florida Town/Gown Task Force to identify problems and make recommendations to initiate change.2 The task force members included individuals representing the student body, the university faculty, and various representatives of the local community.

Other universities also recognize the importance of working together for the common good. Situated in a town of 13,000, South Carolina’s Clemson University, which has 17,100 students, developed a town-and-gown symposium in 2006 called Community Is a Contact Sport: Universities and Cities Reaching Common Ground. Designed to address neighborhood issues, it also provided a forum for concerns, as well as an opportunity for conflict resolution (

From Concern to Conflict

The conflict escalates on multiple levels when town-and-gown issues are set in the context of academic versus private practice medicine. University physicians and community doctors compete for the same patient population. Primary care physicians across the country have complained that when they refer their patients to academic teaching hospitals for specialized care, the patients are absorbed by the university hospitals. They complain that they are not afforded the courtesy of a follow-up letter, nor does the patient return to their care when the acute event is resolved.3 Private practice physicians and community-based hospitals provide important services and are necessary within any community. When the local, private medical community becomes concerned that a university-based medical center seeks to usurp their patients and their livelihood, a heated conflict may ensue.

University-based, research-oriented academic medical centers, with training programs involved in cutting edge technology and highly specialized patient care services, are clearly a positive adjunct to any local community’s—or state’s, for that matter—capability to provide top-notch patient care and services. No one can deny the benefits afforded by this level of expertise. Problems arise when university-based medical centers set a powerful and lustful gaze upon the medical community at large.

During the 1990s, large medical centers across the country bought up community hospitals and medical practices. At that time, and continuing into the present, office overhead—building costs, liability insurance, personnel costs—for private practice groups has often exceeded the ability of these primary care groups to survive. Not unexpectedly, once incorporated into the system, these practices are used to support the subspecialty services at the university medical center, bypassing the community-based subspecialty physicians.

Additionally, large, academic medical centers set up funded and university-supported subspecialty groups that compete head-on with independent practitioners. Private practitioners view these circumstances as stacked competition. The primary-care doctor’s decision in selecting a subspecialty doctor for a patient is no longer based on service, timeliness, and competence, but is instead a result of proscribed referral patterns delineated by the academic institution. Discriminatory referral patterns—not based on merit—result in local discontent, frustration, and unhealthy competition.

Short-Term Savings, Long-Term Loss

These issues are complex. A case can always be made to consolidate resources at the university hospital and avoid duplication of services by stripping away departments in the community hospitals. If pursued to its logical end, this operational model effectively starves community hospitals until they evolve into low acuity, “feeder” stations for the main academic hospital facility. On paper, this plan presents economic advantages. In practice, it not only deprives the metropolitan area of community-based hospital options, but it also results in a dwindling population base and the general decline and disenchantment of the local medical community. As the medical community contracts, so does the patient-base referral radius.

University-owned community hospitals are subject to the discretion of the university medical center. Decision making is attributed to maximum utilization of resources and certification of need, but most observers see the basic principle as economic: ways of garnering a larger portion of the healthcare dollar in the university coffers. Services and even departments provided by community hospitals are likewise subject to the benevolence of the university medical system. Hospitals function like living organisms: If a department such as pediatrics is withdrawn, the hospital continues—but with a limp. Few children can be seen and evaluated in the emergency department; likewise, high-risk obstetrics must be transferred to a major university hospital because the patient may need a neonatal intensive care unit. Hospitalists and internists who happen to be double boarded in medicine and pediatrics steer away from hospitals without a pediatric department. The changes are subtle but, over time, the effects of the loss are apparent.

Hospitalists need to be cognizant of these issues when pursuing employment opportunities. Many career-minded hospitalists seek employment in community-based, full-service hospitals with university medical center affiliations. This combination can provide the best of both worlds: autonomy, opportunities for growth and development, and opportunities for working with house staff and teaching. Checking the status of the relationship between the community hospital and the affiliated university medical center may be an important factor in pre-contract negotiations and decision-making for career hospitalists.

The Bottom Line

The turf battle between community medicine and academic medicine is primarily one of economics. Interesting parallels may be drawn between this conflict and the teachings of Adam Smith. Prior to Smith, economic theory was based on the idea that every dollar you have is one less dollar for me. Smith proposed an entirely different concept: If I help you earn dollars, the economic house will grow, and I, too, will make more dollars, and then you will make more dollars. In this way, the entire system generates more than anyone could have previously imagined. This economic concept extrapolates well to the present discussion of the university medical center versus community medicine.

University health systems do not seem to realize that real growth happens when communities grow together. A robust and vibrant community hospital supports a university medical center with more vigor than an anemic, waning, and disenchanted community hospital that perceives its woes as a result of the powerful—and perhaps dogmatic—university health system. There are enough patients to grow both systems together—the patient base radius grows wider with cooperation and growth—but this cannot happen if the university engenders distrust among local practitioners and the local community. This is a situation that will either be win-win or lose-lose.

Although the crux of the conflict is economic, other aspects of town-and-gown medicine can contribute to better cooperation and understanding. Some academic medical centers have explored ways to incorporate local physicians in university-based clinical trials. These programs offer cutting edge medicine and an opportunity to participate in intellectually stimulating work; at the same time, physicians retain their private practices.

This research opportunity is being offered and supported by a number of academic institutions, including Columbia-Presbyterian in New York City, Duke in Durham, N.C., Partners HealthCare in Boston, the University of Pittsburgh, the University of Rochester (N.Y.), and Washington University (St. Louis, Mo.).4 This is a good-faith start in mending the relationship between the academic and private medical sectors. To achieve a lasting positive relationship, community physicians must trust the academic community to respect their autonomy and to recognize that they have the right to provide full-service care to their patients and to serve their patients without the fear of being unfairly disenfranchised.

The lack of integration of the academic medical community and private practitioners of medicine—the proverbial town and gown—is an old dilemma. It is time to lay it to rest. The solutions are straightforward. Empowering community hospitals and physicians will not diminish the influence of university-based hospitals, nor will there be loss of reimbursement. Just the opposite will occur. In the end, with cooperation, everyone wins; with adversarial actions, all parties lose, especially the patients. TH

Dr. Brezina is a member of the consulting clinical faculty at Duke University, Durham, N.C.


  1. Town and gown in the Middle Ages. Available at: Last accessed March 29, 2007.
  2. University of Florida Web site. Town/gown task force. Available at: Last accessed March 29, 2007.
  3. Adams D, Croasdale M. Town and gown: turning rivalries into relationships [American Medical News Web site]. January 13, 2003. Available at: Last accessed March 20, 2007.
  4. Maguire P. Marriage of town and gown brings clinical research to busy practices [ACP-ASIM Observer Web site]. February 2001. Available at: Last accessed March 20, 2007.

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