Eugene Braunwald's Comments
It was the best of times – it was the worst of times. That is how Charles Dickens opened his famous novel, A Tale of Two Cities. While Dickens was referring to Paris and London at the end of the 18th century, future historians are very likely to say much the same about American Medical Centers during the first few decades of the 21st century. Among the thousands of organizations and activities in our society, why would future historians concern themselves with AMCs? Well, because they are the vital engines of our health system, which is so important to every individual, every family, and to so many aspects of our society and even our economy.
AMCs, with their colleges of Medicine, Dentistry -- and in many instances, schools of Public Health, Nursing and Pharmacy as well – with their teaching hospitals and clinics, their GME and CME programs, bear enormous educational responsibilities. Our doctors, nurses, pharmacists and other health care professionals are only as good as our AMCs.
AMCs are also the centers of the chain of biomedical science. The science chain has many links, from basic discovery to pre-clinical research, to proof -of -concept studies, to the translation of pre-clinical research to patients, to the assessment of clinical efficacy and QOL and finally to an analysis of the balance between benefits and costs of new treatments. Each of these links of the chain is forged principally in AMCs. Each link also provides a home for pre-doctoral, and especially for postdoctoral, research training.
Thirdly, the hospitals and clinics of AMCs obviously provide excellent care to their communities. Because AMCs have developed teams which include highly trained specialists, they also offer tertiary and quaternary care to a much wider catchment area. In this respect AMCs often serve as the courts of last resort for the most seriously ill or most challenging patients in their region. When politicians proclaim that the health care system in the U.S. is the best in the world, they are speaking largely of the AMCs and the advanced care that they provide.
Education, research and clinical care, the three traditional legs of the academic tripod, are rapidly being joined by a fourth leg -- global health. In this effort, the nation’s AMCs are beginning to export the fruits of their research and clinical know-how to developing nations. What a wonderful American export!
The several activities of the modern AMC are inextricably intertwined. Improve one and the others are pulled up as well. Allow one to slip and the others are dragged down.
It is difficult to provide an analogy for AMCs in today’s society. But consider the law. If you had a single organization that included a Law School, attached to a huge law firm with upwards of 500 practicing attorneys, in turn attached to a District and also to an Appellate Court, all in a single juggernaut organization under one CEO, you would be approaching an AMC. Even such a huge legal enterprise wouldn’t require the enormous physical facilities and the many billions of dollars of equipment of an AMC. This is why the multi-billion dollar budgets of AMCs with their thousands of employees are often so intimidating to their parent Universities.
To return to the Dickens analogy. This is really the best of times for AMCs. First, consider education. Despite the well-publicized travails of the medical profession, applications to medical schools are on the rise and, more importantly, the quality and preparation of applicants are rising even more rapidly.
Then consider research. The opportunities for the acquisition of fundamental biological knowledge and its potential application to improving human health have never been greater. Let me give you just a few examples of important biomedical research with strong UR connections. When Dr. Berk was a junior faculty member at Harvard and the Brigham and Women’s Hospital, he described an increased concentration of CRP, a marker of inflammation circulating in the blood stream of patients undergoing an acute coronary event. Brad ended his paper by suggesting that treatment of inflammation might be helpful in the prevention of such events.
This seminal idea has been picked up by many other investigators around the world. One of them, Paul Ridker, was a contemporary of Dr. Berk’s at the Brigham. Paul recently put Brad’s idea to the test. In a large trial of almost 18,000 healthy subjects who had an abnormally elevated CRP, the substance that Dr. Berk studied, Ridker showed the enormous benefit of a statin, a drug that has powerful anti-inflammatory, as well as cholesterol-lowering, actions. Heart attacks and death were reduced almost by half. It has been estimated that the health of tens of millions of persons in the U.S. alone will benefit.
Moreover, many of the statins are now generic and inexpensive. Taken together, these two studies are examples of translational science at its best.
Another example of the great scientific and clinical impact of the research of a Professor of UR is Dr. Arthur Moss’ famed Multicenter Automatic Defibrillator Implantation Trials. That’s quite a mouthful, and mercifully Dr. Moss has shortened it to MADIT. In this trio of trials, Moss and colleagues showed that in patients who developed a transient rhythm disturbance or heart failure after a heart attack, the risk of a fatal heart rhythm disturbance was reduced and life was prolonged with the implantation of a device called an implanted cardiac defibrillator. The worldwide impact of this research is enormous.
Drs. David Smith and Porter Anderson here at Rochester developed a vaccine against a bacterium named Haemophilus influenza type b. This vaccine has virtually wiped out a leading cause of meningitis in preschool children. They then used the same approach to create a vaccine that prevents infection by pneumococcal bacteria, which cause meningitis, ear infections, and pneumonia.
Three UR researchers— Drs. Richard Reichman, William Bonnez, and Robert Rose, developed a vaccine against Human Papillomavirus (HPV).
Researchers in Dr. Robert Notter’s laboratory here were the first to administer purified calf -lung surfactant to premature infants. This led to significantly improved outcomes and opened the door to all subsequent work in this important field.
I could go on and on citing important research here at the UR. But my point is that as a consequence of the enormous achievements of AMCs in education, clinical care and research, their critical value is appreciated by legislators on both sides of the aisle as well as by the Executive Branch of our federal government. AMCs usually get similar respect from their states and local governments. There are few organizations in our society for which this can be said today. AMCs have truly become the jewels in the crown of the beleaguered American Health Care system.
However, getting back to Dickens, this may also be the worst of times for AMCs. The risk is real that their resources are drying up at the very time that their contributions to society have become the most promising.
Let’s consider briefly the sources of revenue of AMCs, examining their three principal activities: Education, Research, and Clinical Care. The smallest fraction of the AMC’s income comes from tuition of undergraduate medical students. Obviously, tuition can’t be raised because, even now, many medical students graduate with debts approaching and in some instances exceeding $200,000. As a matter of fact, over the next few years, medical schools will be forced to provide ever-increasing student aid so that future physicians will not be limited to the offspring of the most affluent. So, chalk that up to a loss of revenue.
Second is the research budget. The NIH is by far the most important sponsor of biomedical research in the nation. Its approximately $30 billion annual budget is one of the few discretionary portions of the federal budget; given the country’s economic problems, this budget will, at best, remain frozen or rise, but will certainly not keep pace with research inflation.
Although $30 billion is a lot of money, it represents less than 1% of the total national expenditure for health care and less than 4% of the federal expenditure for medical care. These are tiny percentages of research support in a research-driven industry. For the federal government to assign only four cents of each dollar that it spends on medical care to improve that care and to make it more cost effective is very small. Other major research-driven industries spend three to 10 times as much.
When an AMC is successful in garnering support from the NIH that sounds like good news. However, it’s important to look under the hood. It has been my experience that even when an outstanding school such as UR obtains $1 from the NIH, it must come up with a minimum of 15 cents. If you apply this 15% rule to the impressive $200 million research budget of this medical school, by my simple formula the UR AMC must raise at least another $30 million each year just to stand still. For decades, 15% has come from philanthropy endowment but mostly from clinical revenues.
The budgets of medical schools have, for many years, been propped up by their teaching hospitals, which have supported the salaries of clinical faculty members. This faculty, in addition to their teaching and research duties, carry out vital hospital functions. Most schools have a “Dean’s tax” on clinical income, which is often used to support basic science departments.
The recent public debate revolving around health care reform during the last 15 months or so has made it painfully clear that health care costs are out of sight and that hospital margins will very soon disappear or may well turn into deficits. It is safe to predict that going forward, it is unlikely that clinical income will be able to continue to support the research and educational missions of our AMCs.
So what are we to do? Give up? Hoist the white flag of surrender? Absolutely not! First of all, let’s look at the historical record. When considering the variability of the NIH budget that I have experienced in my own professional lifetime, I am reminded of the biblical story of the Pharaoh asking Joseph to interpret his dream of seven fat cows emerging from the Nile followed by seven lean cows. And so it has been with the NIH budget. I have lived through seven cycles. And clearly we’re now facing another seven lean years and this cycle may be leaner than before, just as this recession has been deeper. AMCs must find a way of working together to index the federal support for research in some manner to the federal outlay for health care. It is inevitable that the total of health care will rise no matter how health care reform plays out; even 4% of a larger total outlay will be enormously helpful.
AMCs must also assess carefully their educational programs. One of the principal reasons that the costs of undergraduate and GME are so high is that they take so long – and, I believe, much too long. Currently, medical training consists of four and in some instances five quite separate chunks – four years of college, four years of medical school, three to five years of residency and for those planning to be clinical specialists another three years of fellowship. For those preparing for an academic career, an additional three or four years of research training beyond that. Within this almost 20 years of post-high school education, there are now long periods of largely wasted time. The fourth years both of college and of medical school are cases in point. Furthermore, given the high quality of our students, I don’t think that we need to repeat in medical school rigorous college courses in subjects such as molecular biology, genetics and biochemistry.
Another example where we can reduce training time is the five years of residency in general surgery and in the surgical specialties such as Neurosurgery, Urological surgery, cardiothoracic surgery and orthopedic surgery. After the first post-MD year, i.e. the internship year, surgeons spend three years in what could be considered to be a holding pattern until the fifth year, the Chief Residency year, when they really practice surgical skills. I think that we can save at least two years here.
If we condense training programs, there will be fewer people emerging from them who are well into the fourth decade of their lives with heavy family responsibilities and crushing debts. Physicians who complete their training so late are less likely to opt for careers in primary care, in which they are desperately needed. Scientists who complete their post-doctoral fellowships in their late thirties are less likely to conduct risky research for which the payoff can be enormous. They may not be competitive with recently minted PhDs who are four to eight years their junior.
By knocking four or five years off the medical training marathon we’ll save money by having fewer trainee mouths to feed and we will produce graduates who are more nimble than our current crop of middle aged entries in both the physician and the physician-scientist workforces. The streamlining of the education that I propose can’t be done piecemeal. It would be best carried out in a great, well-integrated university. The UR could help lead the way.
You might well ask whether at a time of an information explosion when the knowledge required by practicing physicians is increasing logarithmically, whether it wouldn’t be wiser to lengthen rather than shorten education. I don’t think so. It doesn’t really matter whether medical school is three, four, or five years, or even longer. The advances of knowledge are now so rapid that the actual practice of medicine – the specific diagnostic and therapeutic strategies – turns over every four to five years. It’s been said, only half jokingly, that one-half of what we teach in medical school is wrong and the other half is outdated by the time the student actually becomes a practitioner. If you accept this proposition, what are the principal purposes of undergraduate medical education in the 21st century? I think that there are five:
The first, and in my judgment by far the most important, is the approach to the patient.
Most patients are anxious and frightened. Often they go to great ends to convince themselves that illness does not exist. The physician needs to consider the terrain in which an illness occurs – in terms not only of the patients themselves, but also of their families and social backgrounds. All too often, medical work-ups and records fail to include essential information about the patient’s origins, schooling, job, home and family, and most importantly the patients’ hopes and fears. Without this knowledge, it is difficult for the physician to gain rapport with the patient or to develop insight into the patient’s illness.
Given the changes in the medical care system that are currently underway, it is now more important than before that physicians exhibit humanistic qualities. By humanistic qualities, I am referring to integrity, respect and compassion, as well as the willingness to take the time to explain all aspects of the patient’s illness, and an attitude of being non-judgmental with patients who have lifestyles, attitudes and values different from those of the physician.
A second, and closely related, goal of a medical education is to instill into future physicians a sense of what it means to be a member of a profession rather than a vocation. Supreme Court Justice Louis Brandeis defined a profession as “an occupation that is pursued largely for others and not merely for one’s self.” Also, he stated that: “A profession is an occupation in which the amount of financial return is not the accepted measure of success.”
The third responsibility of a contemporary medical education is to provide future physicians with an approach to the solution of clinical problems. Students must learn how to find the answers to a question--what to look for in textbooks, journals, practice guidelines, the results of clinical trials, the internet--and how to apply modern information science on behalf of their patients. They must be taught how to stay updated in a rapidly changing field, but not be overwhelmed by the never ending quantities of new information.
The fourth goal is to teach collaboration, teamwork and communication with other health professionals, who will become ever more important members of the health care team in the future.
The fifth and final goal is to ignite the spark of curiosity in biomedical science that will inspire a small, but critically important, group of students to pursue a career in research.
Insofar as improving the AMCs’ research mission in the absence of real increases in the budget of the NIH, the key, I believe, must be greater and more effective collaboration.
To enhance collaboration, we must break the barriers that have arisen between faculty in separate divisions within a department, between departments in schools, between schools in universities, between universities, and between academia and industry.
For decades, departments and divisions in medical schools often have operated much like fiefdoms, with largely impenetrable walls.
The first breaches in the walls of clinical departments of medical schools occurred in the 1960s when it became apparent that a multi-departmental, multi-disciplinary approach was important in providing optimal care. In my specialty of cardiology, for example, the birth of cardiac surgery forced a close and highly beneficial collaboration between cardiac surgeons and cardiologists. Soon the specialized skills of cardiovascular roentgenologists, pathologists, pediatricians and anesthesiologists were sought. Oncology is another example of a field in which multi-disciplinary approaches were essential to enhance patient care, education, and research.
AMCs have increasingly developed multi-departmental institutes, centers, and programs. I support this approach. When it is carried out carefully, as is the case here in Rochester, it stimulates translational research, improves the training of investigators and serves as an optimal interface between the AMC and industry.
Let me give you just one example of how the development of a multi-departmental center in a teaching hospital can produce cost savings. Imaging of the cardio-vascular system is becoming ever more important in diagnosis and research. There are several modalities of CV imaging. These include ultrasonography (in which the UR has been a leader), computed tomography, MRI, and nuclear/PET imaging. These modalities have operated independently usually at separate locations in most teaching hospitals. There is considerable redundancy in the information provided by these several modalities and there has been overuse of these expensive tests. The costs of diagnostic imaging are consuming a rapidly increasing portion of our over-strained health care budget.
Two years ago the Brigham opened a new building and placed all CV clinical activities under one roof. All imaging modalities were placed on a single floor of the new CV center and under a single leader. Within a year, the total external support to what had been separate competing groups increased substantially and last week the new director of our multi-modal CV imaging program proudly announced the funding of an application for an NIH training grant to prepare both cardiologists and radiologists in multi-modality imaging. This would not have happened without a CV center.
It is interesting to look closely at what other AMCs are doing about their organizations. Two prominent institutions – the Cleveland Clinic and the Mt Sinai Medical Center in New York City -- are well on their way to going almost totally to an institutionally based organizational model.
However, there are important issues that must be dealt with before this organizational model can be accepted wholesale. In AMCs composed of institutes, who will be responsible for undergraduate medical education? Who will deal with the education of Primary care physicians? These are central tasks for any AMC and they must be done well; they must be recognized and rewarded. I wonder if this can be accomplished in an institute-based AMC.
In these very challenging times, the success of AMCs depends more than ever on the qualities of their leaders. I’m convinced that the AMCs with the greatest forward-looking leadership will not only survive but will come out of this period stronger than ever.
Today, we celebrate the investiture of a new Dean, Dr. Mark Taubman, an event that is of critical importance to the UR School of Medicine and Dentistry, and to this University as a whole. This appointment fills me with great enthusiasm and optimism.
I have known Mark Taubman since he came to the Brigham in 1978 for his medical residency, his cardiology fellowship, and his first few years on the Harvard Faculty, and I have followed his career closely since then.
During his years in Boston, Mark proved to be an outstanding, empathetic physician and a brilliant and creative scientist. The Brigham has prided itself on attracting the most outstanding medical graduates from around the country to its training programs. Mark Taubman was certainly among the very best of the best.
One of the qualities about Marc that I appreciated was that although he was modest and soft spoken compared to some of his more bombastic confreres, he stood up firmly for what he believed, whether it was a diagnosis, a patient care issue, or his research. These qualities were honed in his next four positions. First, as Director of the Cardiology and the CV research training program at Mt. Sinai, then successively as Chief of Cardiology, Chair of Medicine and then as interim CEO of this AMC. I can think of no one in academic medicine today who is more qualified by personal qualities, research accomplishment, and experience to assume the helm of this medical school at this challenging time.
Of course as Dean of the Medical School Marc has a second and equally important role. He plays a critical role on this AMC’s leadership team, under Dr. Brad Berk. Brad and Marc met at the BWH, so I consider myself something of a matchmaker.
Dr. Berk is a brilliant scientist, an accomplished physician and a man of extraordinary vision, who is a well proven, strong CEO of this AMC. Dr. Berk has shown that he is a superb judge of people. He certainly sees the “big picture,” the multiple important roles that this AMC plays in the University, in Rochester and in the nation and how the clinical care that it delivers needs to be reinvented.The Berk-Taubman team is unique in American medicine. I will be watching what goes on in Rochester with intense interest, pride, and, to be frank, with some pangs of regret that we allowed these two extraordinary men to leave the nest in Boston.