Mark Taubman’s Comments
Thank you. I am honored to serve as the Dean of the University of Rochester School of Medicine and Dentistry. I hope to follow in the tradition of my nine predecessors who have each helped to breathe life into Abraham Flexner’s notion of a “medical school of the highest order.” I, too, would like to extend a warm welcome to the three former deans who are with us today – Dr. Robert Joynt, Dr. Marshall Lichtman, and Dr. David Guzick. It means a great deal to me to have you here.
Thanks to Flexner, George Eastman, Rush Rhees, and George Whipple, this medical school has, from its inception, been about forging new paths. It was founded on the Flexnerian model, the idea that medical schools should be affiliated with universities and have a dedicated, structured physician and scientific faculty. With the backing of Eastman and other philanthropists, we had the opportunity to incorporate scientific inquiry, learning, and patient care all under one roof. At the time, these were revolutionary concepts.
Over the last ninety years, the School of Medicine and Dentistry has maintained its reputation for innovation. Within the education mission, we’re known for the biopsychosocial model and the double-helix curriculum. In the scientific realm, we are perhaps best known for doing research that has far-reaching, global impact. For instance, University of Rochester scientists have taken the lead in establishing the criteria for the use of implantable defibrillators in patients with sudden death and heart failure and have played pivotal roles in the development of three vaccines used widely around the world. Because of work like this, the University annually ranks among the top in the nation in terms of the royalties its research garners from industry. And, clinically, we have built upstate New York’s most comprehensive patient care system – with unique services in solid organ transplant, trauma, and complex neuromedicine.
For the last ten years, we have been on an upward trajectory. Through ambitious and careful strategic planning, the School has enjoyed unprecedented growth, including a doubling of our faculty, a $100 million jump in NIH funding, and the tripling of our research space. This year, we saw our NIH funding top $168 million – even without the bolus of federal stimulus funding. And construction is well underway on our new Clinical and Translational Science Building which will open next spring.
But, despite this strong foundation, academic medicine in this country is at a crossroads – and this School cannot escape the powerful dynamics that are reshaping medical schools across America. The economic downturn has stressed our endowments, and tightened philanthropy and industry-sponsored research. The flattening of the NIH budget has resulted in the lowest percentage in history of grants, only 20% of applications, receiving funding. At the same time, the rise in health care costs poses an undeniable threat to our nation’s economy that will necessitate radical changes in health care financing and delivery. Reform efforts will put new pressures on hospital bottom lines at the same time that it requires us to train more primary care physicians. Plus, advances in science and technology are occurring at a dizzying pace – not only in emerging fields like genomics, imaging, bioinformatics, but also in areas such a nanotechnology and health care information technology.
Before I address some of these challenges, I would like to acknowledge Dr. Eugene Braunwald. You have heard much about his accomplishments as a cardiovascular investigator who revolutionized our understanding of hypertrophic cardiomyopathy and whose pioneering work changed the way we treat coronary artery disease. Dr. Braunwald indeed has served as a role model for a whole generation of academic cardiovascular investigators. However, as I begin on my new adventure as Dean, it is Dr. Braunwald’s achievements as the Chairman of Medicine at the Brigham & Women’s Hospital that most stand out for me. From the first day that I entered the Brigham as a medical intern, it was clear that Dr. Braunwald had created an ideal environment that supported the highest quality medical care that promoted outstanding clinical and basic research, and yet still placed teaching and education at the forefront. When one looks out over the landscape of American medicine, it is dominated by Dr. Braunwald’s children, like Brad Berk and me, who were given the opportunity to thrive in the environment he created. As the Dean of the School of Medicine at the University of Rochester, it is this type of environment that will serve as my model.
I would first like to spend a few moments specifically discussing education and how current and future forces will shape how we teach medicine.
The School of Medicine and Dentistry has a long tradition of generating academic physician-scientists. We want to maintain this tradition and provide even more opportunities for our students to engage in research. By organizing ourselves into multidisciplinary Integrated Disease Programs, and by leveraging the Clinical and Translational Science Institute, we will be better able to provide collaborative research opportunities, not only in the basic sciences, but in translational investigation. And we will be able to extend these opportunities to students in our Graduate School of Arts and Sciences and in our Medical Scientist Training Program, both of which have grown in size and strength.
Often academic medical centers have been viewed as part of the ivy tower and have not done a good job at interacting with the community or in educating the community as to the critical role of biomedical research. There is no doubt that the medical school of the 21st century will need to play a greater role in serving and galvanizing the community. We urgently need to address the impending shortage of primary care physicians. This is already a problem in Western New York, and it will become more acute as health care reform extends access to more patients.
We must strike a balance, so that we remain one of the premier centers for developing physician-scientists, at the same time that we foster successful career paths in primary care. We want to produce physicians who stay in our region as practitioners and boost the caliber of our local health care system and we want to produce physician-scientists who continue to push the envelope of investigation both at the University of Rochester and at the other great academic medical centers. With regard to primary care, we will be looking at ways to provide the ideal experience and preserve the enthusiasm of those students who enter undergraduate or graduate training with a declared interest in primary care. We will be working broadly with others in the community to boost satisfaction with the practice of primary care and to dissolve some of the barriers that discourage students from primary care, for example through debt forgiveness. Sparked by a lead gift from Dr. Bob Brent, we have established an endowment designed to help reduce the cost of medical education, with the ultimate goal of tuition-free medical education. We all recognize that this is a lofty and difficult goal, but it is one worthy of aspiration.
Medical education will undergo profound changes in the next decade. Growth in technologies like simulation and robotics will change the way that we teach medicine, and in so doing, change the nature of the medical classroom. Not to mention mobile IT devices like the iPad and Kindle that will likely place all medical information at one’s fingertips. We will need to harness that power and assure that we teach students to sort out the right information and not become flooded with the superfluous.
Within the new data-driven culture of medicine our students and graduates will face new dilemmas. For instance, electronic medical records are transforming the ease and accuracy with which we communicate, thereby reducing errors, and saving time and costly duplication. But because this technology requires a higher level of documentation, the way in which physicians relate to patients can suffer. As an institution founded on the biopsychosocial model, we need to teach our students how to maintain focus on the interpersonal patient-doctor relationship in this more technological, data-driven culture.
Even in a world of EMR’s and protocol-driven care, we must prize the creative art of medicine. For centuries, the hallmark of physician education was making the differential diagnosis, synthesizing information, seeing the patient as a unique individual, testing various hypotheses, then being able to think creatively when things didn’t fit the mold. The drive towards lower cost and higher overall quality must not be so protocol-driven that it prevents the individualization of the patient and inhibits the kind of creativity that makes medicine special – and effective. We will always need to be on the lookout for approaches that will enable us to create compassionate physicians who are also the best thinkers.
With the rise in consumerism, our graduates will practice in an environment of transparent, highly public quality outcomes. That means that we will need to imbue medical students with a thorough understanding of quality processes. We have to prepare them for an environment where they will be increasingly judged and reimbursed based upon quality metrics. We also need to instill an academic discipline into quality improvement – in the form of research and scholarship opportunities - and to expand the number of faculty, residents and students involved in quality outcomes and comparative effectiveness research.
Academic medicine has been silent through much of the recent health care debate. This is not acceptable. Academic medicine needs to be at the table addressing health care reform, and we need to make sure that our students are educated enough to understand the business and politics of health care – not only so that they can better comprehend the impact of health care legislation, but so they are prepared to play a greater role as health care evolves.
Finally, I would be remiss if I did not mention the additional threat to academic medicine of off-shore medical schools that are profit centers designed to train large classes at a fraction of the cost. They have very small non-specialized faculties that teach a standardized curriculum and do no research or clinical work. The students’ clinical training is acquired in U.S. community hospitals.
Next, let’s take a few moments to talk about our research mission.
By adding facilities and faculty recruits, we have grown into one of the top research institutions in the country and we have an ambitious strategic plan that supports additional growth. However, this growth is outstripping our ability to fully support the research enterprise. Research funding is not sufficient to provide all of the needs of our investigators and to support our extensive research facilities. In fact, we lose 30-40 cents on every research dollar. This is not unique to the University of Rochester. At a recent Council of Deans meeting of the AAMC, it was acknowledged that “not every academic medical center can expect to continue to grow in research if federal funding does not increase. The economic model that’s been used to support research is simply not sustainable.“ They highlighted the need to develop new financial and investment models that promote sustainable growth and the responsible stewardship of research support. Such models need to address volatility, create predictable federal investment in research, address return on investment, and define areas where economies of scale are possible and collaboration opportunities exist. It was also acknowledged that we need to do a better job in demonstrating to the public that the long-term shared investment in the generation of new knowledge benefits people and communities. Specifically, we must increase the appreciation of incremental progress in improving the health of the public, and explain the long-term value of undirected basic science research investments. Such benefits include economic stimulation, advanced treatments, improved care, incremental health improvements, improved quality of life, and reduced morbidity and mortality. Addressing these issues will not be easy.
Thankfully, I won’t be facing this challenge alone. We are blessed with an outstanding faculty and outstanding chairs and center directors who enjoy a high level of camaraderie. To achieve this goal, we will need to work together even more closely to look at new models that provide economies of scale and allow for efficiencies in running the research enterprise. Like most other research institutions, we cannot be a “jack-of-all-trades” and will need to focus particularly on well-funded programs in selective areas that have the best opportunity for national and international impact.
So, the challenge will be to right-size the research enterprise so that we can continue to grow programs of excellence, while practicing appropriate fiscal restraint. We must be able to retain our best and brightest faculty and take advantage of exciting changes in technology, such as advancements in genomics, bioinformatics and stem cells. We also want to be prepared to take advantage of new opportunities that emerge as the new NIH director Francis Collins reshapes the NIH roadmap. At the Council of Deans meeting, he enumerated the following five areas of opportunity:
1. Applying opportunities in genomics and other high throughput technologies to understand fundamental biology, and to uncover the causes of specific diseases,
2. Translating basic science discoveries into new and better treatments,
3. Putting science to work for the benefit of health care reform,
4. Encouraging a greater focus on global health, and
5. Reinvigorating and empowering the biomedical research community.
Dr. Collins focused particularly on Comparative Effectiveness Research and on providing mechanisms for academia to bridge the gap between basic science and drug development. Fortunately for us, the centerpiece of Francis Collins’ program is the CTSI, with the ultimate goal of establishing 60 centers throughout the country. Thanks to the efforts of David Guzick, Tom Pearson and many others, we were in the first class of CTSA recipients and are recognized as being the poster child for rapid deployment. One of our priorities will be to avail ourselves of the resources of the CTSI to take full opportunity of new NIH initiatives and to better integrate with our basic sciences.
In the Council of Deans’ action items regarding research, they noted that we are being called on to “Demonstrate the integrative benefits of research and health care especially in light of the ongoing health care reform efforts.” This does not mean that we should focus exclusively on clinical research, comparative effectiveness, and quality-based research. There’s no question we should be taking a leadership role in research designed to improve the quality and decrease the cost of medical care for the region. However, we also need to do a better job of educating the community to the benefits of basic research and the need for continued investment in basic research. There is a widespread and troubling sense that we have done enough basic research – now is the time to apply it. To the contrary, the changes in technology will allow for unprecedented leaps in our basic understanding of cell biology and human diseases. We must sustain our discipline around achieving new basic science insights. Here at home, we need to better engage our business and political leaders so that we can tap into research funding sources that may be available throughout the Rochester community.
And finally there is our clinical mission.
Perhaps the greatest challenge for academic medicine will be to adapt to changes in the system of health care delivery and reimbursement. To again quote the Council of Dean’s working group: “Our current business model is no longer sustainable. The clinical mission of an academic medical center can no longer support our education and research missions as it has in the past. We need to restructure to achieve major efficiencies.”
Research-oriented academic medical centers have long functioned in an environment in which their major role was to handle tertiary and quaternary referrals and provide high-end diagnostic and therapeutic procedures. The centerpiece of the model was the “triple threat” specialist who could run a first-class research program, yet also have great expertise in a narrow range of medical procedures which generated the revenue necessary to partially support the research and also allow for teaching. This model depends on high procedural volume, but also is costly. It also has fostered the development of compartmentalization, with separate, narrowly focused departments.
But, now, as we move toward a system that focuses more closely on efficiencies and lower costs, the incentives will change to advantage those systems that do fewer procedures and can survive under conditions of reduced reimbursement. It will favor Medical Faculty groups that are more integrated and function like large group practices, systems that maximize outpatient resources rather than inpatient services and that integrate with the local community. Programs that can serve as hubs for regional networks will thrive, as will those that focus on prevention, and are innovative rather than reactive. The leading systems will integrate nursing and other skilled providers more closely into their care teams, and they will leverage information technology to their advantage.
Fortunately, over the last several years, URMC has emerged as the largest clinical provider in upstate New York, with robust quaternary programs in organ transplant, pediatrics, orthopaedics, neuromedicine, cancer, and more. Our Center for Community Health is spawning new programs that can intercept habits and behaviors before they come health-threatening. In fact, the Center’s ability to tap into community networks was one of the most compelling components of our CTSA application. We also enjoy a strong and collegial relationship with our School of Nursing, another linchpin in our CTSI. And, thanks to prudent fiscal management and careful planning, we are well into the deployment of eRecord, our comprehensive electronic medical record system.
While all of these challenges taken together may seem daunting, by virtue of this school’s history and our progressive DNA, we are in a much stronger position than most of our counterparts. We have an unprecedented opportunity to take a leadership role in transforming clinical medicine so that we ensure that our community thrives in the new health care environment.
What I have outlined is certainly a challenging task – however it is one that makes the prospect of being Dean at the University of Rochester so exciting. I thank President Seligman, our CEO, Brad Berk, and the trustees for giving me the opportunity to serve as Dean and I look forward to taking on the challenge and working with the faculty, students, and staff to assure that the School of Medicine and Dentistry will be an engine for change and innovation and remain in the forefront of academic institutions.