Volume 18 Number 2 Fall 2001

Philip A. Pizzo

Second Opinion:
The changes in health care finance give new meaning to 'conflict of interest'

by Philip A. Pizzo, MD
Dean, Stanford University School of Medicine

When I first began contemplating a career in medicine in the early 1960s, being a physician was viewed as a noble profession. However, I have the sense that over the past two decades the public’s regard for doctors has diminished despite astonishing advances in physicians’ abilities to improve patients’ health.

This incongruity concerns me deeply. Without the public’s support and trust, the training of future doctors and the viability of teaching hospitals and academic medical centers will be compromised, especially at a time when the nation’s health care finance system is in crisis.
Strides in science and biomedical research have resulted in startling progress. Over the course of my career I have witnessed how biomedical research has fundamentally changed the outcome of previously fatal diseases. For example, as a medical student, I observed that most children with cancer died, often rapidly. Although the fields of chemotherapy and radiation therapy were beginning to yield benefits at that time, their impact was limited. In the four decades that followed, childhood cancer has become curable in nearly 80 percent of newly diagnosed children.

My personal sojourn as a clinical investigator in pediatric cancer and pediatric AIDS has constantly reaffirmed the important confluence of basic research, clinical investigation, education, family-centered interdisciplinary clinical care, community service and advocacy. I am proud to be a physician-scientist as well as a public advocate for research, education and patient care.

I anticipate with great eagerness extraordinary changes in medicine and science during the next decades. Indeed, as the fields of molecular and cellular biology and genetics evolve and medical science continues to incorporate insights from physics, chemistry, mathematics and other disciplines, an ever-brighter light will be shed on human biology, helping physicians and researchers define new approaches to the diagnosis, treatment and prevention of disease.

But over the course of these same decades, I have seen a decline in the public’s respect for physicians. I believe this change in attitude has much to do with the increasingly limited time physicians are able to spend with their patients. Furthermore, some of the extraordinary technical advances that improve diagnosis and management of human illness also seem to impose barriers to human touch and its expressions of concern. And any feelings of alienation patients might have are only aggravated by their concerns over the pressure on health care institutions to make medicine more a business than a profession, or more a commodity than a service.

It appears that just as the public’s medical lexicon is expanding to include many new terms that are both molecular (e.g., DNA, genome, stem cell) and clinical (e.g., CT, MRI), many of our faculty are using terms from a different dictionary. “Market-share, cost allocation, P&L, winners & losers” govern the language of medicine spoken in board and conference rooms and have an important impact on the lives and choices of those who practice medicine in the clinical setting.

Here lies the ironic divergence. At the very time when the resources for biomedical research are increasing, thanks to the doubling of the National Institutes of Health budget, the support for our academic medical centers for teaching and the care they render is decreasing. Remarkably, despite the tremendous accomplishments of the past decade and the promissory note they offer for the future, the lay public, while still enamored and supportive of biomedical research, has lost too much respect for its doctors and the medical centers where their physicians are educated and trained.

As a result, some of our great institutions, like Stanford, are challenged and even threatened.

This is bad news for academic medical centers. Extending discoveries in the laboratory directly to the patient requires a close and ideally seamless association between the basic and clinical science faculty within medical schools and their affiliated hospitals. And herein lies the potential for a conflict of interest that could diminish the quality of health care for generations to come.

The needs and financial requirements for a hospital are different from those of a medical school and research enterprise, and it simply doesn’t take much to drive them apart. This conflict has already led some medical schools to sell their teaching hospitals, further separating the contiguity of our important missions in clinical care, research and education. Sadly, this trend jeopardizes the conduit that makes health improvement possible through research and education.

At the core of the problem faced by Stanford University School of Medicine and other medical schools in this country is that the costs for education and research cannot be met by student tuition or research dollars alone. For example, tuition payments cover only approximately a third of the expenses associated with medical education.

Moreover, even though Stanford’s medical faculty achieves the highest per-capita level of competitive grant support of any in the nation, about 20 percent of research expenses are not covered by grants.

In the past, clinical income was used to help support the missions in education and research in academic medical centers. Today, that is nearly impossible, largely because expenses for clinical care are not met by insurance payments — especially in teaching hospitals that treat the uninsured and patients with the most complex conditions. This is particularly true in northern California where patient care payments are among the lowest in the nation.

Stanford University Medical Center epitomizes this dichotomy between medicine’s burgeoning potential and its dwindling public support. The good news is that we’re in a position to prevail despite these challenges. These challenges require making choices in the nature and scope of our educational programs, in the focus and size of our investments in research, and in the scope and depth of the clinical programs that are provided. Each of these choices must be guided by a commitment to excellence.

Accordingly, it will be necessary to carry out a comprehensive review of the medical education curriculum. In doing so, our overriding goal should address educating future thought-leaders by focusing on the development of physician-scientists and leaders in academic medicine and biomedical research, as well as related leadership opportunities in the public and private sectors. Because of the unique physical relationship of the Medical School to the main Stanford University campus, we can do this especially well. As a result, the physicians and researchers trained at Stanford will be poised to make major changes in their fields. Ultimately they will become leaders who will help point the way to regaining the public trust.

Here are some of the strategic initiatives we are pursuing in order to achieve this:
  • Review the School of Medicine’s curriculum to assure that MD students not only gain core medical skills but are also able to follow creative pathways for interdisciplinary education and individualized career development, including basic science and clinical science, bioengineering, computer sciences, public health, advocacy and public policy, education, law, humanities, religion and ethics, and business.

  • Enhance the School of Medicine’s programs for students pursuing master’s degrees and PhDs. Our school attracts the world’s best graduate students. We must prepare them for success as leaders in academia or in the public or private sectors.

  • Create opportunities for graduate students to become acquainted with the principles and practice of clinical medicine in order to foster an understanding and interest in translational clinical research. This should be increasingly feasible with the computer-based virtual-learning programs being pioneered at Stanford as well as with the use of various clinical simulation models.

  • Depart from the compartmentalized learning that characterizes current medical education and seek to develop a continuum for training physician-scientists that extends throughout medical school, graduate medical education and fellowship training.

  • Enhance basic and clinical investigation by fostering interdisciplinary research efforts. To this end we are creating new programs including biocomputation, bioengineering, genetics/genomics, post-genomic structures, protein networking, chemical biology, cancer biology, microbiology and host defense, neuroscience, stem cell biology and tissue engineering and cardiovascular science.
Choices are also necessary in our clinical programs, identifying those at which we excel and that complement those services offered by other providers in our community. Excellence and innovation in the care we provide should guide our efforts. At this juncture, the primary areas of focus for both the adult and pediatric clinical programs seem best pursued in surgical specialties, cardiovascular diseases, cancer, and brain and behavior, although other important areas will also need to be enhanced as well.

Naturally this means that some other important areas of medicine will be de-emphasized at Stanford, largely because they can be offered by other providers or because they are not as prime for new development and innovation. In pursuing these and related goals we will also want to work closely with our colleagues at the VA hospital, Santa Clara Valley Medical Center and with other community partners to develop a more integrated academic medical center.

Accomplishing our individual and collective goals will require rigorous management of hospital and school operations. It will require accommodation to reductions in services that have been previously valued. It will require even more careful investments in program development, recruitment and capital expansion. It will require us to think more rigorously about every decision that demands school or hospital resources and to do so with a broader Medical Center perspective.

Although our challenges are significant, they are achievable if we stay true to our principles and focused on our missions. We must regain the trust of all people, convince them of the value of academic medicine and excite them about the future of health care. We need to do this through our advocacy, communications and efforts to change the public policy governing health care finance.

We must stay focused on the quality of our research, education and innovations and excellence in patient care. We cannot engage in a conflict of interest that bifurcates clinical care from research and education. They are inextricably intertwined and we must assure that the threads connecting them remain intact so that future generations benefit from science and medicine.


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Copyright © 2001, Stanford University School of Medicine. All rights reserved.