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Personal Perspective

Research and education in health care reform

Ralph I. Horwitz

Stanford University, Palo Alto, California, USA. E-mail:

First published September 10, 2009

To an observer, the periodic national argument over health care reform sounds sadly familiar. Rational discourse has given way to a noisy and dispiriting exchange of sound bites and rigid ideology. Special interest groups, including insurers and drug companies, have already made their deals to preserve their economic advantage, with hospitals and physician groups hoping for similar treatment. The usual goals of health care reform — improved access, improved health care outcomes, and decreased cost — remain elusive, with increased access the only goal likely to emerge from current legislative negotiations. In every previous effort at reform, organized medicine used its considerable influence to undermine improvements in our health care system that would have benefited patients. Now, the more-disorganized and less-influential profession of medicine seems less able to shape policy or legislation for either the profession’s self-interest or the public interest.

In the midst of this disarray, the diminished status of academic medicine and the biomedical research community is notable. The central importance of research and education, and especially their impact on the practice of medicine, does not seem to enter the debate. Only the exaggerated claims for “comparative effectiveness” research appear to have any meaningful role in ongoing discussions and current policy formulations. Yet it is likely that the success of health care reform will depend more than is now recognized on whether medicine broadly, and internal medicine specifically, can assert its leadership in linking health reform to fundamental changes in clinical education and clinical discovery research.

Nearly every discussion of health care reform emphasizes the need for greater primary care and the more judicious use of health care resources by physicians. Internal medicine is central to achieving both of these goals. For the past 50 years, internal medicine has been the front door to medical care for almost all adult patients; it has been the backbone of education for medical students, residents, and fellows training in the subspecialties; and it is also the engine for the nation’s biomedical research programs. Since neither medical schools nor teaching hospitals have been able to focus the health care debate on changes that would have lasting benefit for the health of the public, it falls to the field of internal medicine to reframe the debate in ways that would achieve meaningful reform.

Sadly, the desultory state of education and training in internal medicine illustrates the reasons for the diminished stature of academic medicine more broadly. Medical students unabashedly seek the “ROAD to happiness” with careers in the lifestyle-friendly specialties of radiology, ophthalmology, anesthesiology, and dermatology. While admittedly needed specialties, their disproportionate popularity reflects a shared failure of national health policy (including reimbursement policies), medical school education, and internal medicine training. While changes are desperately needed to deal with the first two failings as part of health care reform, the experience of the last several decades and the current debates suggest that substantive modifications are unlikely. Internal medicine training is the only one for which we in the academic internal medicine community have direct oversight. Yet here too we have failed both our students and the public. What can we do to ensure that the road to happiness for medical students is also the path to renewal for the profession of medicine?

Internal medicine, including its academic departments and professional organizations, must reinvigorate educational programs for both clinical care and clinical discovery research. In clinical education, practitioners of internal medicine should recommit to our traditions even as we embrace contemporary medical science and clinical practice improvements. As an academically based specialty, internal medicine has neglected the still-modern principles of diagnostic parsimony and therapeutic proficiency that have always distinguished the admired internist. It is not too late to emphasize again clinical care rooted in sound bedside skills and a scholarly approach to practice, further enriched by a deep appreciation for the influence of social and environmental factors on the risk for disease and the response to treatment. It is not too late, either, for our field to lead rather than follow the initiatives of this “global generation,” which is dedicated to local and worldwide improvements in human health. These goals cannot be met if we continue to delegate the education of our students and trainees to our most junior, though talented, faculty. Senior faculty and physician-scientists who have fled the wards where students are inspired to choose careers in internal medicine and to adopt the values of our discipline must engage again if we are to realize the renewal of internal medicine and the long-term success of health reform.

Educational change is needed as well to inspire students and trainees to pursue clinical discovery research. Clinical discovery includes the translation of laboratory science to clinical care, as well as the clinical epidemiology and health services research that was “invented” by academic general internal medicine. Ironically, despite its leadership in developing these fields, which constitute the basic science of clinical practice, doctors practicing internal medicine have not succeeded in integrating these research achievements into either clinical education or clinical care. Health reform goals of decreased cost and improved outcomes depend on leadership from the field of internal medicine for advances in clinical discovery research that also advance human health. Without these commitments to innovation in education and research, health care reform will exchange improved access to care for worsening costs and quality.

In health care reform, government has responsibility for ensuring access to medical care for all Americans. Neither further policy analyses nor additional legislative actions will be sufficient to achieve either improved patient outcomes or diminished medical care costs. Achieving these goals is the responsibility of the profession of medicine. Internal medicine will need to lead in this effort by once again promoting effectiveness and efficiency as the hallmarks of medical care. In doing so, internal medicine will also have crafted a new and renewable social contract that holds the promise of delivering at last on our duty to always put the public interest ahead of our profession’s self-interest.