Decline in medical research could open unhealthy gap among physicians

For more than a century, medical education in the United States has meant learning how to practice medicine and how to do research to make medicine better.

But that could be changing.

Given the need for more primary-care physicians, the shortage of certain specialists, and the belief that medical schools boost local economies, 36 institutions have opened across the country in the last 20 years.

That growth "has been accompanied by a shift toward new medical-education models where research plays a minimal role," according to a paper published recently in Science Translational Medicine.

What's the problem? Potentially, a two-tiered system that could harm the quality of medicine in numerous ways, wrote Arthur Feldman, executive dean of the Temple University School of Medicine; Arthur Rubenstein, former dean of the Perelman School of Medicine at the University of Pennsylvania; and their coauthors.

Feldman recently spoke with The Inquirer about the issue.

Question: Why is research so important to medical education?

Answer: Research is important to understand the underlying causes of human disease. To read the medical literature and to be equipped to identify what papers and studies are relevant to your patients, you have to have an understanding of research. Also, as clinical research moves to the community, it will be especially important for community-based physicians to have an understanding of the strengths and limitations of research.

Q: Can you give us a specific example?

A: In my specialty, which is heart failure or heart muscle disease, a decade or two ago, there were one or two genetic abnormalities that were causative of heart abnormalities. Today, there are over 60 identified genes; if you have a mutation in a certain gene, you have an incredibly high chance of having heart failure.

If someone goes to a primary physician with heart failure, that primary physician has to understand how to see if the disease is familial and if other members of that person's family are at risk of developing the disease. They need to know how you go about evaluating that person, how you evaluate their family, and what the positives and negatives are of performing genomic testing. If you've never been exposed to those things in medical school, and if you don't understand the strengths and weaknesses of genomic testing, it becomes very difficult to provide the optimal level of care.

Q: What has changed to make research less important to some medical programs?

A: Today we have the perfect storm. We don't have enough doctors in the U.S., so there's a push to train more medical students. It is expensive to run a medical school, and tuitions, even though they are very high, don't begin to cover the costs. The [National Institutes of Health] has cut back on funding by almost 26 percent since 2004, while the cost of research has increased. And there are not as many people going into research, and those that are often can't get enough funding to support their research.

Some medical schools have shortened medical school from four years to three years for students who have committed to going into primary care in order to lower the cost of their education. For those students, there is no time in the shortened curriculum to be exposed to research.

Q: Will this shift lead to primary-care physicians' sending more patients to specialists who have the research background?

A: There aren't enough specialists to take care of these patients, so the burden of care on primary-care physicians is increasing rather than decreasing. Therefore, we think that the primary-care doctor has to have the same appreciation for and understanding of translational research as the specialist.

Q: In the paper, you talk about a two-tiered system that may develop.

A: There are going to be students coming out of major research universities and medical schools whose teachers are physician-scientists vs. other students who are going to come out of programs where there are very good teachers who don't do research of any sort. That's going to divide the population of graduates into those who come out of a sort of upper tier and those who come out of a lower tier.

It builds an elitism that has never existed in the American medical system.

Q: How can you address this issue?

A: We're writing editorials and talking to legislators, trying to convince our national leaders and the lay public that we need to have more money put into the NIH. Young physician-scientists get stuck between grants that support their training and their first independent NIH funding. Without these physician-scientists, we won't be able to attract students to pursue careers in education and research.

We made a recommendation that the NIH develop an early career grant that would open up the bottleneck. At a recent meeting, Francis Collins, the director of NIH, said that they will be creating such an award next year that will be specifically for young investigators.

Q: What about other sources?

A: In the past, many medical centers supported research using clinical dollars. However, as third-party payers and federal payers have cut back substantially in financing health care, there are far fewer dollars to support medical research, particularly at safety-net hospitals. So we have to look for new resources in addition to the NIH: foundation grants, collaborations with industries, philanthropy, and for opportunities to commercialize discoveries. Those are the four approaches that all of us are taking to try to support our research efforts.