STATE OF THE SCHOOL ADDRESS
MAY 9, 2007
WHEN YOU COME TO A FORK IN THE ROAD, TAKE IT!
Arthur S. Levine, MD
Senior Vice Chancellor for the Health Sciences,
And Dean, School of Medicine
My title this year is a quote from the famous New York Yankee, Yogi Berra, a font of much wisdom, who said, “When you come to a fork in the road, take it!” I have chosen that title because we are at a point in the country’s history, in the history of academic medicine, and in our institution’s own history, where we must make choices – even when the data available to us are incomplete, and we must risk taking the wrong road. Hopefully, we will have the individual and institutional ability to make wise and reasonable choices, even if those choices are not fully informed, and therefore, we will not be paralyzed by the fork in the road. I want to begin my talk by noting first that we are, in fact, a school, and that whatever other purpose we serve, we must remain ever mindful of the priority that a school places on education – in our case, the education of medical and graduate students. I will also speak about our current research plans and challenges, the relationship of our school to the University of Pittsburgh Medical Center, and near the end of my talk, a miscellanea of issues. I will say at the outset that my conclusion today will be that despite the many challenges that we face in each of these areas, the fact of the matter is that as an institution we are thriving. We are, in fact, one of the most financially and academically robust institutions (the medical school and the medical center) in the country at the moment, and I have every reason to believe that my optimism will be sustained by the facts at hand.
Education
With respect to the medical school per se, we are educating almost 600 medical students currently, about half women and half men. The majority of our medical students come here from out-of-state with about 29 percent from Pennsylvania. This latter figure has been dropping in recent years for two reasons. First, our school has become extremely competitive, and the schools with which we compete are very good indeed. They include Harvard, Yale, Stanford, Johns Hopkins, the University of Pennsylvania, UCSF, the University of Michigan, Washington University, Duke, Columbia, and only a very few others in this tier. Most of these schools have substantially larger endowments than ours, and they can offer considerably more grant and scholarship support. Thus, if the students have the academic credentials for admission here, those credentials will also be sufficient for them to gain admission into one of these other schools. Since there is only a small tuition differential between in-state and out-of-state at our school, the most highly qualified Pennsylvania students may matriculate in one of our competitor schools with more scholarship wherewithal. Second, however, while we may lose some students to our competitors, the academic credentials of our contemporary student body have become increasingly strong, i.e., highly competitive in a national context, and therefore, simply being a resident of Pennsylvania provides no assurance of acceptance if the Pennsylvania student’s credentials do not rank with those of our out-of-state applicants. Here I would note that a major reason for the small out-of-state versus in-state tuition differential is that we receive relatively little money from the Commonwealth of Pennsylvania in support of medical education. In fact, Pennsylvania for many years has ranked as the second worst state in the nation with respect to state funding of medical education.
About ten percent of our students are from underrepresented minority populations, but that percentage has been slowly and happily increasing, although not to the extent to which we aspire. Our PhD program is also thriving. We have 333 students in our various graduate programs, with 95 students in the MD/PhD program. The size of the faculty is continuing to grow as well, with almost 2,000 fulltime faculty currently. With respect to compensating the faculty for medical student teaching, this year I made the commitment to increase the amount of money with which we will compensate medical student education. I was amused earlier in the spring when Harvard announced that they had increased their compensation for medical student education dramatically to $17 million; we have been at that figure for a number of years and will be increasing that amount this year and in the years to follow.
With respect to the curriculum, several years ago we carried out a major restructuring of the first two years of medical school, primarily along the lines of modernizing both the substance of the pre-clinical, basic science curriculum and the style with which we teach. To a significant extent, this restructuring was led by our students themselves, and what I have called teaching style is consistent with the very high quality of students that we are now attracting. Of course, it is appropriate that we revisit the curriculum annually as we do in our annual “Curriculum Colloquium,” especially in view of the extraordinary rapidity with which we have come to a fuller understanding of the biology of the human condition within the past decade, if not just the past few years. With respect to style, we have been mindful of the fact that our brains are not all “hardwired” in the same way: Some of us learn well by rote, some sterically, some kinesthetically, some early in the morning, some late at night, and so forth. One style of education does not fit all, and therefore we are employing not only traditional lectures, but computer-based learning, problem-based learning, and simulation-based learning such that every student is able to individualize the strategy with which he or she approaches the curriculum.
The Methods and Logic in Medicine course has been a major success. This is a course that emphasizes critical reading of the literature and understanding of research methods and methodology, the ethics of research, and so forth – all in preparation for the fact that a mandatory part of our curriculum now includes a substantial exposure to research for all of our medical students. We are one of the very few schools nationally that has such a requirement as a part of the curriculum, here called the “Mentored Scholarly Project.” In fact, these scholarly projects are research, but because it is possible to enjoy and master the practice of the scientific method in many ways, we wanted to emphasize the breadth of research opportunities available to our students with this somewhat more transcendent identification. We now have 300 medical students engaged in scholarly research and almost as many mentors for those students. Students in the class of 2008 have been the first authors of more than 35 abstracts presented at national meetings this year. They have also been authors or co-authors on a substantial number of peer-reviewed journal publications. Given that 2008 is the first class for which the scholarly project is a mandatory requirement, these figures are quite impressive.
We have also been very successful in recruiting faculty for the clinical curriculum, despite considerable pressures for clinical productivity in this cohort. We do not lack for inspired mentors both for the small groups and for clinical skills instruction. However, it is my hope that we will be able to recruit an even larger number of faculty during the coming year for clinical skills instruction. Because we continue to revisit the many elements of the curriculum, frequently changing these elements, we have an appropriate focus on evaluation. Curricula have a biology unto themselves, and we cannot allow them to become fossilized. Here, teachers evaluate the performance of their students, students evaluate the performance of their teachers, and both evaluate the adequacy and modernity of what is being taught. We also have innovative electives for the first and second year students which have opened new opportunities for study and exploration.
With respect to student electives, you may have read just last week in the local newspapers about one of our medical students who has begun her scholarly project at the Carnegie Museum of Natural History. She and faculty members in the Department of Radiology and curators from the museum removed the mummy of a young child from its vitrine, and have undertaken CAT scanning of the mummy in an attempt to understand why this particular mummy demonstrates an apparently enlarged skull. This is one example of the breadth of research opportunities available to our students.
We recently have begun a similar relationship with the Carnegie Museum of Art – again as a substrate for student research. For example, understanding the mood, behavior, and affect of a portrait artist and the acuity with which he or she has rendered a portrait is instructive with respect to how physicians sharpen their diagnostic acuity. Of course, there is also much to be learned from studying the evolution of a particular artist’s work, especially when that artist, in the course of his or her life, undergoes changes in cognition, affect, or behavior – e.g., Willem de Kooning, who continued to paint throughout as his Alzheimer’s disease progressed.
Why is research important to medical education and in the practice of state-of-the-art medicine? First of all, we must recognize that there continues to be a decline in the number of graduate physicians in this country who choose to embark upon substantive careers as physician-scientists. Because of our very considerable resources and the many activities in which we engage as a research-focused medical school, it is my feeling that we are obligated to graduate more of the nation’s physician-scientists. My hope is that by exposing all of our students meaningfully to research throughout medical school, we will be one of the provenances which increase the number of physician-scientists nationally. However, even if we do not achieve this goal fully, there is little question but that the independent and creative application of the scientific method fosters the emergence of independent and creative thinking in our physicians. If I were to be very ill and have a complex of symptoms and signs that did not correspond exactly to what is written in the textbooks, I would want a physician who would, to use the popular cliché, think out of the box. When a medical student gains confidence in his or her ability to think that way, by undertaking independent research, in the long run, I believe that he or she will become a better physician.
With respect to the class that will enter our school at the end of this summer, as of this date, we have more than 5,500 applicants for 145 positions. This represents a six percent increase over the previous year. Our admissions committee members have interviewed about one out of five of these applicants, and to date, offers of admission have been given to about 370 applicants for the class of 145. Fifty-five percent of applicants to whom admission has been offered are women, and nineteen percent are from underrepresented minority populations, which is the highest figure we have ever reached. Although the class has not yet completely gelled, I believe that we will settle on a mean Medical College Admission Test (MCAT) score for this class of 11.5, with a grade point average of about 3.75. These mean figures place us comfortably in the top decile of U.S. medical schools.
As I had discussed earlier, one of the great challenges that we face is the provision of scholarship monies for our students. When I arrived here in 1998, Pittsburgh was the worst of the thirteen schools with which we regularly compete with respect to scholarship support for our students. Currently, we are in the upper third of that tier, but I have had to make hard choices on spending the discretionary monies available to me in this way. However, this must continue to be a very high priority, not only to enhance our competitive position, but because we – like every other medical school – are graduating a generation of medical students with extraordinary debt. In 2006, the cost of attendance at our medical school, as is true with most private schools nationally, was about $37,000 per year, and with living expenses, about $60,000 per year. As I noted earlier, in our school there is only a modest tuition reduction for in-state students. As is also true nationally, 85 percent of our graduates were in debt in 2006, and their mean debt was almost $140,000. Interest on this debt compounds during the four years of medical school and during our graduates’ residencies and their fellowships, so we are producing a generation of young physicians in this country who will confront a debt of almost a quarter of a million dollars by the time they are ready to start an independent career. It is unlikely that a young physician with that degree of debt will think about becoming a physician-scientist, a pediatrician, an internist, or a family practice physician – the debt is just too great. Thus, this will limit our graduates’ choice of specialty and their choice of geography as well. I ask for your support as I continue to prioritize the application of our discretionary monies to the scholarship fund such that we can produce graduates who have had the same flexibility in career choice that we ourselves have had.
We are doing very well indeed with respect to where we place our graduates for residency training. Of this year’s graduates (the class of 2007), about sixty percent have been accepted to one of the nation’s top-tier residencies, with graduates going to the Peter Bent Brigham Hospital, Massachusetts General, Yale, UCSF, Johns Hopkins, Penn, Michigan, other schools in that tier, and of course our own programs at UPMC. This is quite a remarkable statistic, both historically and in a nationally competitive context.
You may have read about the presumed physician shortage in the United States. We do know that the enrollment of first year medical students per 100,000 population has progressively declined since 1980. We have moved from a ratio of about 7.3 physicians per 100,000 population to fewer than 5. This has been a cause for alarm, and there is considerable momentum nationally to build new medical schools and to expand the size of existing schools. A medical school is now planned for Scranton, Pennsylvania, and in many other states, new medical schools are being built. My own preference, however, is not to increase the size of our medical student body. Interestingly, AAMC data does not suggest a physician shortage in the Commonwealth, probably because the population is static and the birth rate is declining. Whatever allopathic gap might exist has been filled by osteopathic physicians, many of whom practice in rural parts of the state. Given that we are a research-focused institution and as a priority we wish to develop more physician-scientists, I believe that we are right-sized at the moment. In any case, we do not have the resources to make this school any larger, although this is something we can revisit as the years unfold and to ask again if we have remained right-sized.
The graduate program has been growing in the number of PhD degrees awarded by our school. All of our programs have been increasingly successful in attracting not only more students, but higher quality students, particularly the newer programs in Structural Biology/Molecular Biophysics, Computational Biology, Neuroscience, and Integrative Molecular Biology. Although these are new programs, they have gathered momentum quickly and are attracting a large number of highly qualified students.
We are also doing very well in regards to postdoctoral fellows. I am particularly pleased that we now have clarity and transparency with respect to our postdoctoral fellowship mechanisms: We no longer have seventeen different employment mechanisms for postdocs, but only two – postdoctoral fellows compensated directly and competitively by the NIH or foundation funds, and postdoctoral fellows supported by investigator-specific grants. We currently have about 550 postdoctoral fellows. We have been listed recently in a number of publications as one of the top national venues with respect to the reported satisfaction of postdoctoral fellows who have undertaken their training here.
With respect to the characteristics of our faculty, I do want to remind you that we have several pathways, both non-tenured and tenured, by which faculty members can achieve promotion. In the tenure track, one can be an investigator-educator, a clinician-investigator, or a clinician-educator primarily.
It is important that we retain flexibility with respect to criteria for tenure. It is certainly the case that when this institution was migrating from a regional institution to a top-tier national institution, with a focus on research, there was appropriate insistence on a tenure appointment depending not only on the candidate having had at least one NIH R01 grant, but in fact having had that grant renewed. However, because of the current challenges with NIH funding, which I will soon discuss, and because the school has now reached a position of great recognition and visibility with respect to its research program, I believe that we can relax a bit and be sensitive to the fact that it takes many different kinds of behavior and achievement to make a great institution. I think we would all agree that tenure is appropriate for faculty members who are magnificent clinician-educators, and that we would want this magnificence to be stable and durable. I have charged the tenure committee and the Executive Committee with conceptualizing tenure with somewhat more breadth than may have been the case historically.
Research
I want now to turn to the NIH’s appropriation. The NIH supports about 75 percent of all of our research, and it is therefore critical that we understand the dynamics and economics of this Federal agency. Between 1998 and 2003, the NIH appropriation was doubled by Congress from about $13 billion annually to about $26 billion. This does not necessarily mean that twice as much money went to grants, because much of the money was shifted into AIDS research, and in particular, AIDS clinical trial contracts. Nonetheless, even if not a doubling of grant funds, that was certainly a very significant increase in grant support in that five-year period.
Unfortunately, since 2003, the NIH appropriation has been level, or if anything, has declined somewhat in actual dollars. Importantly, it is the decrease in constant dollars that has been most alarming, i.e., the real purchasing power normalized for inflation. In this regard, we have already lost about 13 percent of the purchasing power of the NIH appropriation since 2003. This has been compounded by the fact that since the end of the doubling in 2002, there has been a doubling of the number of grant applications to the NIH.
This has been occasioned by the fact that during the dramatic doubling between 1998 and 2003, many institutions came to believe that this largess would endure forever. Thus, many institutions built new research buildings, trained many more young investigators, recruited more faculty, and thereby substantially increased the pool of grant applicants. Thus, the doubling of the pool primarily comprises individual investigators rather than an increased number of applications per investigator. In fact, mean applications per investigator have only increased from 1.2 to 1.4. Thus, we have doubled the number of investigators applying for grants, especially young investigators, while reducing the actual purchasing power of the NIH appropriation because of inflation. This has ended with a current success rate of 16 to 19 percent (after multiple resubmissions), depending upon the type of grant. For first time R01 grantees, the success rate is less than 16 percent, a grim fact. The next figure reveals even more disturbing data: The percentage of the total NIH appropriation allocated to competing research project grants has fallen very significantly from a high of more than 16 percent in 2000, to around 11 percent this year. Thus, there is less money, there are more applications, and more of the NIH appropriation is being invested in instruments other than investigator-initiated research. The latter include large contracts and other elements of the NIH appropriation that may not have the same degree of rigorous peer review that characterizes investigator-initiated research – and possibly not the same amount of creativity. It is my hope that within the next year, the NIH will shift whatever its appropriation may be more toward investigator-initiated research, where the ultimate yields to scientific insight and its translation to clinical medicine have been higher than in contract-supported research.
One of the other casualties of the NIH appropriation is, of course, the fate of young investigators:
This figure reveals the percentage of traditional NIH grants awarded to young investigators over time. In 1980, more than 20 percent of grants went to people 35 or younger, and currently, that figure is about 1 or 2 percent. This is a multi-determined reality, but in any case, the result is that of the increasing difficulty of first time proposers being funded at an early age. Most young scientists are spending many more years as postdoctoral fellows than would have been the case historically. Whatever the reasons may be, the fact is that we are missing out increasingly on a generation of young investigators whom I believe all of us would acknowledge to have a level of intellectual energy, risk-taking and what may be called naïve creativity than was the case historically. This too must be reversed if we are going to continue to thrive as a national scientific enterprise. There is one bright spot, and below is a copy of a letter signed by a number of influential congressmen.
There is a comparable letter on the Senate side, with both letters proposing to their colleagues and the leaders of the appropriation committees in the House and in the Senate that the NIH appropriation should be increased by 6.7 percent annually each year for the next three years. This would yield a total of almost a 21 percent increase and would bring us back to where we were in 2003 with respect to purchasing power. We will not be ahead of the game, but at least we will not continue to lose money because of inflation. The problem with this calculus, however, is that by law, there is a very restrictive cap on the amount of discretionary spending that Congress can appropriate and all discretionary money comes under that same cap. Unless that cap is raised by at least $7 billion, it will not be possible for Congress to allocate 6.7 percent to the NIH, and we may remain at a 2.5-3 percent increase, which again will not keep up with the inflationary rate of biomedical research, which is at least 4 percent annually. It is heartening that there is a tremendous bipartisan interest on both the Senate and the House of Representatives sides to try to be more helpful to the NIH. We are no longer hearing about how the NIH wastes money, that scientists just “play,” how there is no benefit to health from basic research, and how it takes too long to cure cancer. Much of that language has disappeared over the last few months and there seems to be growing momentum in support of both basic and clinical research. (Regrettably, after I gave this talk, in June the House Committee voted a 1.9 percent NIH increase and the Senate 2.8 percent, with a likely agreement on 2.3-2.4 percent.)
Another reason for our thriving as a research-focused medical school is that we have been successful in recruiting an extraordinary new generation of junior investigators in all of our departments in the past few years, and of course, a very large number of highly accomplished senior investigators as well. We have built wonderful educational programs to train our junior faculty in becoming successful researchers, and here there is much support in each of our departments. We also have a very strong culture and history of inter- and multi-disciplinary collaborative partnerships with other institutions; inter- and multi-disciplinarily, of course, characterize contemporary biomedical and behavioral research. If one reads any issue of the New England Journal of Medicine, one will find papers co-authored by a molecular biologist, a cell biologist, an immunologist, a surgeon, and so forth. This is being driven by the science per se and comprises a thematic or programmatic approach which has long characterized our institution. We also have an exceptional amount of institutional support, and in particular, our affiliation with UPMC has been extremely robust and extremely rewarding. We have one of the largest patient cohorts in the country with respect to inpatients and outpatients who are willing volunteers for clinical trials and for other aspects of clinical investigation. We also have one of the most sophisticated and increasingly interoperable electronic health records – of increasing value in the support of clinical investigation – and, as I mentioned earlier, our educational opportunities for advanced training in research methods are very robust. All of these advantages have allowed us to continue to grow with respect to NIH funding, which is the benchmark that our school and comparable institutions use as a quantitative and qualitative measure of research excellence.
In 2005, we were ranked 7th nationally with respect to our faculty’s receipt of NIH awards, and although the NIH has not yet released final data for FY06, it appears that we will rank 6th for this past year.
This ascendancy is very satisfying for two reasons: (1) our research is well funded, and (2) it certainly gives us great recognition and visibility, making the recruitment of both junior and senior faculty easier. Perhaps most importantly, our NIH ranking is the only objective metric that we have in a nationally-competitive, peer-reviewed context that can be used to assess us as a generality. It is very difficult to measure the quality of education or the true quality of patient care, and I choose not to measure our faculty’s satisfaction with their parking spaces! However, we can assume that our NIH ranking means that we are well positioned to attract high quality students and residents, high quality faculty, and to offer high quality patient care.
The next slide describes the compound annual growth rate in NIH awards to children’s hospitals and pediatric departments between 2000 and 2005. You will see that our Children’s Hospital leads all other such entities with respect to this measure of research growth over time.
Indeed, our Children’s Hospital’s research program has grown more in NIH support than any other institution in the country during this five year period, and with the move next year to the new Children’s Hospital campus in Lawrenceville, the space available for research focused on pediatric diseases and disorders will double, and so this rewarding trajectory will be sustained.
Medical School Finances in Relation to UPMC
The next slide describes our actual revenues and expenses for fiscal ’06 and our projected revenues and expenses for fiscal ’07.
Revenues directly deposited in medical school accounts are in excess of one-half billion dollars, and with the pass-through of dollars from the hospitals and the practice plan, total revenues are approximately $1.2 billion. At the end of FY06, we had a net income of about $76 million and will have close to $40 million in net income at the end of FY07. These “profits” are carried over and invested in increased scholarship funds, new laboratory construction, etc. (Net income was higher in fiscal ’06 than fiscal ’07 because we had carried over unexpended money in the earlier fiscal year for the completion of construction of Biomedical Science Tower 3 in ’07.) Of course, much of this net income is in restricted accounts and can only be spent for specific purposes.
The next slide describes the academic support that the School of Medicine has received from UPMC between FY01 and FY07. These are the monies which we invest in education, infrastructure, faculty recruiting, basic science departments, and so forth.
This year we will receive almost $135 million in academic support, including monies transferred directly to my office, to the clinical departments, to the institutes, and for construction. There are very few other medical schools that receive this level of funding from their associated hospital system, purely in support of academics. In fact, in the June 13, 2007 issue of the Journal of the American Medical Association (JAMA), there appears an article describing the relationship of the hospital system and the medical school at the University of Pennsylvania and the University of Pittsburgh (“Clinical Investments in Biomedical Research: Lessons from Two Academic Medical Centers”). This article was authored by Dr. Marjorie Bowman, a department chair at Penn who spent a year, often in residence here, on a sabbatical fellowship to prepare herself as a decanal candidate; Dr. Arthur Rubenstein, my homologue at Penn; and myself. The financial data at Penn are very similar to ours, and I believe that Dr. Rubenstein and I may be seen as heroic by other deans throughout the country who will offer our paper to their hospital CEO’s and inquire as to why they have not yet been successful in duplicating this largess. Of course, UPMC is thriving as an academic medical center, almost uniquely. In fact, UPMC is now one of the largest – arguably, the largest – academic medical center in the United States, which is counterintuitive because Pittsburgh is a small city; of course, UPMC comprises a vast system.
UPMC’s budget for FY07 is well in excess of $6 billion, with both a very healthy operating and investment margin (excess of revenue over expense), and with a market share of almost 50 percent in this county and 26 percent in the 29 counties served by UPMC. UPMC’s health insurance plan has also continued to grow, and although small by comparison with the “Blues,” the number of subscribers to the UPMC insurance plan is now sufficiently large as to assert real leverage in the insurance marketplace. This plan is also one of very high quality, with a particular focus on disease prevention. To summarize, a combination of circumstances, including highly intelligent, aggressive, and creative leadership, great attention to managerial detail, focus on quality, and, at least to an extent, good luck, have eventuated in UPMC’s success. In turn, the capacity of UPMC for funds transfer to the medical school has been a major element in our success as well.
UPMC also has a growing international reach:
There are now a number of satellite radiotherapy centers managed by UPMC in Ireland, and as is well known, a highly successful, state-of-the-art tertiary care hospital in Sicily managed by UPMC. We are increasingly focused on Sicily as a venue for further expansion of our research efforts, representing a partnership between our institution and the government of Italy. In Qatar, UPMC has a large contract for providing emergency medical services in that Middle Eastern country, involving our Department of Emergency Medicine and faculty members of the School of Health and Rehabilitation Sciences. UPMC and our school continue to assess other opportunities for extending our reach abroad. As I have noted earlier, the Commonwealth of Pennsylvania has a flat population and a declining number of births. Therefore it is important that we not depend solely on this state’s population for our continuing growth in either clinical revenues or the tax-based state appropriation to our school. In fact, these international ventures are allowing us to import dollars to our own institution, while at the same time exporting high quality medicine and high quality biomedical research. In a word, we are doing well while doing good.
State Appropriations
Let me speak again about our appropriation from the state for medical education:
The School of Medicine per se has received less than $9 million annually in support of the education of medical students for many years. Even when the state appropriation for the Western Psychiatric Institute, the Cancer Institute, and the McGowan Institute for Regenerative Medicine are included, it is still the case that the state appropriation has been basically flat. In fact, the only reason we receive even that much is because the Commonwealth is using Federal Medicaid dollars in support of medical education, just as Medicaid dollars are used by all academic medical centers in support of graduate medical education. Still, as I described earlier, Pennsylvania is the second lowest of all of the states with respect to the state appropriation for medical education. Even though our University is state-related, we do not receive very much more than Penn’s medical school, and Penn is a fully private University.
Alternative Sources of Research Funding
Back to the title of today’s talk and the “fork in the road” – here is one such fork: The next slide demonstrates that industry and other private sources are an increasing source of funding for academic medical centers and medical schools.
The increase in private funding of medical schools as a percent of those schools’ total support has been quite dramatic since the 1980s, just as Federal funding as a percent of the total has decreased. These data demand that we pay close attention to alternative sources of funding, other than the NIH. The next slide describes the emergence of private foundations primarily focused on biomedical research, and research related to healthcare, over time.
In 2004, there were more than 174 national foundations focused on health-related research, with aggregate assets of more than $18 billion. The number of such foundations and their funds are probably 25 to 30 percent larger currently. We need to be imaginative, nimble and aggressive with respect to seeking such funding given that private sources are “stepping up to the plate.” Indeed, there has been a dramatic surge in philanthropy of all sorts in the United States, and for all purposes, in the past few years, much of this surge occasioned by the growing number of .com and hedge fund billionaires. The aggregate amount of money donated by individuals, foundations and by industry to support all purposes is about $260 billion annually, of which about five percent is focused on biomedical research. We must work closely with these philanthropic sources to increase that fraction, and of course, to focus whatever that fraction might be on us!
New Buildings, New Departments, and New Faculty
Biomedical Science Tower 3 is now fully occupied, and it has proven to be a wonderful venue and provenance for biomedical research. The top floors house our new Drug Discovery Institute and our new Center for Vaccine Research. The Drug Discovery Institute, jointly directed by our Department of Pharmacology, the University’s Department of Chemistry, and the School of Pharmacy, is one of the most sophisticated academic facilities in the country with state-of-the-art high throughput drug synthesis and cell-based screening of drug activity. The Center for Vaccine Research will not be fully productive until late this year because the biocontainment laboratory, necessary for full productivity, is still under construction. This is a BSL-3 level facility which will occupy a full floor of the building, allowing for primate vaccine trials. Infectious diseases of particular early interest in the Center for Vaccine Research are dengue, malaria, drug-resistant tuberculosis, and influenza. We are in the midst of recruiting an outstanding cohort of investigators focused on vaccine research and development. The lower floors of BST3 contain one of the country’s only two Departments of Structural Biology located in a School of Medicine (the other being Stanford). In addition to this new Department, another still young department is that of Computational Biology, and these two departments work “cheek by jowl” to predict and then to experimentally test structural models of proteins and nucleic acids. Much of the middle section of BST3 is focused on neuroscience research and developmental biology – the latter including 11,000 zebra fish tanks, probably the largest or certainly one of the largest such facilities worldwide. Given the growing interest in zebra fish as a facile vertebrate model for studies on development, disease, and drug screening, the establishment of this facility gives us a great advantage in many areas of research. BST3 can be seen, on somewhat facile terms, as a “percolator” – the notion that the data being obtained on the lower floors with respect to protein structure is “wafting up through the air shafts” and informing drug discovery and vaccine development on the top floors.
Here I would note that there has been a dramatic shift in focus in the past few years with respect to protein research and the human proteome map, from simply identifying and cataloging sequence, to defining the real structures of real proteins in given cellular contexts, and especially, the actual dynamics of these structures. Not only must we consider their folding and unfolding, but the harmonic motions associated with proteins and the correlation of this very active and dynamic sense of structure with how these proteins may actually function within the cell, the nature of their interactions, their interactions with drugs and other small molecules, and how this information informs our understanding of the roots of a given disease and as a platform for identifying targets for drug discovery.
At the same time, our computational biologists are employing extremely sophisticated computational methods to examine in great detail the interactions of network pathway elements, especially with respect to cell signaling pathways. In fact, the cell will be the major research challenge of this century just as documenting the structure and function of DNA was the challenge of the past century. It is likely that hundreds of signaling pathways exist in each of our cells, with each such pathway informed by the products of perhaps twenty or thirty genes – all interacting at an instant in time in a given cell at a given developmental stage. Clearly, we will not run out of grant opportunities in this area any time soon!
In my 2006 State of the School talk, I described several of the major senior faculty members whom we had recruited recently, but now I want to describe to you a few of the young, tenure track assistant professors whom we have recruited very recently also. In fact, these few are simply examples and I could have chosen many more junior faculty members in this cohort. Ivan Maly has joined us recently as an Assistant Professor of Computational Biology. Ivan trained at Northwestern and MIT, and his particular research interest is on the development of quantitative models that explain cellular morphogenesis from the systems standpoint. Ivan’s work includes an integration of molecular motor-driven transport phenomena, cytoskeleton dynamics, cell signaling, and so forth – in particular, using T-lymphocytes as a model system. Thus Ivan is not only an excellent computational biologist but also a well-trained experimentalist who builds models and then vets them at the laboratory bench.
Elodie Ghedin has also joined us recently from The Institute for Genomic Research (“TIGR”). Earlier, Elodie had been with the Genome Institute at the NIH, with an adjunct faculty appointment at George Washington University. Elodie’s PhD is in molecular parasitology. She was the first author on a recent landmark paper in Nature in which she and her colleagues presented the genomic sequences of many human influenza strains obtained worldwide. Technically, this work, which Elodie continues here, is extremely sophisticated and cutting edge, and it is allowing us to understand the molecular and evolutionary basis for the emergence of new influenza strains such as the H5N1 strain of avian influenza.
Laura Niedernhofer is a tenure track Assistant Professor of Pharmacology. She received her MD and PhD degrees at Vanderbilt and undertook her postdoctoral training in one of the world’s leading laboratories focused on the recognition of DNA damage and its repair (Erasmus University, in the Netherlands). Laura is studying the impact of mis-repaired DNA damage both on aging and on oncogenesis. She authored a landmark paper in Nature this past year and she is increasingly recognized as one of the country’s most prominent young investigators working in a research area that is at the very heart of cancer etiology – not to mention aging, developmental anomalies, and heritable diseases.
Gonzalo Torres has been recently recruited as a tenure track Assistant Professor in our Department of Neurobiology. Gonzalo undertook his early training in South America, received his PhD at Saint Louis University, and carried out his postdoctoral training in a Howard Hughes lab at Duke. Gonzalo’s particular research focus is on monoamine transporters and how psychostimulants compromise the normal function of these transporters. Gonzalo also has been widely recognized for his achievements in what is still a very early career.
Still youthful – especially with respect to intellectual energy – but more senior is Dr. Angela Gronenborn. Here I want to note that last week Angela was elected to the U.S. National Academy of Sciences. Short of a Nobel Prize, there is no more important honor for an American scientist than to be elected to the Academy. Angela is our second faculty member (and Department Chair) to be elected since her arrival in Pittsburgh, Susan Amara being the first.
(Here I asked Angela to stand for a moment so that she could be recognized by our audience.) Knowing of Angela’s modesty, I hope that she will not be embarrassed by the applause; I had in mind the President, when during his annual State of the Union Address he (or perhaps someday, she) identifies a person in the balcony who has recently performed a heroic deed.
With respect to other recently recruited senior members of our faculty, here I want to note Dr. Fadi Lakkis, Thomas Starzl’s successor as Scientific Director of the Transplant Institute. UPMC remains the world’s leading center for organ transplantation, having undertaken almost half of all of the organ transplants that have been carried out worldwide to date. However, the fact of the matter is that transplantation is not yet a perfect art, and graft survival (all organs considered) remains at around 50 percent at ten years following transplantation. This figure is considerably increased in renal transplantation, but there is a cost to this survival because a lifetime of chemical immunosuppression following transplantation means that our patients are very susceptible to opportunistic infections and to the emergence of cancer. Dr. Lakkis is particularly focused on gaining further insight into both innate and adaptive immunity so as to provide a rational basis for suppressing the body’s response to an allogeneic organ without suppressing the activity of the patient’s own immune system. Dr. Lakkis is aided in his mission by Dr. Amadeo Marcos, the Transplant Institute’s Clinical Director, and of course, by the continuing wisdom and experience of Dr. Starzl (who last year received the National Medal of Science from President Bush). Dr. Lakkis’ particular research interest is on innate immunity, our most primitive immune system, which had its origin at least 800 million years ago in creatures such as the sponge, but which appears functionally to not be much different now than it was then.
We have an increasing interest in nanoscience and the use of nanoplatforms, both as molecular motors and as molecular sensors. For example, one can imagine inserting such a sensor in a cell and by dint of its ability to detect cellular glucose, to instruct a nano-sized insulin pump. One might also be able to manipulate the multi-drug resistance mechanism that characterizes a tumor cell’s resistance to chemotherapy at the nanoscale level. Dr. Joanne Yeh, another recent recruit to our school and a member of the faculty of the Department of Structural Biology, is an X-ray crystallographer, but she also has an interest in nanoscience as part of the rapidly growing University consortium focused on this very important new area in biomedical science. Here I would note that the University’s Department of Physics is also increasingly interested in this area, and we have recently co-recruited a young faculty member, now completing his postdoctoral training at the Rockefeller University, who will undertake his research both in the Department of Physics and in the medical school.
Finally, with respect to our school’s future research planning, it is my belief that in the next decade we will be able to detect the expression of individual genes, in vivo, using magnetic resonance imaging on a molecular scale. Recent results at both Cal Tech and Carnegie Mellon suggest this possibility in rodents. I do think we are positioned to continue our migration from biochemical visualization of a gene product; to cellular visualization of gene expression using fluorescent dyes; and now to utilize a ferritin-encoding gene linked to a gene promoter of interest, that would capture iron and thereby become detectable to magnetic resonance when that promoter is up-regulated. An example of the applicability of such molecular imaging again relates to cancer chemotherapy. Currently, to determine whether a tumor is or is not responsive to a given chemotherapeutic agent, we must often observe the tumor for weeks or months before we can conclude sensitivity or resistance to treatment. However, if we knew of a particular gene or set of genes that would be expressed or not expressed depending upon the sensitivity or resistance of a cell to chemotherapy, we might be able to visualize this circumstance very quickly and spare the patient unnecessary toxicity as well as not losing time before another drug was employed. Our Department of Radiology is extremely interested in this new strategy, and it is my hope that at next year’s talk I will be able to describe plans and investigators in this area in more concrete terms.
Translating Advances in Basic Research to Health Care
We have learned more about human biology, and biology in general, in the past few decades than we have known heretofore in the entire history of science, and the pace of discovery is awesome. However, the translation of these advances to evidence-based medicine, and to the public health in general, is feeble. Several years ago, Claude L’Enfant, then the Director of the NHLBI, NIH, in delivering the Shattuck Lecture at Harvard Medical School, gave an “A” to American basic biomedical research, a “C” to its translation to evidence-based medicine, and an “F” to health care in our country. In 2003, a study from the RAND Corporation, published in the New England Journal of Medicine, revealed that at best 50 percent of patients in the United States with common chronic illnesses were being treated by established guidelines.
Moreover, approximately 47 million people in this country have no health insurance, and the majority of this population are employed but in small businesses that do not provide health insurance, or they are self-employed with no health insurance. Most of the truly indigent are eligible, at the least, for Medicaid. Medical care in this country is extraordinary and certainly at the cutting edge for patients who are well-insured, knowledgeable, and with ready access to major academic medical centers. The faculty, staff, and students of this University are privileged, indeed, to have access to top-tier medical care at our own Institution. But the majority of our country’s population, citizen and non-citizen alike, have no such access. In fact, even when patients are well-insured, the probability is that they are not being treated in cost effective ways, nor in ways consistent with the science of medicine. Nonetheless, on a per capita basis, this country spends almost twice as much for health care as any other developed country, but with no better outcomes and no longer lives. Indeed, two important metrics of the public health, the neonatal mortality rate and average life span, rank poorly in this country compared to most other, if not all, developed countries.
Many major academic medical centers are not as effective as they might be in providing evidence-based medical care to most patients. The very organization of academic medical centers and the fact that most have a high degree of fragmentation and clinical “siloism,” as well as a shortage of physician-scientists who are trained to translate basic science advances to bedside medicine, means that health care, even in leading centers, is neither as efficient nor as cost effective as should be the case.
The NIH, aware of these impediments as well as various regulatory roadblocks, and a limited interface with the communities that surround such centers, led this agency to develop a new funding mechanism, the “Clinical and Translational Science Award” (CTSA). You are probably all aware that ours was one of the first twelve institutions nationally to win one of these coveted awards, and ours was for almost $85 million – the largest single grant that this University has ever received. The goals of these awards are to develop organizational models and structures that will be more effective in implementing laboratory advances, to identify new strategies to bring these advances to bedside medicine with more rapidity, to lower the barriers that have been provoked by the fact of many discrete disciplines and departments in academic medical centers, and in general, to identify creative mechanisms to address complex clinical problems. A more transcendent goal is for awardees to be “transformative” – catalyzing change, breaking down barriers, and addressing the need for regulation with greater rationale and wisdom.
HIPAA (the “privacy act”) is a good example of regulation gone awry. While it is critical that we protect personal health information such that a patient is not treated prejudicially with respect to employment, insurance, et al., the bureaucracy now created to ensure this privacy has eventuated in substantially reduced recruitment to clinical trials, a slowing of the pace of translational research, and an increased cost in time and money to institutions implementing HIPAA. HIPAA requires formal, written consent of patients for researchers to utilize protected health information. As one might imagine, this certainly puts a crimp in research based on retrospective chart reviews, where patients may be lost to follow-up or dead, to outcomes research, to research based on tissue repositories, and to generational research, where we might in fact have the DNA of a grandparent, but a grandparent long since dead. My view is that the pendulum has swung too far in the direction of gratuitous and excessive regulation and that we must achieve a greater equipoise if we are to be helpful rather than harmful to patients. The problem is compounded by the fact that nationally, only four percent of all of the patients eligible for any given clinical trial enroll in such a trial. Much of our own CTSA-based effort will be focused in this direction. Further, it is apparent that health informatics will play a critical role in addressing many of our health care problems. No patient’s health should have to depend on written medical records locked in a file, nor should electronic medical records fail to be interoperable. I am hoping my State of the School talk next year will inform you about the rapid progress we will have made, using faculty, creativity, and UPMC resources, to address Claude L’Enfant’s “F” for health care in ways that will allow us to be a model for the rest of the nation.
Partners
We have many partners in innovation.
UPMC, of course, is our most important partner, and indeed, we are joined at the hip. We have one of the few geographies nationally where not only the medical school nor all of the schools of the health sciences, but the medical center, the entire university, and a complementary institution, Carnegie Mellon University, all share essentially one campus – not to mention the Carnegie Museums, which we increasingly view as great resources for illuminating the human condition. There are very few places worldwide that have this kind of intellectually critical mass in one venue. Another important partner is the Pittsburgh Life Sciences Greenhouse, the mission of which is to translate our faculty discoveries and inventions to start-up companies in this region. The next slide illustrates the Intel Research Laboratory, which occupies the top floors of this building which is located on Forbes Avenue between the two University campuses.
This has proven to be a great asset for us. Some years ago Intel decided to build what were called “Intel University Labs,” using the Bell Telephone labs of an earlier time as a model. The Bell Telephone labs were private laboratories funded by the Company; seven Nobel Laureates worked at the Bell Telephone labs, which sadly no longer exist. With this model in mind, Intel established their first lab in Seattle, their second in Berkeley, and their third in Cambridge, England – all obvious powerhouses in computational science. Recently, Intel established its fourth university lab in Pittsburgh, moving many of their top scientists here, and with an “open source” plan for intellectual property, welcoming collaboration with Pitt and Carnegie Mellon investigators. One of the first collaborative projects undertaken is called “Diamond,” which is a collaborative effort involving a number of our faculty, as well as CMU and Intel investigators. Diamond software creates a digitized database of images such that any new image can be compared with the database. For example, we know that the diagnostic accuracy of mammograms has some margin of error with respect to the radiologist’s conclusion as to whether a mammogram is normal or demonstrates a pre-malignant or malignant lesion. In the Diamond Project, a database has been created of thousands of mammograms, annotated with the clinical outcome associated with that image.
Thus, any new mammogram imposed upon this database will match images with known outcomes, thereby improving diagnostic accuracy. This strategy can be applied to any digitized image base, including skin lesions, liver biopsies, and the like.
Another important partner is the RAND Corporation.
Their building is located at Fifth Avenue and Craig Street proximate to the University’s campus. RAND is the country’s leading “think tank,” and the Pittsburgh facility houses a new health policy institute which is a partnership with our medical school faculty. Dr. Wishwa Kapoor is the Pitt side Co-director of the RAND-Pitt Health Policy Institute. More than 30 researchers are housed in this building, and they are focused primarily on health policy related to drug and alcohol abuse; health care organization models; health disparities; maternal, child, and adolescent health; health care quality; new research methods in clinical investigation, and so forth. Our partnership with RAND has been another great asset.
Benchmarks of Success
We can measure our success in many objective ways, including our ranking with respect to awards from the NIH and our specific success in obtaining NIH grants focused on high-risk research, multi- and inter-disciplinary research, and clinical/translational research. Other metrics include the quality of students and faculty that we are currently recruiting, the quality and quantity of our research space, and how well we are doing with respect to our capacity to relieve student debt. The innovation and novelty of our medical school curriculum is still another benchmark, as is the quality of the residencies that our medical school graduates obtain. With respect to our success in translating basic laboratory advances to evidence-based medicine and ultimately to healthcare, much of this migration is beyond our control, and the “ACF” paradigm that I earlier described is far more a national than a local issue. Nonetheless, in Pittsburgh we are rich and robust in resources and people that can begin to address the translation to safe and effective medicine and to high quality healthcare for all of our population, using strategies and mechanisms that are more challenging elsewhere. Thus, it is my view that for example, having won a Clinical and Translational Science Award, and with a very large patient population and an interoperable Electronic Medical Record, we can accomplish advances here that will serve as a model for the nation. The amount of “protected time” for our clinical faculty remains a major issue, especially in an era when faculty with clinical responsibilities must care for more patients, and generate more revenue by so doing, as reimbursement for that care decreases. We are still oscillating around that mean, and I do not believe that we have yet achieved a resting position. After all, physicians who choose to work within an academic medical center do so because they have academic aspirations and must be encouraged to live out those aspirations, even if there are some financial consequences both for the individual and for the medical center.
We also need to be more effective with respect to philanthropy. Pittsburgh does not have a strong tradition of individual philanthropy. Nationally, about 80 percent of all philanthropic gifts come from individuals, and not from foundations, societies, and corporations. Here, however, 80 percent of our gifts come from the latter organizations and not from individuals. I believe that there are two disincentives to individual giving in our community: Because the foundations have had such a long and robust history of philanthropy here in the wake of the Industrial Revolution, individuals do not appear to have felt obligated to donate qua individuals. Moreover, the great success of UPMC and its “profitability” may also be a disincentive, at least for some individuals, since they do not distinguish between UPMC and the medical school and believe that we have all of the monies that we need. In some sense, there is truth to this notion since we would need a totally unrestricted endowment in excess of $3 billion to yield the yearly discretionary income that we already obtain, through the Affiliation Agreement, from UPMC. However, when it comes to support for research and education, “too much is never enough.” Thus, all of us, given the opportunity, need to ensure that this community understands the difference between the medical school and UPMC. And further, the community must understand that the “profits” of UPMC are monies that must be continually reinvested, for example in long term capital projects such as replacing the older Oakland hospitals, if we are to sustain our momentum and further grow our excellence.
Still another benchmark of success is our ability to collaborate across departments of the medical school, the other health science schools, the University as a whole, Carnegie Mellon University, and the other partners that I have described. Contemporary biomedical research is multi-disciplinary and inter-disciplinary to a very large extent, driven by the science itself. We can measure our success in this regard by the funds we receive in support of program project grants and other trans-disciplinary efforts. Finally, our success as entrepreneurs is another important benchmark. If we fail to get our discoveries and inventions to the marketplace, they will not be accessible to the public, nor will we have a source of funding through license and royalty streams as one alternative to NIH funding.
Threats to Our Success
At the federal level, the decreasing NIH appropriation is our greatest threat, given that the NIH supports between 70 and 80 percent of our research expense. For fiscal year 2008, the news continues to be poor. As I noted earlier, the likelihood is that the House-Senate Budget Conference will yield a final 2.3 percent for the NIH for FY08, just when the inflationary increase in biomedical research continues to average around four percent. Thus, we will be further behind. Although decreasing UPMC revenues could be another threat, this seems unlikely given that UPMC is increasingly buffered because of its multiple sources of revenue beyond clinical compensation, including investment income, the health insurance plan, international ventures, and strategic business initiatives. Student debt is a threat to our legacy because of the constraining effect it will have on the career and geographic choices made by our graduates. Unfunded regulatory mandates are also a threat to our success, and we now pay approximately $16 million each year in support of the staffing and other administrative and overhead costs required to ensure that we are compliant with all of the requirements of human and animal subject research, radiation safety, biohazard protection, grant and contract audits, etc. The political process can also present a threat. For example, Pennsylvania is one of a few states wherein the derivation of embryonic stem cells is illegal so that even if we had non-Federal funds with which to support this derivation, we would not be able to engage in such research. Of course, Pennsylvania is also one of a few of the large states not investing state money in embryonic stem cell research. To the extent that embryonic stem cell research may eventually be funded more flexibly and to a larger extent by the Federal government and already is being funded privately in such states as Massachusetts and California, this is a threat to our overall research momentum.
With respect to local “threats,” we are out of research space and our medical school building is aging. However, there are bright spots: We have a magnificent new Biomedical Science Tower 3; the new Magee research wing has now opened – allowing a doubling of our space for research on reproductive and developmental biology; and the new Children’s research tower on the Lawrenceville campus will have more than twice its current research space. The state appropriation to the medical school does, however, continue to be a threat, given its meagerness. I have already discussed the threat to “protected time” for our clinical faculty, and the fact that our philanthropic coffers must improve. Again, it is important to recognize that no matter how well-funded we are by the NIH or any other external source, it is still the case that about one-quarter of the cost of our research program must be paid with institutional funds, and this must come from a combination of UPMC funds transfer, philanthropic dollars, tuition, the state appropriation, and endowment interest.
We are “seizing the day,” while most other institutions are hunkered down in view of the NIH situation. We, however, are continuing to recruit faculty and to construct more buildings as discussed above. We are taking some risk in this investment, but if we fail to take that risk, we will ultimately lose our momentum.
Other Issues
We have developed a coherent and effective mechanism for “Bridge Funding.” I do not want any laboratory that has had a long and successful record of NIH funding to have to lay off research staff or even to close because of the current NIH situation. Neither do I want to truncate nor abort the careers of our young investigators; they must be supported to obtain the research results needed to later position themselves for external funding. Any laboratory here that has had a strong record of prior support and that currently has reasonable scores on proposed grants is eligible for bridge funding. We have established an internal “study section” that will allocate funds using such criteria as the current “pink sheet” reviews, the response to these reviews by the investigator, and our best guess as to the likelihood of ultimate funding of a given grant. The actual funds will derive from the departments, but if the departments do not have sufficient monies to provide the bridge funding approved by our internal committee, then my office will provide those monies. Given that the Bridge Funding criteria are met, we will make every attempt to provide funds for the 18 to 24 months that might be required before a given grant is ultimately funded by the NIH.
With regard to leadership positions, I want to note that I have recently appointed Dr. Amin Kassam to succeed Dr. Lunsford as the Chair of the Department of Neurological Surgery, and that we continue to search for a successor to Dr. Glorioso as Chair of the Department of Molecular Genetics and Biochemistry.
With regard to stem cell research, it is certainly the case that we can undertake research with such cells, provided that they are derived elsewhere and that we do not violate Federal law if we are using Federal money in support of such research. (This of course means that we cannot study human embryonic stem cell lines not currently approved by the Federal government in any laboratory building that has Federal support or tax relief – which includes all of our current laboratory buildings.) I do want to note here that as scientists, we must be very cautious in discussing the therapeutic implications of human embryonic stem cells. There is no question but that they are, and will increasingly be, invaluable for understanding the roots of disease, but we do not yet know whether they will be useful for durably treating, safely and effectively, any human disease or disorder. Studies on “whole genome associations” comprise another major area of investigation going forth, and the technologies now available to us, especially in our Genomics and Proteomics Core Facility, will increasingly allow us to correlate the phenotypes of human disease and disorder with the polymorphic genome anomalies that underlie these diseases and disorders. It seems quite clear that the common chronic diseases of humans – asthma, chronic obstructive pulmonary disease, many forms of cancer, adult diabetes, many forms of cardiovascular disease – all the ills that emerge fairly late in life, past reproductive age – are not caused by single gene mutations but rather by suites of single nucleotide polymorphisms. With the completion of the “Hap-Map,” we can now distinguish genomic patterns associated with the discrete ancestry of the world’s major populations from patterns associated with disease. Until quite recently, this has only been possible in Iceland, where Decode, Inc. has been able to correlate the health history, going back many generations for every citizen of that country, with the DNA obtained from every one of those citizens. The NIH is investing an increasing amount of money in research on whole genome associations. I, myself, have now been appointed to the National Advisory Council for the NIH entity where this money will be focused, and I am hopeful that this appointment will be useful to our institution as a whole – at the least, with respect to the general knowledge and scientific insight that I will gain as a member of this Council. The NIH also has growing interest in the “micro-biome,” which represents an attempt to define the genomes of the countless micro-organisms which populate the earth to a far greater extent than the population of higher organisms. It is quite clear, in our experience of just the past several years – first with HIV, then with SARS, and now with avian influenza – that there will always emerge a micro-organism that will threaten our health if we fail to understand the evolutionary behavior as well as the physiology and biology of micro-organisms.
Another broad area for research investment here, as elsewhere, is the study of gene-environment interaction. It is a given that we are a combination of nature and nurture, but we know very little about evanescent environmental exposures. We know a great deal about people exposed to asbestos who develop mesothelioma and a great deal about workers exposed to benzene who develop acute myelocytic leukemia. However, without footprints detectable by currently available technology, we cannot predict that a fetus or an infant with an evanescent exposure to a toxin or a virus will develop coronary artery disease 60 years later. Finally, I do observe again that while DNA was the focus of the scientific community in the past century, in this century it will be the cell and all of the known and unknown concomitants of cell biology, including the micro- and macro-environment in which the cell finds itself.
Relationships with Industry
Much has been written in the press, especially in the past year, with respect to the relations between physicians and the pharmaceutical and device industries. In particular, the New York Times has had many articles on the “free lunches” brought to physicians’ offices by pharmaceutical companies, and by the payments made to physicians for consulting, speaking, ghost writing journal articles, and in other ways lending themselves to the perception that they are being bribed to promote one product over others, even if this increases the cost of healthcare, or worse, compromises safe and effective healthcare. The issue has gained the attention of Congress and cannot be dismissed. (A study will soon be published from Baylor wherein fMRI studies reveal dramatic effects on brain activity when the person being studied is offered even a trivial gift as opposed to a sanction.) At my direction, Drs. Barbara Barnes and Randy Juhl, working with a faculty committee, have spent many months drafting a new policy on faculty and staff relations with industry that would apply across the board at all UPMC and health science school entities. Today’s New York Times contains an article about oncologists who are inappropriately prescribing marrow growth factors as a consequence of direct or indirect industry support. Unless ended, the reality of our relationships with industry, let alone the perception, will most certainly erode public and congressional support for our mission. Finally, I note that a number of top tier schools, including Penn, Stanford, Yale, and Michigan, already have a policy in place similar to the one we propose, and it is our goal to have our policy in place by September of this year. I want to note also that because our policy covers all of UPMC, it would, in fact, be more far-reaching than the policy of any other institution so far described.
Central Tensions in Medicine
I want to conclude my talk today with a slide presented by others at a recent meeting of the “Clinical Research Forum” in Washington. The slide speaks for itself, and I have already discussed most of the tensions summarized here.
I do want to comment especially on the tension between prevention and treatment. Most reimbursement for medical care relates to treatment, and usually invasive treatment, with very little for prevention. In Pittsburgh, we should reflect on the example of the Salk vaccine versus the iron lung, and the fact that the vaccine has been infinitely more effective and cheaper in preventing polio than had been the case with treatment once the disease had occurred. We must realign the incentives for preventing disease versus treating it.
We must become increasingly mindful of private support for research and wean ourselves from utter dependence on the NIH. I believe that the NIH’s situation will endure for a number of years given the cost to the Federal government for military operations, for anti-terrorism, and for the unfunded Medicare and Social Security liabilities. With these expenses, and what many would consider a retrogressive tax rationale, it will be very difficult for Congress and the administration to fund the NIH such that it will truly match the extraordinary opportunities that we now have in biomedical research. All of these central tensions reflect the “fork in the road” that has served as the title of today’s talk. As I have said earlier, we are in a unique position in Pittsburgh to address these tensions because of the success both of the medical school and of UPMC as measured by any set of benchmarks, as well as the unequivocal support and autonomy offered to us by the University. Thus, I will conclude by focusing on opportunity rather than threat, and I urge all of you to join me in welcoming that opportunity and “taking the fork in the road” – even if there’s risk in so doing!