By Elaine Weiss
For 25 years at a handful of medical schools, the Robert Wood Johnson Clinical Scholars Program has been teaching young physicians how to shake up the status quo in our nation's health care system.
t’s noontime and the Robert Wood Johnson Clinical Scholars are sitting around a conference room table, munching tuna fish sandwiches and glimpsing their future. The view, even from this windowless Carnegie Building room, is remarkable.
They are listening to Woodrow Myers, director of health care management for the Ford Motor Company, describe the twists and hairpin turns of his career path since he himself was a Robert Wood Johnson as Health Commissioner of Indiana (when a boy named Ryan White was denied entry to school because he had AIDS) and his stint as New York City’s Clinical Scholar 20 years ago. He is regaling them with stories about his days as Health Commissioner of Indiana (when a boy named Ryan White was denied entry to school because he had AIDS) and his stint as New York City's Commissioner of Health, where he found himself in an explosive political minefield. There’s always politics and money involved in public health policy work, he tells these young physicians hanging on his every word. Get used to it.
It’s the weekly guest-speaker lunch seminar for the RWJ scholars, where medical movers and shakers and health care policy honchos break bread with the elite cadre of doctors chosen for this national fellowship program. And as often happens at these guest talks, what the scholars are hearing both opens their eyes and agitates their minds.
"It’s exciting to see people pushing the envelope," says Victoria Holloway, who finished the program last June. "It makes you see what’s possible."
Myers’ avuncular monologue moves from the beautiful data bases for epidemiological research, to the importance of his business school training, to the key role media relations plays in public health advocacy—the value of a good sound bite in getting a message across. And he gives them a taste of what healthcare work in the private sector is like as he describes his current job.
The group around the table listens intently, laughs, gasps and asks a lot of questions. Myers is offering them another scenario for combining medical skills, research training, and a passion for improving the nation’s health care system. Every one of them in his or her own way is eager to shake up the status quo.
The mission of the Clinical Scholars Program is neither modest nor faint-hearted: It aims to cultivate the next generation of leaders in American health care—creative thinkers committed to making a difference—and equip them with the research and analytic skills to design and implement new approaches. "We take physicians at the beginning of their careers," explains Neil Powe, who co-directs the program at Hopkins, "and show them there are countless ways they can make a difference in medicine and health care. At the same time, we give them a wider view of leadership positions that reaches beyond academia to government and industry."
Powe, who holds an M.D. and M.P.H. from Harvard and an M.B.A. from The Wharton School, was himself an RWJ Clinical Scholar at Penn in the mid ’80s. The fellowship, he says, affected his career in a big way by giving him a couple of years to develop his knowledge around issues he felt strongly about. In his case that led him directly into outcomes research, a new field that determines the effectiveness of standard medical practices. Powe now directs Hopkins’ Welch Center for Prevention, Epidemiology and Clinical Research.
Why would a physician do this?" asks Leon Gordis, the distinguished faculty member (he’s a professor of pediatrics and epidemiology in the Schools of Medicine and Public Health), who directs Hopkins’ RWJ Clinical Scholars program, one of seven in the nation. Why would men and women who have finished their medical residencies take two years out of their budding careers to study principles of epidemiology, statistical methods and outcomes research design? Why would they interrupt or defer their practices to take course work in the social sciences, health care policy and ethics?
It’s not a sudden Eureka thing, according to Gordis. "These are people who usually have had a long-standing interest in health care policy. They’re concerned about things like accessibility to care, the plight of the uninsured and inequalities in the quality of care available to different populations. Other young doctors recognize these inadequacies, of course, but mostly they just go on, practice medicine, and curse the system. These people really want to confront what’s wrong with the health system," Gordis says, with obvious pride. "They’ve said, ‘I want to look at the system and see how I can fix it.’ And they realize that if they just do clinical medicine, they’re unlikely to make any kind of a broad impact."
But the link between wanting to change the system and knowing how to approach the system isn’t always clear. "You have to decide if you want to be a policy mover and shaker yourself, using the research of others and critiquing it, or if you want to be the researcher," Gordis points out. "And you can’t know which one is for you until you’ve learned how to do research."
And so, these young M.D.s, just at the beginning of their clinical careers are learning to assess the efficacy of current practices and to propose alternatives for those that don’t seem to be working. From the moment they arrive in the program, they are plunged into seminars and classes designed to equip them with the body of knowledge they’ll need to participate in national health care debates and make key policy decisions.
The original national Clinical Scholars Program was spearheaded by the Commonwealth Fund and the Carnegie Foundation 30 years ago and taken over by the Robert Wood Johnson Foundation in the mid-1970s. Ten years ago, Robert Wood Johnson decided the program needed an infusion of new ideas and held a national competition for medical schools to submit proposals to become program sites. Three new schools—Michigan, University of Chicago and Hopkins—were selected to join Yale, UCLA, UNC at Chapel Hill, and the University of Washington at Seattle.
Today, each RWJ program designs a curriculum with a research emphasis, typically two priority areas, that reflects the strengths and interests of its faculty.
Hopkins, for example, concentrates on the organization and financing of health care and the evaluation of health care practices and interventions (outcomes research), while the University of Michigan emphasizes social and cultural relations in medicine and equitable access to quality health care. The University of Chicago concentrates on demographics, economics and sociology, and UCLA focuses on health care for America’s at-risk populations and a changing social and economic environment.
Applicants for the fellowship program can apply to one or several sites, ranking their choices. The programs all have their own flavor and style, "but I tell applicants—don’t get blinded by the different priority areas," Gordis says. "The resources and the range of research opportunities at each school are actually much broader than those listed."
After interviewing candidates, each program ranks its preferences. These are reviewed by the program’s national advisory committee, which does its own ranking based on applicants’ interests, strengths and personal considerations and decides who would fit best where. "It’s like the annual match for residencies, but done by a committee and not computers," Gordis says.
Every year about 30 new physicians are selected to become clinical scholars at one of the program’s seven sites. And each July a few of them begin their two-year clinical scholar training at Hopkins. Funding from the RWJ Foundation, managed through the dean’s office here, helps support a core faculty of 11 and provides for administrative support and fellowship stipends. A closeness develops among the small group of scholars. "You meet people who have the most fascinating ideas," Kelly Gebo said of Holloway and Amal Murarka, the two others in the cohort who finished the program last June. "We come from very different places and different economic backgrounds."
The RWJ program is rigorous. For two years, clinical scholars find themselves enmeshed in a world of seminar discussions dealing with the economic and political structures of American health care at the same time they attend classes to learn the complex quantitative and analytic methods that go into designing a good study. They learn to recognize the strengths, limitations, and biases of different design models, and they discover how to collect data so it’s valid and reliable. Then, using the newest and most rigorous methods in qualitative research, they become facile with instruments that measure such things as quality of life and of care and learn to use biostatistics and quantitative methods to analyze information with state-of-the-art computer programs. Finally, they master the methodology necessary to carry out discriminating clinical outcomes assessments that analyze large data bases. And all this they do within the first nine months of the fellowship, because now they must apply everything they’ve learned to a research project that addresses an important health policy issue.
Research studies by RWJ clinical scholars tackle thorny topics so they have a solid track record of publication in the most prestigious and influential journals. At times, they even thrust the young physician into the thick of a national health care debate.
No one knows this better than Cary Gross. In June 1999, just as Gross was finishing the Clinical Scholars Program at Hopkins, he got a phone call from Harold Varmus, then director of the National Institutes of Health. Varmus was about to go before a U.S. Senate appropriations subcommittee and wanted to use Gross’s fellowship study in his testimony. The study analyzed the relation between NIH research funding for specific diseases and the onus those diseases place on American society. It wasn’t yet published in the New England Journal of Medicine, but Varmus was already well acquainted with the findings—he’d written the editorial that would accompany the article in the June 17, 1999 issue.
Carried out with Public Health associate professor Gerard Anderson and Powe, Gross’s project tackled the sensitive issue of whether the allocation of NIH research funds toward specific diseases bore any correlation to the "burden" that disease places on the American population. (Critics often contend that NIH funding priorities are tainted by political and media pressures.) The analysis of 29 separate diseases revealed that funding levels did correlate with certain kinds of "burden-of-disease" measurements, but not others. So, Gross decided to use a new, broader form of measurement to answer the question, a method that took into account the years of healthy life a person lost because of the disability and the incidence of death caused by the disease.
In the year since his study’s publication, Cary Gross, who’s now at the Yale School of Medicine in a faculty position that’s about 70 percent health policy research and 30 percent clinical work, has seen it reverberate through the health care system. Because, says Powe, "everyone is interested in figuring out a more rational basis for deciding funding priorities."
Today, policymakers at the NIH are using Gross’s results both to justify the agency’s funding decisions and to fine-tune its mechanism. And specific disease advocacy groups are using the study to look at the burden their disease places on society as they make their case for NIH funding. Cary’s research, Powe says, "instilled a measure of rationality into a very political process."
One more study by a 1999 clinical scholar, Pushkal Garg, became the focus of national media attention (with articles in the New York Times and Wall Street Journal) and raised red flags within the medical, provider and regulatory communities. Published in the NEJM in November 1999, it found that for-profit renal dialysis facilities have a higher patient mortality rate and poorer transplant-referral record than not-for-profit facilities.
As a result of Garg’s findings, government regulatory agencies are looking closely at strategies for providing better quality of care for renal patients, says co-author Neil Powe, a renal specialist himself. "And there may be proposals for greater oversight or regulation of the dialysis industry."
Clinical scholars frequently choose to design projects closely tied to their medical specialties. Amal Murarka, a specialist in pediatric intensive care, spent his two years learning to understand the psychological and social dimensions of treating gravely ill children and communicating with their families. Murarka says it’s important to be able to apply what you do clinically to scholarship, but he senses a polarization in academic medicine between these two ends of the spectrum. "Most clinical scholars want both research and clinical careers," he says.
But Leon Gordis, the voice of experience, says that combination isn’t easy to come by. "A lot of people want to do both, but as they mature, they tend to lean more towards one career or the other," he says. The RWJ program demonstrates that it’s possible to bridge these two sides of the profession.
Sixteen physicians so far have graduated from the program at Johns Hopkins. And like RWJ clinical scholars at the other sites (the resume of the Surgeon General of the United States, David Satcher, notes that he was an RWJ Clinical Scholar at UCLA, class of ’76), they’ve gone on to occupy elite positions in academic medicine, public health organizations, health care administration in both the public and private sectors, pharmaceutical companies, and entrepreneurial ventures.
All of them have also become part of the close-knit and influential national RWJ clinical scholar alumni roster. "They say it’s like a fraternity," Holloway says. "You call someone in the alumni list book and their doors are just open to you. It plugs you into an incredible network."