For Dean Alpern, Making Science the ‘Language of Medicine’ Is a Priority

Dr. Robert J. Alpern is about to begin his second five-year term as dean of the Yale School of Medicine.

With over 1,000 students, almost 2,000 faculty and a budget approaching $1 billion, the enterprise over which Alpern presides is by far the largest of the University’s graduate programs. It is also one of the oldest — in fact, it is preparing to celebrate its 200th birthday next year.

The Yale Bulletin & Calendar recently met with Alpern, who reflected on his first term at Yale and shared his vision for the future. The following is an edited transcript of that conversation.

What are the most dramatic changes you’ve implemented since taking over as dean in 2004? And, conversely, what qualities of YSM do you think are most enduring?

When I came to Yale, I found a tradition of excellence. But President Levin and I shared a commitment to make this great school even better. I was determined that the success of our superb faculty would be enhanced — not hindered — by the administration. Our relationship with Yale-New Haven Hospital was also strained five years ago. Happily, the two institutions are working together well now.

In 2004, I also focused on defining a central vision for the school, uniform administrative and management principles, and a coherent strategic plan to achieve our academic mission. Management of our space was a high priority. For example, the Amistad Building was conceived as an office building, not a research building. I don’t know where we would be today, programmatically or financially, had we not quickly made the shift to a research building.

I came to appreciate, however, that it was relatively easy to attract great faculty and start new programs, like stem cell research, or strengthen existing areas, like cell biology, by leveraging the Yale name. The northeast location, the reputation of Yale University, and most importantly the acknowledged excellence of our faculty and students are very attractive to new faculty recruits.

Before coming to Yale, you were dean of the University of Texas Southwestern Medical School; yet you began your career as a clinical nephrologist. How did you make the transition from the bench to the boardroom?

I was very fortunate to have learned from some great academic leaders before coming to New Haven. UT Southwestern, where I spent six years as dean, was an incredibly well-run institution. The paradox of academics is that most deans are promoted into a complex role with little administrative experience. My job involves managing a billion dollar budget — so I need administrative skills as well as leadership skills and good taste when it comes to making decisions regarding the academic program.

But I also enjoy doing research, which consumed 80% of my time before I became dean in Dallas. I still maintain an active lab, and we are doing good work. But the lab is smaller than in the past, and I can no longer devote the amount of time to research that I used to. When I read the scientific literature now, I need to read more broadly — in genetics and cancer and other fields beyond nephrology.

You have taken a leadership role nationally in recommending fundamental changes in the way we educate physicians. What would you like to see changed, and how would it impact medical education at Yale?

I have felt it is important at a school like Yale that the dean has a presence on the national scene. I have made it a priority to be involved in national issues, but not at the expense of running the school.

The Association of American Medical Colleges has asked me to serve on a number of committees, but the one committee I agreed to co-chair was the task force looking at how science is taught in medical schools and at the undergraduate level.

Science is the language of medicine. There is a school of thought in this era of “evidence-based medicine” that physicians will become more like robots — making a diagnosis and simply executing on “best practices” with little analysis or interpretation of the literature. Yet without a thorough understanding of how the body works, physicians cannot successfully treat complicated conditions. Evidence-based medicine is important, but it must be interpreted in the context of science.

So our task force has recommended changing the pre-med requirements to emphasize competencies, not course completion, as the core determinant for entrance to medical school. There is still four to five years of work to be done to follow-up on our recommendations, but I believe our report will eventually lead to a transformation of the MCAT, so it becomes a better test of a student’s ability to think critically, and to vast improvements in pre-medical and medical school science education. I certainly hope that both Yale College and Yale School of Medicine will participate in and hopefully lead this process.

All Yale medical students must complete a research thesis before they graduate. What is the benefit of this requirement?

I believe it is important that all physicians understand what goes into research. This is ingrained at Yale, where a research thesis has been a requirement since 1839. But it is expensive. We are fortunate to have an endowment to support the thesis requirement. Many students actually do a fifth year at Yale to pursue their research — and we do not charge tuition for that year, frequently providing a stipend, thanks to our endowment.

Many of our alumni state that the thesis experience was the best part of their medical education — even if they have gone into clinical practice.

We’ve made great strides in recent years in our understanding of basic science. How have those advances improved clinical care, and what can we do to speed up the bench-to-bedside process?

Basic research is important — and we do it at a high level at Yale. There are many examples of where basic science has led to progress in clinical medicine — like statins for high cholesterol, ACE inhibitors for hypertension and kinase inhibitors for cancer.

Clinical research is more expensive, and it is more difficult to accomplish. Unfortunately, the model of applied research at pharmaceutical companies seems to be breaking down and they are increasingly looking to academic institutions like Yale for the next breakthroughs.

The Yale Center for Clinical Investigation (YCCI) has been a tremendous success; it has helped a lot of young faculty to get started in clinical research. Now we are focusing on driving clinical trials, especially in the Cancer Center. But to accelerate the process, we will need to raise an endowment to support YCCI and supplement the funding we receive from the National Institutes of Health (NIH).

How will national healthcare reform impact the practice of medicine, if the United States moves toward a single payer system?

Universal health insurance would be a win for everyone. Until we have it, we will not be able to provide the quality of healthcare that everyone needs and deserves. We currently have a two-tiered system — those who are insured get very good healthcare, and those who are uninsured get healthcare that is an embarrassment.

If we go to a single payer, however, we run the risk that the government could put a new system in place and then start cutting back on reimbursement to hospitals and physicians, as has happened with Medicaid. I am nervous about having a monopoly in the provision of healthcare.

Primary care has to be addressed by healthcare reform. We have to figure out a way of incentivizing more doctors to go into primary care. Congress also needs to address the terrible debt burden of medical students, which is unsustainable.

What medical breakthroughs do you foresee in the next decade?

I think the major advances in the next few years will be in four areas: cancer, Alz­heimer’s, non-invasive approaches to surgery, and autoimmune diseases, such as multiple sclerosis, Crohn’s and rheumatoid arthritis.

What are the biggest challenges that the Yale School of Medicine will be facing over the next five years?

Our biggest challenges revolve around our three central missions — education, research and clinical care. One-on-one and small-group teaching, which we do a lot of, is very expensive. We have to figure out a way to maintain the high quality of a Yale education and, at the same time, shift the burden off our students who graduate with a crushing amount of debt. On the research front, the challenge will be to maintain the scale and quality of research, even as the NIH limits its support. The clinical practice is growing quickly in size and quality, fueled in large part by a shared commitment from the medical school and Yale-New Haven Hospital. While some components of our clinical practice are profitable and thus relatively easy to grow, many other components, such as primary care, are important to our missions to serve the community and educate our students, but require large financial subsidies.

Smilow Cancer Hospital recently admitted its first patients. How will that new facility impact the School of Medicine?

When I came here five years ago, I identified cancer and heart disease, the two biggest killers in the United States, as priorities to grow. Happily, the hospital shared this vision.

Smilow Hospital, as beautiful as it is, does not in itself make the practice excellent. But it does provide an extraordinary infrastructure with the latest equipment for patient care and is a magnet for recruiting great people like Tom Lynch, the new director of the Yale Cancer Center. And now that we are moving forward with a Cancer Biology Institute on the West Campus, we have started a national search for the leader of that enterprise, which will further elevate the Yale Cancer Center. It is my goal that in five to 10 years we should be among the top five cancer centers in the country, and I am optimistic that we can achieve this.

— By Robin Hogen

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