Correspondence

Distribution of Research Awards from the National Institutes of Health among Medical Schools

N Engl J Med 2000; 342:1753-1755June 8, 2000

Article

To the Editor:

As department chairs at a medical school that falls in the bottom half of the list of National Institutes of Health (NIH) beneficiaries, we wish to comment on the article by Moy et al. (Jan. 27 issue).1 This study of the distribution of NIH research awards among medical schools cannot answer the most important question it raises: Is the concentration of research among a few institutions in the best interests of medicine and science? We suggest it is not.

For the traditionally less successful schools, the authors suggest that they “may wish to reconsider their investment in a research mission.” This suggestion implies that many medical schools might content themselves with teaching and providing services. We think that the third leg of the traditional three-legged stool represented by a medical school's engagement in clinical research is not ornamental, if medical schools are to fulfill their trust to their students and patients. Research is a crucial element in the life of such institutions because it is the means by which the missions of education and service transcend the learning and practice of a trade, respectively, to become informed by the spirit of scientific inquiry.

In addition, it is now accepted that diversity is more than a matter of the equal distribution of the right to participate. It is an indispensable mechanism by which a richer base of perspectives strengthens a group's endeavors. Persistent exclusion of many schools from the research dialogue may be robbing us of needed viewpoints, or even the occasional heresy. History provides no evidence that the progress of science has been best served in the houses of the secure elite.

The authors' findings call for analysis of and remedy for the unevenness of research funding for medical schools, not strategies for its accommodation. We now must ask for a reevaluation of institutional and national strategies that have allowed so many medical schools with historically poor research funding to remain stagnant in this respect and scrutiny of the current system of peer review for assurance that novel initiatives in new settings can compete appropriately with proposals continuing established lines of investigation in traditionally funded settings.

Finally, we should work to understand the relation between institutional investment in research and the accomplishment of research. How much investment is required to enable a talented, curious person to formulate a question, propose a line of inquiry, and compete successfully for support?

Mark Gibson, M.D.
Bonita Stanton, M.D.
West Virginia University School of Medicine, Morgantown, WV 26508

1 References

1. 1

   Moy E, Griner PF, Challoner DR, Perry DR. Distribution of research awards from the National Institutes of Health among medical schools. N Engl J Med 2000;342:250-255
   Full Text | Web of Science | Medline

To the Editor:

The article by Moy et al. documenting the increasing concentration of NIH research funding among a select group of medical schools raises policy questions about education, the putative core mission of all medical schools. One potential issue is the negative impact of this policy on teaching at the schools highly funded by the NIH. The primacy of the research mission of medical schools has been well documented.1 However, research is not self-supporting; it is subsidized at a cost of about 10 to 25 cents for every dollar of federal research support received.2 This money comes primarily from clinical revenues, the same revenues that pay for teaching. These revenues are not only threatened; they are also generated by precisely those faculty members who are not valued in the academic social structure. This problem is magnified by the fact that the increase in NIH funding is occurring primarily among physicians in clinical departments that are essential to medical schools. Yet, already, a large proportion of faculty members in research-oriented medical schools lack the characteristics and qualities of good physician role models.3

Forecasts of a greatly expanded NIH budget provide tantalizing prospects to deans seeking solutions to their financial difficulties. However, as the availability of clinical revenues to subsidize research decreases, increased research funding may actually put medical education at even greater risk. How will these medical schools meet their obligations to medical education, their unique mission, much less improve their performance? This will be a challenge for research-oriented medical schools whose faculty members are committed to providing high-quality medical education.

David C. Aron, M.D.
Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH 44106

John N. Aucott, M.D.
Park Medical Group, Lutherville, MD 21093

Klara K. Papp, Ph.D.
Case Western Reserve University School of Medicine, Cleveland, OH 44106

3 References

1. 1

   Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. New York: Oxford University Press, 1999.
   

2. 2

   Maximizing the investment: principles to guide the federal-academic partnership in biomedical and health sciences research. Washington, D.C.: Association of American Medical Colleges, 1998.
   

3. 3

   Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending-physician role models. N Engl J Med 1998;339:1986-1993
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Our paper focused on trends in the distribution of NIH research awards among medical schools. We thank the authors of these letters for directing attention to some of the implications of these trends.

Drs. Gibson and Stanton express concern that the exclusion of many medical schools from research may reduce the diversity of research and slow the pace of discovery. We agree. However, we note that no school is currently excluded from research and that every U.S. medical school receives NIH funding. In our study, we showed that even the least research-intensive schools had absolute increases in the numbers and amounts of NIH awards. They were just not receiving increases proportionate to those enjoyed by other schools. Hence, we do not believe that any school is at risk for exclusion from research.

Dr. Aron and colleagues write that medical schools that place too much emphasis on research may limit the time available for faculty members to teach. Again, we agree. The impressive curricular reforms implemented by U.S. medical schools in recent years, such as the increasing use of small-group, problem-based learning and of clinical rotations in community-based ambulatory care sites, have greatly increased the demand for teachers. Concurrently, pressures to increase the productivity of faculty members in the areas of patient care and research threaten the time available for teaching. The Association of American Medical Colleges is concerned about this threat and is monitoring the ability of medical schools to continue to make advances in their curricula. Fortunately, no evidence has yet surfaced indicating that any school has been unable to meet its teaching needs or that the ability to meet teaching demands differs between schools that are research-intensive and those that are not.

The concern expressed by the authors of the letters highlights the need for medical schools to continue to monitor the extent to which their core missions meet the needs of the public. Priorities in research, education, and clinical care need to be carefully balanced to enable these missions to function synergistically and deliver the greatest benefit to society.

Ernest Moy, M.D., M.P.H.
Paul F. Griner, M.D.
Association of American Medical Colleges, Washington, DC 20037