Advocacy: A New Arena for the Translational Scientist

On February 14, 2011, Dr. Harry Selker, President of the Society for Clinical and Translational Science (SCTS) sent an “e‐mail alert” to all members of the Association for Clinical Research Training, the Association for Patient Oriented Research, the Clinical Research Forum, and the SCTS. ¹ It informed everyone of the vote scheduled in the House of Representatives regarding HR 1, a radical plan to cut $100 billion from discretionary spending in the current fiscal year’s budget by substantially reducing spending in a wide range of programs including the National Institutes of Health, the Agency for Health Research and Quality, the Health Resources and Services Administration and other agencies of the Public Health Service. In particular, the bill proposed a reduction of $1.6 billion in the NIH budget for the remaining 7 months of the 2011 fiscal year (a reduction of 4% from 2010 levels) and a 16% reduction from 2010 levels in spending for the budgetary division that includes the National Science Foundation. ² As pointed out in Dr. Selker’s email alert, the proposed cuts could stifle translational research, inextricably harm training programs, and severely cut comparative effectiveness research through decreased funding for AHRQ. Dr. Selker is to be congratulated for initiating a program of advocacy in a Society that is only 2 years old and for taking on an issue that is of great importance to everyone in the translational research community.

Dr. Selker was not the only leader to disseminate a “call‐to‐action” in response to the news from Capitol Hill. William T. Talman, President of the Federation of American Societies for Experimental Biology (FASEB) also sent an alert and asked the members of FASEB to lobby their representatives. ³ More than 1,000 individuals called their Representatives to protest the cuts in NIH funding research. Other web‐alerts came from a diverse array of professional societies including the California Primary Care Associates, the American Lung Association, and the Association of Career and Technical Education, to name a few. ⁴

Unfortunately, these many advocacy efforts were not rewarded by action on the part of the House of Representatives. Voting along party lines, all but three of the 238 Republican Representatives approved the bill while all 186 Democrats opposed it. ⁵ Representatives Markey (D‐MA), Schakowsky (D‐IL), Courtney (D‐CT), Higgins (D‐NY), Holt (D‐NJ), and Davis (D‐CA) attempted to introduce an amendment to restore full funding for the NIH; but it was not brought to the floor of the House. HR 1 must now come before the Senate before it can be enacted into law. Irrespective of the actions taken by the Senate, one must worry that the funding levels set in HR 1 will become a set point for the fiscal 2012 budget.

President Obama has continued to express support for science. He noted during a visit to Pennsylvania State University at University Park that: “Government has a responsibility to live within its means….But we also have a responsibility to invest in those areas that are going to have the biggest impact. And in this century, those areas are education and infrastructure and innovation.” ⁶ Stating that biomedical research is “essential” to the health of individuals and the economy and that innovation in biomedical research creates jobs and products, the Obama administration has asked for $32 billion for the NIH in fiscal 2012. ⁷ , ⁸ However, the modest $3.2% increase in the budget will result in an overall NIH budget that is at best “flat” in the current fiscal environment. Coming at a time when we are reaching the poststimulus “cliff” in NIH funding and when Congress wants to remove $1 billion from the current fiscal budget—the future looks bleak for science and discovery. ⁹

The pending cuts in the NIH budget are but one item in a growing list of recent or recommended budgetary cuts at both the state and the federal level that threaten the clinical and translational sciences. For example, the Medicare Payment Advisory Commission (MedPAC) recently recognized that teaching hospitals serve as “linchpins of their local health care systems and contribute to stunning advances in medical science.” ¹⁰ Yet the commission also noted that academic medical centers failed to teach residents (and presumably students) “the requisite new perspectives and skills for evidence‐based practice, effective use of information technology, quality measurement and improvement, cost awareness, care coordination, leadership of interdisciplinary teams, and shared decision making.” ¹⁰ It further pointed out that there needed to be a shift in perspective on “what it means to be a good doctor.” ¹⁰ MedPAC proposed that the Secretary of the Department of Health and Human Services (HHS) create an expert advisory group that would develop new standards and a method of linking standards with new payment incentives. It also recommended that Medicare withhold $3.5 billion from what it currently contributes to teaching hospitals for graduate medical education and use those funds to leverage teaching hospitals to comply with the yet to be established standards created by the new HHS committee.

MedPAC has calculated that the $3.5 billion in funds that will be withheld is equivalent to the amount that is attributable to the increased testing and longer lengths of stay that are seen at teaching hospitals. Glenn Hackbarth, an attorney who chairs MedPAC, noted that: “we would like to see programs receiving all $3.5 billion, because that would mean that new standards are in place and being met.” ¹⁰ These actions seem disingenuous since students and residents learn to be better doctors by “practicing” at the bedside under the tutelage of experienced clinicians. Lectures from health policy experts and health economists are an important addition for the education of tomorrow’s doctors. However, I doubt it will significantly bend the nation’s healthcare cost curve in the near future.

The great irony is that the individuals most capable of creating programs that are focused on improving our health care delivery system are housed in the clinical and translational science programs at academic medical centers across the United States—the very centers that will be most harmed by proposed cuts in NIH funding and Medicare support for graduate medical education. Indeed, it is T3 and T4 investigators who have created the “science” that underpins efforts at academic health centers to improve the linkage between quality standards and clinical care, to effectively transition care from hospitals to the community, to create new means to speed up the incorporation of practice guidelines into clinical practice, to rapidly and efficiently create the drugs of tomorrow and to develop new methodologies for teaching students and residents by creatively linking healthcare economists, health policy analysts, social scientists, experts in the legal aspects of healthcare delivery systems, epidemiologists and social psychologists with the more traditional areas of expertise in academic medical centers.

Another enormous threat to the clinical and translational sciences looms as states try to mitigate their increasing indebtedness by limiting their support for Medicaid. The vast majority of the nation’s poor and uninsured receive both their inpatient and outpatient care from physicians at academic medical centers. We cannot therefore ignore the proposed draconian cuts in state Medicaid funding. Just last week, the Commonwealth of Pennsylvania eliminated Adultbasic, a bare‐bones health insurance safety net that covered 40,764 residents who were not poor enough to receive Medicaid but who were not old enough to be eligible for Medicare. Jan Brewer, Governor of Arizona,proposed that 250,000 people be dropped from the state’s Medicaid programs in order to deflate the increasing budget deficit in the state. Brewer discontinued Medicaid support for lung, heart, liver and bone marrow transplants this past October. In New York, the legislature announced that it is considering the governor’s efforts to cut $2.3 billion from the dollars Medicaid pays providers. And, New Jersey governor Chris Christie, faced with $1.3 billion in Medicaid debt, called for cuts of up to $500 million in Medicaid payments to providers.

It would seem to me that at a time when the fiscal underpinning of our academic pursuits are being challenged at both the state and federal level we should take the example of Drs. Selker and Talman and become strong advocates for the many components of the clinical and translational sciences—all of which have the potential for improving the health of our country while at the same time making healthcare more efficient, more accessible and less costly. Yet not everyone would agree. Thomas Huddle, a professor of medicine at the University of Alabama Birmingham School of Medicine wrote in the March 2011 issue of Academic Medicine that: “Claims that academic health centers should systematically foster advocacy are deeply problematic. Although advocacy may coexist alongside the core university activities of research and education, insofar as it infects those activities, advocacy is likely to subvert them, as advocacy seeks change rather than knowledge. And official efforts on behalf of advocacy will undermine university aspirations to objectivity and neutrality.” ¹¹ Huddle goes on to note that: “The medical profession should steadfastly resist attempts to add advocacy to its essential professional commitments.” ¹¹

I believe that Huddle errs by assuming that advocacy is “inevitably political.” He points to a definition of advocacy that was recently proffered by Mark Earnest and his colleagues at the University of Colorado: an “action taken by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well‐being.” ¹² I would use a very different definition of advocacy: “giving aid to a cause—as synonymous with support, encouragement, backing, sponsorship or promotion.” Huddle fears that if the profession of medicine becomes a political community it will be less a profession and more a political interest group. I would argue that if we are to remain a profession of scientists and clinicians, we must have an open interchange with the public and with our elected leaders. We must promote the fundamental principles that underpin our profession and advocate for the funding and support that is critical for achieving our collective goal of improving the health of our nation. To do otherwise will cause us to quickly devolve into a guild of scientists and clinicians and we will lose the ability to self‐regulate our profession. The Physician’s Charter takes a very different view of advocacy than that espoused by Huddle. Authored in 2002 through a partnership between the American Board of Internal Medicine, the American College of Physicians Foundation and the European Federation of Internal Medicine, the charter articulated the need for professional commitments of physicians and healthcare professionals “to improve access to high quality of care, maintain trust by managing conflicts of interest, and “advocate” for a “just and cost‐effective distribution of finite resources.” ¹³

The rapid passage of HR 1, the inability of Democratic Representatives to amend HR 1 to preserve funding for the NIH, and the confusing rhetoric from the White House regarding NIH funding, point to the need to enhance our efforts at advocating for the Clinical and Translational Sciences. I proffer five actions that could hopefully make our efforts more successful. First, the efforts at advocacy should be collaborative across the many societies that include clinical and translational scientists. These include not only the SCTS and FASEB, but also organizations such as the American Society for Clinical Investigation, the Association of American Physicians, the Institute of Medicine, the American Board of Internal Medicine, and numerous specialty societies including the American Heart Association, the American Cancer Society, and the American Surgical Association just to name a few. Second, we must recognize that “advocacy” is a science unto itself. The professional and research societies that encompass the physicians, investigators, and academicians that pursue research in the clinical and translational sciences may or may not have the requisite levels of expertise or the resources to undertake advocacy efforts. We must therefore seek the help of experienced experts in advocacy, public policy, and public relations to insure that we are effectively getting our message across to Congress and to the general public.

Third, we must not forget that numerous for‐profit industries benefit directly or indirectly from having a robust national program in the clinical and translational sciences. These entities often have expertise in advocacy and public relations. They include clinical research organizations, the pharmaceutical and device industry, manufacturers who supply laboratory equipment and reagents, medical education organizations, and healthcare consulting groups. Similarly, we should not forget the many nonprofit foundations and nongovernment organizations that advocate for patients and health care delivery organizations—many of which have active public relations, and advocacy groups. We should seek support and advice from anyone willing to help in our efforts.

Fourth, clinical and translational science programs that are embedded in academic medical centers that are coupled with large universities should take advantage of their integration to collaborate with faculty in their schools of public health, public policy, business, economics and law. The faculty members of these departments and schools have enormous expertise in advocacy and public policy and a fundamental knowledge regarding how our state and federal governments work. Their help and guidance in these challenging times will be critical for the success of our advocacy efforts. Finally, we believe this journal can also play an important role in educating our readership regarding the complex economic and political issues that we all face. We will continue to provide information about ongoing discussions in Congress, at the NIH and in our various state capitals that will affect our ability to fulfill our missions. We also invite individuals to submit timely and relevant reports that provide information about programs in public policy or health care advocacy that are relevant to members of the clinical and translational science community. Only by working together will we be able to maintain the resources and infrastructure that are necessary to improve the health of our nation through pursuit of the T1, T2, T3, and T4 components of the clinical and translational sciences.