As Brigham and Women’s Hospital celebrates its 100th anniversary, it is a fitting time to recognize the long, important and fruitful relationship between Harvard Medical School and one of the country’s leading hospitals, one that has flourished through decades of medical evolution as each institution and our faculty helped to shape each other’s trajectory and the face of modern medicine. In recognition of this vital partnership, I was asked to contribute a chapter to "The Teaching Hospital: Brigham and Women's Hospital and the Evolution of Academic Medicine" (McGraw Hill, 2014), which is being published as a tribute to the Brigham’s centennial year. I share with you here some of my reflections on the rich history and success of our productive collaboration with one of the world’s great medical institutions.
From its beginnings as Peter Bent Brigham Hospital in 1913, the Brigham Hospital has been an essential partner in the life of Harvard Medical School. Between the founding of the School in 1782 and 1913, medical education underwent dramatic changes in the U.S., such as the introduction of scientific training into the preclinical curriculum and the increasing importance of in-hospital experiences for medical students. Like most medical schools at that time, HMS did not own any hospitals, so education requiring hospital experience involved arrangements between schools and hospitals. Massachusetts General Hospital, Boston City Hospital, Boston Lying-in Hospital, McLean Hospital, and Boston Children’s Hospital were the main providers of clinical training for HMS students at the time of the Brigham’s founding, although no formal affiliation agreement existed until 1949. The HMS move to the Longwood Medical Area in 1906 influenced the site chosen for the Brigham. Beyond the geographic proximity, Brigham leadership sought from the outset to develop the closest possible scientific, clinical and educational relationships with the medical school next door, which began when it allowed HMS to nominate its initial chief of surgery, Harvey Cushing, and chief of medicine, Henry Christian. This set the stage for increasing HMS involvement in faculty appointments at all HMS-affiliated hospitals.
Before examining the high points of the Brigham–HMS relationship, it would be useful to describe the elements of what we now often call the "Harvard medical community," or Harvard medicine. HMS is one of the 12 degree-granting schools of Harvard University. It is the oldest of Harvard’s graduate schools, and the farthest from the main campus in Cambridge. HMS admits about 165 MD students per year into a four-year medical curriculum, and about 120 PhD students. It has formal affiliation agreements with 16 clinical and research affiliates, including four major teaching affiliates--the Brigham, Mass General, Beth Israel Deaconess Medical Center and Boston Children’s Hospital--where HMS students receive clinical education in their third year and throughout much of their fourth year. Through these agreements, the hospital affiliates, which are independent fiscal entities, have agreed to align themselves and their faculties exclusively with HMS. As a consequence, these entities are universally referred to as "Harvard teaching hospitals," to the benefit of both Harvard and the hospitals.
HMS directly hires and houses approximately 200 faculty on its campus--the Quad--in basic and social science departments. An additional 8,000 full-time, and another 4,000 part-time faculty, are employed by the affiliates, all of whom hold HMS faculty appointments granted by the School and Harvard University. This relationship is considered by all parties to be critical to the success of the School, the affiliated institutions and the faculty.
The Brigham and HMS are interrelated across a broad array of activities. As noted, all the Brigham faculty members are granted an academic rank ranging from instructor, an annual appointment currently with little review, to professor, which represents the highest level of achievement and recognition. As I write, the Brigham has 956 HMS instructors, 515 assistant professors, 296 associate professors, and 220 professors. Among the professors, a small number hold endowed professorships through HMS, which confer both honor and financial resources to the incumbent. These the Brigham faculty members reside academically in one of 14 clinical departments overseen by HMS (e.g., medicine, surgery and radiology) and a minority--currently about 20 faculty--also hold appointments in a Quad basic-science department. Many Brigham faculty members play important roles in the education of medical students, both during the two preclinical years as masters of the student societies, course directors or tutors; and during the clinical clerkships, now called the principal clinical experience (PCE). About one-third of HMS students participate in the PCE at the Brigham.
HMS students are a vital component of the life of the Brigham, its faculty and its programs. Brigham faculty members are also integral to life at HMS, where many participate in and lead preclinical courses. Many HMS students pursue required scholarly projects with the Brigham faculty, in areas from basic science to clinical studies to social science. the Brigham is also a highly sought-after hospital among HMS graduating students seeking residency and fellowship training. As a result, many outstanding students--HMS is the most selective medical school in the country--eventually become faculty there. One-fifth of our students are also in the Health Science and Technology program, a joint venture between HMS and the MIT. A the Brigham faculty member has often served as the HMS leader of this program over the years, beginning with Joseph Bonventre, the Samuel A. Levine Professor of Medicine, through today with David E. Cohen, the Robert H. Ebert Professor of Medicine and Health Sciences and Technology at the Brigham.
According to the model by which HMS operates, each affiliate conducts research programs in its own research facilities. However, a significant component of research at the Brigham has been located in space within the New Research Building, which is leased from HMS. One major element of this arrangement is a Brigham genetics program, located strategically near the HMS Department of Genetics, where faculty, including Stephen Elledge, the Gregor Mendel Professor of Genetics and of Medicine, Raju Kucherlapati, the Paul C. Cabot Professor of Genetics, Mitzi Kuroda, professor of genetics, and Christine Seidman, the Thomas W. Smith Professor of Medicine, have joint roles. Another area of strategic alliance is in neurology. Dennis Selkoe, the Vincent and Stella Coates Professor of Neurologic Diseases in the Department of Neurology at the Brigham, played a key role in founding and co-leading the Harvard NeuroDiscovery Center, originally the Harvard Center of Neurodegeneration and Repair. Funded by a significant anonymous gift to HMS, this program leverages neuroscience expertise across all of Harvard, through pilot grants, cores and other community-building efforts, with the dean of HMS serving as chair of its advisory board. HMS manages a major segment of the animal facilities employed by Brigham faculty.
Over time, many clinical and research programs at the Brigham have become tightly linked to those at HMS. To highlight just a few of these, HMS and the hospital have deeply interrelated and synergistic programs in the area of global health. This alliance arose out of the passion and accomplishments of Paul Farmer, Kolokotrones University Professor of Global Health and Social Medicine, and Jim Yong Kim, currently president of the World Bank. These two physicians graduated from HMS one year apart, and both received doctoral degrees in medical anthropology from Harvard University. They both participated in medical residencies at the Brigham, where Farmer also completed subspecialty training in infectious diseases. While students, they cofounded the organization Partners In Health (PIH) and became national leaders in the field of global health with faculty appointments in medicine at the Brigham, and in the Department of Social Medicine at HMS. This department has now been renamed Global Health and Social Medicine (GHSM) and is chaired by Farmer. While pursuing their interests at HMS and PIH, in collaboration with residency director and associate professor of medicine Joel Katz, Farmer and Kim also pioneered a highly competitive global-health equity track in the internal medicine residency program at the Brigham, a program that may well become a national model. A Division of Global Health Equity at the Brigham houses the faculty for this program, and many of these faculty members also hold appointments at HMS in GHSM. Together, GHSM, the Division of Global Health Equity, and PIH function as a highly effective and mutually beneficial superorganism. Although at times the borders between these entities can blur, creating administrative ambiguity and financial complexity, these difficulties are more than compensated for by the innovative and transformative work the programs perform.
A second example of the collaborative relationship between HMS and the Brigham lies in the realm of clinical research. Beginning in 1961, the Brigham had an outstanding general clinical research center (GCRC) funded by the National Institutes of Health, in which complex human experiments were conducted. Three other HMS affiliates also had similar programs. When NIH announced in 2006 that the GCRC program would be replaced by clinical translational science centers (CTSCs), and that Harvard institutions could have a total of only one center, there was much uncertainty and some consternation at the thought that these fully autonomous programs would likely be ending. In the end, after extensive discussion, it was agreed that HMS would submit the grant, with Lee Nadler, HMS Dean for Clinical and Translational Research and the Virginia and D.K. Ludwig Professor of Medicine, as principal investigator. This decision was made with the full cooperation and involvement of all pre-existing holders of GCRCs, including the Brigham.
There was also agreement about institutional support in the form of financial contributions totaling $15 million per year for five years from Harvard University, HMS and each of the affiliated hospitals. A complex multi-institutional governance structure was established, demonstrating both the effect of external pressure and the capacity of HMS leaders to rise to the occasion. The grant was funded on the first attempt, and the federal support of $24 million per year was the largest among CTSCs nationwide. A far more integrated human research laboratory has now taken the place of the previously independent and uncoordinated GCRCs. Brigham faculty play a key role in the leadership of this program, today named Harvard Catalyst The Harvard Clinical and Translational Science Center. Its leadership team includes, among others, Elliott Antman, Associate Dean for Clinical and Translational Research and HMS professor of medicine, who leads the educational effort, and Barbara Bierer, HMS professor of medicine, who leads the regulatory program. Harvard Catalyst, including its Brigham components, is a national model for CTSCs.
HMS is also heavily involved in graduate education in biomedical science, with nearly 700 students enrolled in PhD programs in the Division of Medical Sciences, which is part of the Graduate School of Arts and Sciences at Harvard University and home to many of the most highly rated graduate programs in the world. David Golan, the George R. Minot Professor of Medicine at the Brigham, and professor of biological chemistry and molecular pharmacology, is dean for graduate education at HMS. He jointly oversees the MD-PhD program with the dean for medical education, Jules Dienstag, the Carl W. Walter Professor of Medicine, and the program director, Stephen Blacklow, Gustavus Adolphus Pfeiffer Professor of Biological Chemistry and Molecular Pharmacology and a longstanding member of the Brigham’s Department of Pathology. The MD-PhD students often choose Brigham labs for their research, and the Brigham is a preferred site for them to pursue residencies and, often, their subsequent careers. Brigham leadership, including Joseph Loscalzo, Hersey Professor of the Theory and Practice of Physic and head of the Department of Medicine at the Brigham, and Thomas Michel, professor of medicine, has played a critical role in creating a new and exciting track in our graduate program, the Leder Human Biology and Translational Medicine Program at Harvard. This program creates new opportunities for hospital-based faculty to train graduate students in medical science related to faculty research.
It should be evident by now that HMS and the Brigham are very closely aligned in a way that immeasurably strengthens both institutions with respect to both function and reputation. It should not be forgotten, however, that there are constant challenges to this close relationship, resulting in part from the fact that each institution maintains independent governance and finances. Furthermore--a rarity among American medical schools--HMS had no history of receiving funds, also known as a dean’s tax, from the clinical affiliates. During prosperous times, when all institutions were experiencing financial success, this situation was tenable. During periods of financial difficulty, with flat or falling NIH budgets, poor endowment returns and problems with the national economy, this model will likely not be sustainable. Two responses to periods of financial challenge have been notable. First, the partner institutions and HMS developed a plan to provide new funds from all organizations to compensate clinical educators. In a second important effort, there was agreement to provide modest financial support to HMS from the affiliates for a three-year period, support that is proportional to the size of the affiliates’ HMS faculty. The extension of this support will be an important indicator of the strength of the bonds that tie us together.
Indeed, we must all acknowledge the dramatic changes that will likely shape our institutions, both jointly and individually, over the coming decades. In the realm of clinical medicine, it is clear that the share of economic resources flowing into the U.S. health care sector is unsustainably large. By one means or another, forces will emerge to profoundly alter this flow of resources over the coming years, and, we can hope, improving, rather than reducing, the quality and safety of the care that we deliver. The Affordable Care Act--whatever an individual’s views may be on its benefits or failures--will not by itself correct this course. Whatever changes take hold through further regulation or market forces, they will almost certainly involve an enhanced need for primary care, care coordination and multidisciplinary teams, as well as more appropriate, and perhaps limited, utilization of some specialty services. How institutions such as the Brigham respond to this challenge will have material impact on the future of the hospital, HMS and our relationship. Although extremely deep in specialty and tertiary care, the Brigham is also a leader in primary care and is dedicated to planning for systems redesign, so I am hopeful about how it may contribute in the future. Many factors will also push HMS to institute important changes to our educational curriculum. Among these will be a need to have greater ambulatory--as opposed to inpatient--experience, new models of team training and greater recognition of the new pedagogical models required by students steeped in the digital age. In all of these areas, HMS will work closely with Brigham faculty, who are key players in the design and conduct of our medical education program. Finally, the future of biomedical research is now evolving in response to fiscal realities and the need to increase the success by which we translate basic research into safe and effective therapies. I am convinced that HMS and the Brigham, as well as other HMS affiliates, will need to work together more effectively if we are to succeed and remain the leaders that we are today.
A model through which strategic planning and cooperation leverage our individual strengths and resources will far outpace the model of the past century, in which, with a few important exceptions, our institutions pursued largely separate agendas in independent, albeit successful, pursuit of scientific excellence. The success or failure of this more collaborative approach will occupy the future leadership of HMS and the Brigham for decades to come. I am committed to substantially dedicating the remaining period of my deanship to realizing this vision.