A first term marked by progress and growth

With kudos from Yale’s president and his peers, Robert Alpern signs on for another five-year term as dean.

When Robert Alpern was appointed dean in 2004, his vision for the School of Medicine was to build programs in education, research and clinical care to rival the best in the world. “Yale already has many outstanding programs in these three arenas that are likely among the best, but no medical school is perfect in all aspects,” he said in an interview from Dallas, where he was then dean of the University of Texas Southwestern Medical School. “We will identify our priorities for program improvement and then move forward.”

Coming to Yale with a reputation for being at once easygoing and ambitious, the new dean rallied faculty, set priorities and vowed to build an already formidable institution into something even greater. In the dozen years preceding his arrival, the medical school had slipped from third to 11th in the annual U.S. News and World Report survey and from third to eighth in funding by the National Institutes of Health. By March 2009, however, it had moved back up several rungs on both lists.

While Alpern discounts rankings as often-flawed indicators of quality, he recognizes that they reflect how the school is perceived. Much more important are the real accomplishments of the faculty; by that yardstick, he said, the school is “soaring.” He credits his leadership team and says that the real proof of quality can be seen in the creation of new programs that lift Yale above its peers. Among them are multidisciplinary groups focused on cellular neuroscience, neurodegeneration and repair, stem cell biology, human and translational immunology, and cell biology. The school has also seen continued growth in areas where it already excelled, such as genetics, immunobiology and internal medicine.

Alpern has also expanded the clinical practice and the school’s capacity to conduct clinical research. In 2006, the School of Medicine won a landmark grant under the NIH Clinical and Translational Science Awards (CTSA) Program. The $57 million grant—Yale’s largest ever—has been critical in building infrastructure linking the school’s research base to the clinical practice.

One of the clinical initiatives is a new transplant program with outstanding liver and kidney components. A new chief of cardiology arrived last summer and is building the section’s strength in interventional cardiology, heart failure, electrophysiology and basic research. The Smilow Cancer Hospital is set to open in the fall, and in February Alpern named a new director for Yale Cancer Center. Five biomedical institutes and three new core facilities are planned for the West Campus.

In announcing Alpern’s second term in February, Yale President Richard C. Levin said that faculty and staff are enthusiastic in their support for the dean. Levin went on to say that Alpern had “transformed the school’s relationship with Yale-New Haven Hospital (YNHH), a profound change that will have a lasting impact on the school’s clinical mission.”

“To take a school as good as Yale and make it better is exciting, and we’ve come a long way,” Alpern said. “The reason I’ve signed on for another five years is to continue that ascent.”

—Michael Fitzsousa

Online: Yale Netcasts
Robert J. Alpern: Vision for the School of Medicine

Yale obesity expert lauds New York tax dedicated to health programs

When Kelly Brownell, Ph.D., published an op-ed piece in The New York Times in 1994 pioneering a tax on junk food, he became the focal point of a nasty controversy. Rush Limbaugh lashed out at the notion of the government telling people what to eat, and Brownell accumulated “a very thick file of angry letters. I got things from people saying, ‘We know where you live and we’re going to drive you right into the New Haven Harbor,’ ” Brownell said.

But he stood firm, and this year he has seen a glimmer of hope in New York Gov. David Paterson’s recent proposal for an 18 percent tax on non-diet soda and sugary beverages containing less than 70 percent real fruit juice. Paterson’s plan is the highest tax ever proposed on food, and the estimated $404 million in revenue it could generate in its first year would fund public health programs, including obesity prevention. If the proposal survives a comprehensive legislative and public review of Paterson’s budget, it could be adopted as early as April.

“It’s a whole new kettle of fish right now,” said Brownell, professor of psychology and epidemiology, and director of the Rudd Center for Food Policy and Obesity at Yale. He cited the troubled economy, mounting research linking soft drink intake to health issues and a growing concern about child obesity. “I think the social situation has changed enough that these taxes are going to happen at some point. Once the door opens, I would expect there will be a flood of others wanting to go through it.”

The tide may be turning already. While many New Yorkers and representatives of the beverage industry are highly critical of Paterson’s tax, Brownell has had calls from advocates in two other states that he said may soon go public with similar proposals.

Over the years, the “fat tax” has also surfaced as a “snack tax,” a “Twinkie tax” and a “miracle tax diet,” but rarely has it gotten off the legislative floor. California, Maine and Maryland all passed taxes of about 4 to 5 percent, and all later repealed them, mostly in response to food industry resistance. Smaller taxes on junk food in more than a dozen other states have been too insignificant to drive down consumption or spark a fight with the food industry, Brownell said.

New York’s proposed soda tax is exactly the kind of food tax Brownell favors, because the potential revenue would be dedicated to health-related programs, and he applauds Paterson’s bold approach. “I give the governor credit for proposing a large tax and not pussy-footing around. It makes sense to tackle this aggressively,” he said.

More than any other food category, sugared beverages have been linked to poor diet, a higher rate of obesity and increased risk of diabetes. Studies also suggest that an 18 percent increase in price would drive consumption down by about 15 to 18 percent. “If consumption of sugared beverages goes down, that could have a whopping effect on public health,” Brownell said.

—Kathy Katella

Online: Yale Netcasts
Kelly Brownell: Human Food Cravings

Internal medicine continues outreach with focus on “human infrastructure” abroad

For nearly three decades, the School of Medicine’s international health program has provided career-changing experiences for medical residents by sending them to developing countries. Now Yale is taking the Yale/Johnson & Johnson Physician Scholars in International Health Program a step further by developing “human infrastructure” at partner sites.

Rather than helping only American doctors develop a sense of global citizenship and commitment to caring for the poor, the program has made ambitious plans to build the long-term capabilities of its sites abroad. The program, which typically sent American doctors to as many as 15 foreign sites, now focuses on only six. A sense that Western institutions had profited asymmetrically from a brain drain from developing countries—a realization prompted in part by increased international communication among researchers in the AIDS era—drove the change.

“It became clear that we as faculty and Yale as an institution have an obligation … to people all over the world,” said Asghar Rastegar, M.D., new director of the international health program, which has partnered with Johnson & Johnson since 2001. Based in part on Rastegar’s own experience as a faculty member at Shiraz University in Iran, the redesign emphasizes bilateral benefits and long-term in-depth commitment. Physicians in the program now serve in the host country as both learners and teachers; and they bring equipment and materials with them, helping the site itself expand its capacity to care for the sick. In turn, the host countries send physicians on learning trips to the United States.

The pilot program, developed by Majid Sadigh, M.D., associate professor of medicine, is in Kampala, Uganda, at Mulago Hospital, the teaching hospital of Makerere University. The hospital has a ward staffed full time by Yale faculty and residents working side by side with their colleagues from Makerere, and sends physicians to New Haven for specialty training. Fred Okuku, M.D., a resident physician, spent six months at Yale learning to perform mammograms and ultrasounds, then returned to Uganda with the training and equipment—a mobile mammography van—to diagnose early-stage breast cancer. The inexpensive cancer treatment available at Mulago—surgery—will save lives that would otherwise have been lost to a late diagnosis.

Though the program has slimmed from 15 sites to just six, those six—in Eritrea, Honduras, South Africa, Uganda, Liberia and Indonesia—are being transformed by the new philosophy. At Tugela Ferry, South Africa, a site directed by Gerald H. Friedland, M.D., professor of medicine, and devoted to research on and care of patients with HIV and tuberculosis, the husband-and-wife team of Scott Heysell, M.D., M.P.H., and Tanya Thomas, M.D., is spending a year at the local hospital. In war-ravaged Liberia, Yale has joined five American medical schools in a collaboration with the John F. Kennedy Medical Center. And Rastegar is working with Eritrea’s first medical school to develop an internal medicine residency there.

The international health program outreach continues to expand, sponsoring classes in international medicine for medical, nursing and physician associate students interested in global health. These projects, said Michele Barry, M.D., HS ’77, a longtime co-director of the program who stepped down in March to become senior associate dean for global health at Stanford University, will bring fresh hope to caregivers in the sites’ low-resource communities. “I think there is a role for us to really stop the brain drain—to stop people like Fred Okuku from thinking he only has a hospice,” Barry said.

—Jenny Blair

Recommendations for rest periods for residents meets with skepticism

For decades, doctors in training have endured long hours and sleepless nights during residency. Due to concerns that their resultant fatigue might harm patients, in 2003 an 80-hour limit on weekly duty hours, along with a 30-hour limit on work periods, became mandatory for hospitals approved by the Accreditation Council for Graduate Medical Education. But a recent report by the Institute of Medicine (IOM) recommends stricter duty-hours rules that would allow residents more rest, while calling for stronger enforcement of existing rules.

Issued in December, the IOM report is the work of a committee of physicians and sleep experts that examined studies on the relationships among duty hours, sleep physiology and patient safety, including some research done since the 2003 changes. The committee concluded that the evidence was “nascent … but sufficient to recommend action now.” It proposed, among other changes, that residents working 30-hour periods pause on or before the 16th hour for five hours’ rest, and that they be granted an uninterrupted 48 hours each month to catch up on sleep. The 80-hour weekly maximum would remain in effect, as would such other 2003 rules as 10 hours off after a work day.

Yale educators, however, have reservations about the report. Peter N. Herbert, M.D. ’67, HS ’69, senior vice president of medical affairs at Yale-New Haven Hospital, called it “disappointing,” citing the scarcity of evidence that scheduling of duty hours affects patient safety. “It reflected, to many of us, a confusion about what their purpose was,” Herbert said. “It would probably be much more worthwhile to look at what work hours and schedules do to resident education.”

“We’re certainly philosophically on board with believing that rested, clear-thinking people provide better care,” said Stephen J. Huot, Ph.D. ’81, M.D. ’85, HS ’87, chair of the primary care internal medicine residency. But, he said, these well-intended changes might actually jeopardize patients, since they would require more frequent handoffs of patient care and might diminish access to care at some medical centers.

Academic neurosurgeons greeted the report with dismay. Neurosurgical operations last longer than other types of surgery, said Dennis D. Spencer, M.D., HS ’77, chair of the department, requiring longer and more flexible duty hours. “The 16-hour shift with the 10-hour-at-home rule means that our chief residents will never be able to come back to the hospital and see patients they may have operated on, or they will be unable to come to the hospital the next day,” Spencer said. “They will never learn responsibility for their patients and they will erode the mentor/student bond with attending faculty who are attempting to give them more responsibility. This destroys one of the main competencies we are supposed to be teaching—professionalism.”

Though the IOM committee estimated that the cost of adopting its recommendations could reach $1.7 billion annually, it recommended that these changes be adopted within two years.

Whether or not the new rules are adopted, the culture change alone implied by a 16-hour work period—a move toward shift work—has some physicians worried. Continuity of care and teaching a physician to “own” a patient, said Dean Robert J. Alpern, M.D., Ensign Professor of Medicine, are valuable lessons. “This focus on work hours has removed that culture from medicine,” he said. “Nobody seems to be concerned about where we’re headed with this loss in continuity of care.”

“We need to figure out how to continue to instill a sense of complete responsibility for the care of your patient—putting the patient’s needs above your own needs and do so in an educational system that allows you to still function as a person,” said Huot.

—J.B.

et cetera

Medical campus gets green award

The Amistad Street Building has received a gold “greenness” rating from the U.S. Green Building Council’s Leadership in Energy and Environmental Design program. Among the “green” features is a 7,500-gallon tank that recycles storm water collected from the roof. Additional features include laboratory cabinetry made from wood produced in sustainable forests, a heat recovery system and energy-efficient bulbs and occupancy sensors that help cut electricity use. Recycling of renovation debris reduced construction waste by 70 percent.

The project, which provides laboratory space for the Interdepartmental Program in Vascular Biology and Therapeutics, the Yale Stem Cell Center and the Human and Translational Immunology Program, was built around the existing shell and core of the building.

“This project presented all the challenges one typically finds when striving to build sustainably in an existing building,” said Virginia Chapman, director of construction and renovation for the School of Medicine’s facilities office. “But we made it work—and work rather well.”

—Charles Gershman

Economic situation worsens for Yale

In an e-mail to the Yale community in February, President Richard C. Levin said the deteriorating economic situation would require budget cuts beyond those he had called for in December. “The mounting evidence suggesting a prolonged recession has caused us to recognize that we need to take a more aggressive approach to budget reductions for the coming fiscal year,” Levin wrote.

Levin called for cuts in all 2009-2010 budgets by an amount equal to 7.5 percent of the salaries and benefits of all non-faculty staff and a 7.5 percent reduction in non-salary expenditures, up from the 5 percent he had called for in December. These measures could save $37 million in next year’s operating budget, Levin said. But, he added, “… if external con-ditions deteriorate significantly, we may be required to take further action next year.”

—John Curtis


			Originally published in Yale Medicine, Spring 2009. Copyright © 2009 Yale University School of Medicine. All rights reserved.