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Academic Medicine Grapples with Uncertainty and Change in the Face of Sequestration

AAMC Reporter June 2013

By Eve Glicksman

The wound is tender and yet to heal. Medical schools and teaching hospitals have been roughed up on all sides by the political force known as sequestration. The latest and most devastating announcement of federal spending cuts has left AAMC-member institutions uncertain about the future.

The National Institutes of Health (NIH) will lose $1.7 billion in funds for research during the first year of sequestration alone. Medicare providers face a 2 percent reduction in payments that were already below market rates. In response, layoffs and freezes on new hires are on the rise at medical schools, teaching hospitals, and research facilities throughout the country.

Medicare-funded services will lose the most in overall dollars, but university research and education programs will suffer a double whammy. Since hospital revenue frequently is funneled into medical research and education, income for new studies, faculty development, or student diversity initiatives also will decline.

With many unknowns, there is little choice but to prepare for the worst. Residency programs are planning around the threat of fewer graduate medical education (GME) positions. Promising research projects are being scrapped, delayed, or scaled down. Requests for new hospital equipment are on hold.

In 2000, the NIH funded one in three grants; it now funds one in six. Competition has replaced collaboration among scientists. “It’s about survival. The grant climate is turning into the Hunger Games,” said cellular microbiologist Elizabeth R. Moore, Ph.D., assistant professor at Sanford School of Medicine at the University of South Dakota. “This is not conducive for moving science forward.”

Exacerbating these anxieties are uncertainties about grant status, when the funding cuts will strike, or how reductions will be implemented. “Good science relies on stable funding, and no one knows year to year now,” said Kirsten Bibbins-Domingo, Ph.D., M.D., associate professor of medicine and epidemiology and biostatistics at the University of California, San Francisco (UCSF) School of Medicine. “There’s the feeling we can’t invest in long-term plans.”

Even more sobering is that these spending caps are scheduled to continue for eight more years. Discouraged by the dim job prospects ahead, students and young graduates in the sciences are starting to leave the field. Senior faculty members are being wooed by well-endowed labs in China and Hong Kong.

“Sequestration will have consequences for years to come. Our nation will fall behind and lose its reputation for scientific innovation,” said AAMC President and CEO Darrell G. Kirch, M.D. “All the money we have invested in building a diverse biomedical workforce will go wasted if the next generation of researchers leaves medical science because they cannot find jobs or obtain grants. Any interruption in medical research stemming from that loss would hurt scores of patients desperately waiting for treatments and cures.”

With estimates that the NIH will award 703 fewer grants in 2013 alone, Moore noted that industries relying on basic science research from universities also will take a hit. “Industry needs basic biomedical science. When we start to falter, it will collapse, too. It’s the domino effect at a time when America is trying to come back.”

No medical college or teaching hospital will elude the reach of sequestration. In response to Medicare and state Medicaid cuts, the Detroit Medical Center laid off 300 employees in April. The morale at universities is so low that faculty members are debating the morality of encouraging students to enter graduate science programs, said William T. Jackson, Ph.D., assistant professor of microbiology and molecular genetics at the Medical College of Wisconsin. “The reality is that the odds are against anyone in the United States pursuing an academic science career.”

Jackson describes his own emotional roller coaster as an academic researcher waiting for word about a grant he submitted in June 2012. “That’s a lifetime in science—far too long to know.” He is on the cusp of having to close down his lab and has a student wondering how she will finish her thesis if the grant is lost.

Another repercussion of the sequester is that truly pioneering research may not be possible, Jackson added. “Many of the great innovations we’ve seen in biological science over the last 50 years came from small labs striking out and taking risks.” When grants are at a premium, highrisk projects are far less likely to get funding, he said.

Bibbins-Domingo noted that a range of outstanding work is “hanging on a shoestring.” Grant awards often are reduced, some by as much as 50 percent. These reductions can require investigators to take shortcuts, which ultimately compromise study results. Research teams may be forced to eliminate control groups, use smaller samples, or do without more sophisticated technology.

All this will have a trickle-down effect on patient care. Preventive health programs, such as immunization campaigns or the tracking of infectious diseases, often are the first to go when budgets are tight. Scaling back support for basic science research will delay discoveries that could prevent or cure serious conditions and diseases. If teaching hospitals are forced to cut GME positions, that also will limit staff available to care for patients.

To address the problems, forward-thinking institutions are scrambling to develop creative partnerships with industry, private foundations, and outside philanthropy to make up for waning government support. Large institutions have other coffers they can dig into to recoup losses, but smaller medical centers will need to be resourceful. The University of Kentucky College of Medicine reduced the size of its doctoral physiology program by a third. Scientists at the University of South Dakota have ramped up the number of grant applications they are submitting and are expanding the review process to make their applications more competitive. Other universities are being forced to cut back on financial aid programs.

Jackson is hoping that a public outcry can influence Congress to rethink the spending cuts in biomedical research. “A lot of nonscientists believe that the NIH is just a campus in Bethesda,” he said. “We need to get the word out that the NIH is enormous and funds projects in every state.” Moore seconded that: “Scientists are used to being apolitical, but we can’t be silent now,” she said.