Readers respond to funding academic medical centers, the ‘residency research arms race,’ and more

STAT now publishes selected Letters to the Editor received in response to First Opinion essays to encourage robust, good-faith discussion about difficult issues. Submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay.

“Medical students lose in the research arms race for residency slots,” by Anmol Shrestha

As a medical historian and a user of health care, I hope medical school deans and curriculum committees, and residency programs pay attention to this essay.

— Janet Golden

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This was a terrific essay. It is so true that physician training should be geared to the practice of medicine, leave the research to Ph.D.s. That is their territory. M.D./Ph.D. programs can bridge the gap for physicians who want to do original clinical research.

— Scott Barnes

“Why isn’t there agreement on when women need to start getting mammograms?” by Barron H. Lerner

Simple. It’s about breasts. There would be a sonic boom agreement if it was about penises.

— Samantha Hewes

“Solving academic medical centers’ existential crisis,” by Ravi Thadhani and Anne Klibanski

As medical students at a private academic medical center, we respect the urgency raised by Thadhani and Klibanski around barriers to academic medical institutions serving their tripartite mission. Yet, we believe that their calls for increased funding oversimplify the challenges facing America’s health system. We argue that financial strain is created by inequitable health financing structures that overpay private academic medical centers at the expense of safety net hospitals. Solutions must focus on external and internal resource redistribution to prioritize local communities.

When discussing financial deficits at academic medical centers, funding disparities between private and safety net hospitals must be acknowledged. In New York City, private academic medical centers received 60% of the federal government’s Medicaid disproportionate share hospital payments in 2015, but served just 29% of the city’s uninsured population. Solutions to the health system’s fiscal crisis must involve increased funding for safety net hospitals to reflect their tremendous role in safeguarding community health.

Additionally, we find that attributing financial strain to rising labor costs distracts from internal sources of strain, including uncontrolled executive pay. Our institution’s CEO makes more than $12 million a year, yet when nurses went on strike in 2023 calling for increased pay and safer staffing ratios, leadership labeled their demands financially unsustainable. We do not pretend to understand the complex dynamics of hospital financing, but we find it difficult to grasp a crisis created by rising labor costs when executives are paid in such excess.

Finally, we fear that private, academic medical centers’ singular focus on innovative funding structures may worsen health disparities. Academic medical centers often lack transparency around their investments, which sometimes misalign with their stated missions. For instance, our health system acquired a local community hospital in 2013 but is now attempting to close it to maximize profits elsewhere. We question the intentions of academic medical centers that accept federal funds while restructuring to increase profit at the expense of local communities.

As Thadhani and Klibanski call for increased funding for world-class, lifesaving research, we call on private academic medical centers to examine their purported community benefit, their relationships with safety net hospitals, and the wealth gap between their executives and their communities. Federal research funds must be tied to a hospital’s history of serving nearby communities, full disclosure of investments, and improvement of local health outcomes. Anything less should prompt further questioning of the nonprofit status of these academic medical centers.

Zachary Gallin and Emily Xu, Icahn School of Medicine at Mount Sinai

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With all due respect to Drs. Thadhani and Klibanski, the financial problems that plague academic medical centers cannot be solved on the revenue side of the ledger. Having worked for more than three decades in academic medicine, as well as in the commercial world of medical device startups, I can say with confidence that the former are among the most inefficient institutions in American society today, an addiction enabled by decades of absurd payments by private medical insurance. Many/most/nearly all of the obscene costs intrinsic to these hospitals is promulgated by endless uncompensated and unproductive government meddling and mandates, the end product of which is DMV-like bureaucracy and bloat.

Moreover, the same regulations that hamstring hospital finances are sucking the soul out of the professions that do the hard work of actually caring for patients. Instead of predictably repeating the endless mantra of “we need more money,” it is time for academic hospitals to look internally and fix their costs with a meat axe. If that means AGGRESSIVELY petitioning the government for meaningful regulatory relief or even better payment for indigent care that limits the crazy and inefficient cross-subsidization of such care via private insurance, so be it. The political clout of academic hospitals makes them uniquely suited to lead the challenge against needless government mandates. Nevertheless, let’s first get their house in order and address the core problem before endlessly asking for even more money. For some creative ideas about how best to rein in cost and regulations, I urge academic hospitals to turn to freestanding ambulatory surgical centers or even old- fashioned physician private practices which are undergoing a renaissance via concierge medicine. It’s long overdue that academic medical hospitals resume their historic leadership throughout all of U.S. health care.

— John Adler, Stanford University