The medical school’s ‘hidden treasure’

As is the case at most medical schools, Yale’s Department of Internal Medicine is by far its largest, with over 300 faculty members. These faculty are organized into sections, most of which carry names easily mapped onto familiar medical specialties: Nephrology, Geriatrics, Rheumatology, and so on. But the less descriptive name of the Section of General Internal Medicine (GIM), which claims 91 of the department’s faculty as members, makes its role far less obvious, which is perhaps what leads Dean Robert J. Alpern, M.D., to call the section “a hidden treasure of Yale.”

Many of GIM’s activities are quite visible: The section is home to the many Yale primary care physicians who work at Yale Internal Medicine Associates (a part of Yale Medical Group), Yale-New Haven Hospital, the VA Connecticut Healthcare System in West Haven, Conn., and clinics and hospitals as far afield as Waterbury, Conn., which together have patient visits in the tens of thousands each year. GIM is also an important educational resource, contributing to three departmental residency programs and numerous medical-student teaching services, which are overseen by some of the medical school’s most outstanding clinician-educators.

The more “hidden” aspect of GIM is that the section is a research powerhouse, with a robust and extraordinarily diverse portfolio. The section’s physician-scientists study such topics as targeting insulin resistance to prevent stroke and heart attacks, HIV and comorbid disease in aging veterans, occupational asthma and hearing loss, and the effectiveness of health-education video games. They advise the national organizations that judge hospitals. They investigate the diffusion of surgical robot technology and develop office-based treatments for drug addiction and alcohol dependence. They examine the epidemiology and treatment of congestive heart failure, cancer, and stroke. They develop curricular guidelines that are used in internal-medicine residency programs nationwide. And, in keeping with the whole-patient philosophy of general internal medicine, they study the big picture, scrutinizing patient safety, clinical effectiveness, and discrimination in health care.

“In many very good places, the general medicine section is simply a group of clinicians to see primary-care patients,” says Jack A. Elias, M.D., Waldemar Von Zedtwitz Professor and chair of the Department of Internal Medicine. By contrast, he says, Yale’s GIM physicians, “while providing expert primary care, are also doing things that are going to impact patient care and national policy. They’re going to impact how we take care of people from impoverished and affluent backgrounds, alter how we take care of people with heart failure, change how we deal with drug addiction and provide important insights into ways to provide less expensive and safer patient care. They’re at a level that almost no other section of general medicine is at.”

Founded in 1975, the GIM ranks among the highest of the Department of Medicine’s sections in research funding ranking first in 2010-2011. And keeping pace with the department as a whole, it has recently enjoyed meteoric growth. In 2002, it employed 39 full-time faculty; today there are 91. Research funding totaled $4 million in 2004, but by 2011 it had zoomed to $21 million, mostly from federal sources (see figure).

“We’re spread thick,” says GIM Section Chief Patrick G. O’Connor, M.D., M.P.H., of the section’s varied research projects. “We approach each of these research areas in a scientifically rigorous manner, and the reputation of the faculty and their success at getting funding in these areas through peer-reviewed federal sources speaks for itself.” Some of the most exciting work in the section, he adds, is being done by up-and-coming junior faculty recruited in the last five or six years.

For example, Joseph S. Ross, M.D., M.H.S., who joined the section in 2008, has already been a co-author of some 70 peer-reviewed original research papers, including some presenting methods to use Medicare data to assess quality and performance at hospitals. Ross did a postdoctoral fellowship at Yale, then worked in New York City before being recruited back to Yale in 2010. “I was really excited to come back, partly because of the community of individuals in the section, some of whom I’d trained with,” he recalls. “It just makes it a very stimulating and provocative environment to be around so many good thinkers.”

Those thinkers include Marcella Nunez-Smith, M.D., M.H.S., who established the Eastern Caribbean Health Outcomes Research Network (ECHORN), which O’Connor calls the “Framingham Study of the Caribbean”—a reference to the landmark Massachusetts heart study that has been providing crucial information on cardiovascular disease since 1948. Awarded a five-year, $5.3 million NIH grant last fall, ECHORN will examine disease burden and conduct capacity-building studies in that region in collaboration with four island universities.

Ross and Nunez-Smith share a special bond with many other GIM faculty members, including O’Connor: they are alumni of Yale’s Robert Wood Johnson (RWJ) Clinical Scholars program. The School of Medicine is one of only four sites in the nation that host the program, a prestigious postresidency fellowship for physicians planning careers in policy, leadership, and/or research. GIM regularly hosts RWJ Scholars, and the section’s faculty includes alumni of the Yale program along with alumni of three RWJ Clinical Scholars programs at other institutions.

“Having that incredible program here has allowed Yale to pick the best graduates each year and get them to stay,” says Alpern, who says the RWJ Scholars initiative has been a crucial ingredient in GIM’s research excellence. “There’s absolutely been a tremendous synergy between the Clinical Scholars program and the section,” agrees Associate Professor of Medicine Cary P. Gross, M.D., associate director of the Yale program and an alumnus of Johns Hopkins’ RWJ program. “Because the Scholars program is at Yale, we have a home-field advantage when it comes to recruiting talented Clinical Scholars graduates to come and join us,” and the example set by internist-scholars makes for a very supportive environment for all junior faculty, he adds.

Emily Wang, M.D., M.A.S., assistant professor of medicine, cites that environment as key to her work with some of the most vulnerable patients: ex-prisoners. During her internal medicine residency at the University of California-San Francisco, she cared for diabetic patients in the emergency department who had lost access to medical care after serving their sentences.

“It seemed like a frustrating and inefficient way to care for any population,” she recalls. She sought parolees’ advice, then opened a clinic there in 2006, which has since served 700 patients and provided a model not only for a similar clinic in New Haven, but also for 17 other sites around the country, including in Boston, Baltimore, and Los Angeles. Mentored by GIM senior faculty member David A. Fiellin, M.D., professor of medicine and public health, and cardiologist Harlan Krumholz, M.D., the Harold H. Hines Jr. Professor of Medicine and director of the Yale RWJ Clinical Scholars program, Wang has received a grant from the National Heart, Lung, and Blood Institute to study cardiovascular disease in the formerly incarcerated.

“What I’ve always found so refreshing and invigorating here is that people really want to establish new ties and share their ideas and share their resources. Faculty members here really do not want to work in silos,” says Gross. “I’ve been here 10 years. I’ve never even thought of moving.”