Ralph I. Horwitz
Thinking outside the biology box at SUMC’s largest department
Horwitz’ move to Stanford came in the midst of a career that started with an M.D. degree from Pennsylvania State University in 1973, followed by residency training at Montreal’s McGill University and Harvard’s Massachusetts General Hospital. Before service at Case, Horwitz was chair of the Department of Internal Medicine and the Harold H. Hines Jr. Professor of Medicine and Epidemiology at the Yale University School of Medicine.
Almost exactly one year after returning to a department chair role, this time at Stanford, we talked with Horwitz about why he made the move, what he has done so far, and what he hopes to accomplish for his broad constituency — patients, trainees, staff and approximately 190 faculty members in 14 divisions and programs in the Medical School’s largest department. His role obviously also influences a broad range of community and referral physicians in a variety of medical subspecialties.
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Q: Other than perhaps preferring California weather to Cleveland’s harsher climate, what brought you to Stanford and a departmental role here?
HORWITZ: Believe me, it was a lot more than weather. I saw this as a terrific opportunity to return to clinical care, teaching and research. The discipline of medicine, particularly the training of physicians in a research environment, is at the core of what a great medical school is all about. If this department can continue to become a model of science-based medical practice and education in the 21st century, I’ll feel as if I’m in the right place at the right time.
Q: What did you find when you arrived?
HORWITZ: I found a superb department with examples of true excellence, but also a department that didn’t always work together as effectively as it might. We have some very strong clinical programs but they often lack either depth or breadth. I saw the shortcomings as a challenge that could be overcome. This is a relatively small department of medicine in a small school of medicine. We’re never likely to be able to fulfill all of the clinical needs out there, but we can certainly aspire to achieve national leadership in the quality of clinical care and education and in the programs of research that we promote.
Q: What have you done so far?
HORWITZ: For one thing we’ve begun to renew leadership in the department, in some instances by making relatively simple changes such as reinvigorating the feeling of common spirit generated by a well attended medical grand rounds that is both intellectually interesting and clinically relevant. But more broadly, the dean has given us an opportunity to recruit many incremental faculty to the department, including members of our leadership team. Late last year Abraham Verghese joined us as senior associate chair for the theory and practice of medicine. He’s a best selling author with an international reputation for the commitment to the craft of medicine, and he is already having an impact on both training and mentoring of younger colleagues. He’s helping to reinvigorate our housestaff recruitment and is taking the lead in redesigning our clerkship program for third-year medical students.
Q: How about leadership on the clinical side?
HORWITZ: We have a new chief of gastroenterology, Pankaj Jay Pasricha, who is building new and expanded capability in digestive diseases and hepatology. We also recruited a new chief of nephrology, Glenn Chertow, who was a professor of medicine at UCSF. We’ve also begun to recruit new faculty in numerous divisions within the department. In the process we will be able to create clinical programs that have greater impact than ever. So I think there is a sense of movement, a feeling of excitement with a clear set of goals that signal our commitment to become the most vibrant department of medicine in the nation.
Q: Can you talk about the role of financial management?
HORWITZ: We have a new and successful senior associate chair for finance and administration, Osman Akhtar. Our faculty members know the truth of the old adage, “no margin, no mission.” We must be able to support the education and research that complements the great clinical care that we provide. Every one of our revenue streams is under pressure: insurance companies are cutting back on reimbursement, the NIH has never faced a tighter fiscal environment, and nobody pays us to teach on the wards or in the clinics. Yet our aspirations and our ambitions are larger than ever. So we need to be fiscally accountable. But I’m very fortunate to be part of a team at Stanford that understands the importance of the department’s financial health.
Q: What about patient care?
HORWITZ: I think that patients have every reason to believe today that they will get care at Stanford that is as good as anywhere in the country. We can and must strengthen the personal experience that our patients have, but we should be proud of the care we offer right now.
Q: You have gone on record as saying that HIV/AIDS changed everything in medicine. How does that fit into your leadership?
HORWITZ: I do think that HIV/AIDS has been an extraordinary challenge to the profession, but it has also been an opportunity for us to reinforce important values. AIDS has forced us to learn medicine more broadly than ever before because of its cumulative effects on so many different organ systems. AIDS has also forced us to incorporate the biology of medicine with the often overlooked social and psychological dynamics. Because of the struggles to treat our patients, AIDS has forced us to recognize our own frailty and vulnerability as physicians. It has been a great opportunity to the profession — even as it has brought great burden and illness to people who are infected with the virus. Almost all of us have had to care for AIDS patients at one time or another in ways that reminded us of why we are in medicine. Now that AIDS has become a global epidemic, it has also reinforced the importance of global health as a key part of what we do in this country — not just what happens overseas.
Q: Beyond AIDS, what do you see as major clinical themes in medicine?
HORWITZ: Emerging and reemerging infectious diseases, here and abroad, are going to have an enormous impact on medicine, and chronic illnesses are expanding in scope and impact as well. The epidemic of obesity and diabetes is going to change the face of health care in this country in very profound ways. And of course, we are confronted by an aging population that we are ill prepared to manage. I think we have to be prepared for a great deal of change in medicine ahead.
Q: How do you manage the potential conflict between the need for expanding clinical services with the need to nurture research and education?
HORWITZ: I’m quite mindful of the balance between clinical excellence and research. We are making major financial investments both in the infrastructure for research and the recruitment of faculty who can contribute to both basic and clinical research in medicine. We will also complement those investments with expanded programs of clinical care and education, because despite our relatively small size, we want to be leaders in the quality of medical care and leaders in clinical and research education.
Q: Speaking of education, when you recruit housestaff, how does the balance of scientist vs. clinician play out?
HORWITZ: Like many of our peer institutions we want to create an environment here that is equal to the ability of the extraordinary young people who come here. Housestaff are the soul of our department. We will offer them the opportunity to have unsurpassed training in clinical medicine. But having said that, no one should leave this training program who doesn’t feel trained to pursue careers in research and education, as well. And in my mind there is no better place to get that versatile training than at Stanford.
Q: What are some primary assets of the training program?
HORWITZ: For one thing we have great balance of three terrific hospitals. SHC provides care for complex chronic illnesses in a university context; the Palo Alto VA hospital is among the very best in the nation at providing integrated care across the full spectrum of clinical problems; and Santa Clara Valley Medical Center is one of the country’s leading safety-net hospitals. It opens its doors wide to everyone who needs care regardless of their ability to pay, and the environment there, and the range of illness that our housestaff see there, is just stunning.
Q: How do you bring young, ambitious trainees on board to work on the wards when they may have a research goal?
HORWITZ: Look, clinical medicine and research are not competing activities. People who work in the lab also want to be great doctors. Our faculty members are remarkable in balancing research and clinical care and they model that balance for our trainees.
Q: So is there an assumption that psychosocial issues and science are of equal importance?
HORWITZ: The integration of the social and biological aspects of illness I think is one of the great opportunities that Stanford has to lead American medicine in exciting new directions.
Q: Why specifically Stanford?
HORWITZ: Great institutions probably have more similarities than differences, so to stand out we often look for subtle but crucial distinctions. In Stanford’s case, I think one edge may simply be geography. We’re a pleasant walk to the main campus of a great university and in close proximity to Silicon Valley’s enormous innovative glow. The opportunities for cross-fertilization can’t be overestimated, and the geographic opportunities for that interaction are unprecedented here.
Q: What would you expect five years from now?
HORWITZ: People around the country and beyond will say that there is no more exciting place to practice medicine, pursue research and learn medicine then at Stanford. And our patients will continue to know this is the right place to come for care. We should expect no less for ourselves and our colleagues.
