Academic internal medicine in the United States: current trends, future implications for academic nephrology.

T he American Society of Nephrology will celebrate its 50th anniversary in 2016. At the time of this commemoration, the United States will spend approximately 20% of its gross domestic product on health care, the Medicare program will face bankruptcy, and an estimated 67,000 people will have end-stage renal disease (1-3). Compared with other countries, the United States spends considerably more of its gross domestic product on health care (4). When total health spending is analyzed, public support (federal and state spending) in the United States is consistent with countries with government-run health systems (5). However, in contrast to those nations, private support is higher in this country, accounting for more than half of overall health spending. Despite this spending on health care, the number of uninsured Americans, which has increased from 40 to 47 million since 2000, is expected to swell to 56 million by 2013 (6). Millions more have gaps in their coverage, are underinsured, or face annual decisions about continuing coverage due to higher deductibles and copayments. Nearly 20% of the uninsured are children, and a disproportionate share of the uninsured are members of racial and ethnic minority groups (7). For decades, the United States has led the world in educating the next generation of physicians and other health professionals, conducting groundbreaking research, and providing cutting-edge care to patients. For example, more than half the recipients of the Nobel Prize for Physiology and Medicine since 1970 have been U.S. citizens (versus less than 10% of the recipients of the Nobel Prize for Literature) (8,9). Nonetheless, the Institute of Medicine in 1999 declared that 98,000 people die in the United States each year as a result of medical errors. The report raised awareness about healthcare quality and spawned a cottage industry for organizations that evaluate performance, including the National Quality Forum, the Leapfrog Group, and HealthGrades. Regulators, insurers, and providers are still trying to meet the Institute of Medicine’s ‘minimum goal‘ of cutting medical errors in half by 2004 (10). Beyond medical errors, the quality of care varies depending on ethnicity, socioeconomic status, and level of education (11).