For the better part of a year, Stevens worked in the office of then-Senator Nancy Landon Kassebaum, the Kansas Republican who headed the Labor and Human Resources Committee, on a variety of legislation, including a bill to reform the system of medical insurance. And as the fellowship entered its final months in the spring of 1996, Stevens was looking forward to returning to the Cleveland campus in September. He intended, he told The Chronicle reporter, to put even more emphasis on teaching health policy to his medical school students.

But Stevens never returned to Case Western Reserve. The dean under whom he had served had left the university while Stevens was in Washington, and though Stevens was invited to return, "it was a different set of circumstances," he said in a recent interview, involving the kind of "institutional politics" that occurs whenever there are changes in campus leadership. Instead, he moved to the federal Department of Veterans Affairs for three years as chief of academic affiliations, and he is currently vice-president for medical school standards and assessments at the Association of American Medical Colleges.

Stevens's experience in Washington-"It was enormously valuable," he said-together with his frustrated plans for reforming the academic medical system, echo in some important ways the gratification and the difficulties that the Health Policy Fellowships Program has experienced almost from the day it began in the spring of 1973.

The program, initiated only a year after its sponsor, The Robert Wood Johnson Foundation, became a major national philanthropic foundation, has endured significant revisions in some of its initial goals, along with the recognition that some of those objectives were impossible to achieve and needed to be abandoned. That the Health Policy Fellowships Program is still flourishing, more than a quarter of a century after its conception, is, if nothing else, testimony to the Foundation's pragmatism and flexibility. But at the same time it is a lesson in how easily the reach of an ambitious, policy-oriented foundation can exceed its grasp.

Since the Health Policy Fellowships Program began, it has selected six mid-career physicians and other health care professionals each year-most of them from academic faculties-and sent them to Washington for three months of intensive orientation in how the federal government operates, followed by nine months of full-time service as aides to members of Congress or to congressional committees involved in formulating national health policy or, less frequently, to executive branch officers in the same policy area. Through the end of 2000, 170 Fellows have participated, at a cost to the Foundation of $16.3 million.

The intention, at least at the outset, was "to provide outstanding mid-career health professionals working in academic settings with a better understanding of the major issues in health policy and a knowledge of how federal health policies are established in the United States."² The expectation was that these men and women, wise in the ways of Washington, might take senior health policy positions in the federal government while also bringing their newly acquired knowledge and political savvy to bear on their institutions, the academic medical centers that dominate health care in the United States. Underlying these goals was the feeling on the part of the Foundation's leaders that the academic centers needed to change and that the Health Policy Fellows would return to their institutions and take on the role of change agents.

Dr. Smith Goes to Washington

The first six Health Policy Fellows were picked in February of 1974 and arrived in Washington that September. Every year since then, another half a dozen men and women have come to the capital as Health Policy Fellows.

Under the auspices of the Institute of Medicine, a branch of the National Academy of Sciences, the Fellows are exposed, during their initial three-month training program, to more than 130 organized briefing sessions as well as meetings with White House aides, heads of relevant federal agencies, leaders of think tanks and interest groups and staff members from the major health committees and subcommittees of the House and Senate. They also participate in seminars on health economics, the congressional budget process, and the federal decision-making process and politics. These sessions are augmented by occasional trips outside of Washington and end with an intensive five-week series of orientation programs that the American Political Science Association conducts for its Congressional Fellowship Program and also makes available to the Health Policy Fellows. "The orientation experience was a rapid yet complete induction into the Washington world of health policy," said Thomas B. Valuck, a 1998-99 Fellow, who is now the vice-president of external affairs at the University of Kansas Medical Center, in his end-of-fellowship evaluation of the program.

A glance at the orientation schedules for recent classes of Fellows bears out Valuck's description. On a typical day, the Fellows might begin at 9:00 a.m. a few blocks from the program's Georgetown headquarters with a 90-minute briefing on the Urban Institute's health-related activities. Next they might travel to the heart of Washington's lobbying community for an hour-long discussion of major issues facing the pharmaceutical industry. Then back to Georgetown for lunch with an alumnus of the program. Finally, the Fellows might cross the Potomac to Alexandria, Virginia, for a two-hour briefing on the agenda of the Institute for Alternative Futures. On another day, the Fellows might spend almost eight hours in a seminar on health policy conducted by a former director of the federal agency that runs Medicare and Medicaid.

All this is preparation, of course, for the heart of the fellowship: the assignment to a congressional or executive branch office. Alumni of the program have described the process of choosing an assignment as turbulent and stressful, according to a team of outside experts who evaluated the program almost a decade ago. To those evaluators, the placement process resembled "a crude marketplace," in which "Fellows seem to find their way to offices that need and want them. . . ." As the program's World Wide Web site describes the process, the Fellows, during the latter stage of the orientation, meet as a group and individually with congressional or executive branch officials active in health issues and, in consultation with the program's director, Marion Ein Lewin of the Institute of Medicine, "negotiate" their assignments. Senate assignments, it turns out, are far more popular than House placements. For the past seven years, all of the Fellows went to work in Senate offices.

The first group-the class of 1974-75-included a psychiatry professor at an East Coast medical school, a professor of family and community medicine and assistant vice-chancellor for academic affairs at a state university on the West Coast, the chairman of the pediatrics department at an East Coast medical school, an associate professor of the history of medicine and public health at another East Coast academic medical center, a member of the faculty at a Southern medical school, and a medical researcher at still another East Coast medical school. All but the assistant vice-chancellor were physicians, though later classes included dentists, registered nurses, and others in the academic community.

In fact, the six Fellows selected each year were chosen exclusively from academic faculties in medicine and other health professions until 1993. In that year, following the recommendation by the team of independent evaluators the year before, the Foundation extended eligibility for fellowships to all health care professionals, not just academics, including administrators of health maintenance organizations, whether operated for profit or not. But until very recently, attempts to market the program to these organizations hadn't met with much success. That's in part because many of these organizations felt that they couldn't afford to let employees take a year off from work and because many of the potential applicants worried that there wouldn't be a job for them after their year in Washington. And it's in part because candidates from these organizations weren't seen as competitive with the traditional candidates. This has begun to change, however. With the class of 2000-2001, for the first time, half of the Health Policy Fellows came from outside of academic medicine: one from a community health center in Brockport, New York; a second from Anthem Blue Cross and Blue Shield in East Haven, Connecticut; and a third from La Familia Medical Center in Santa Fe, New Mexico.

Whatever the reasons, there has been no significant increase in the pool of applicants from which the six Fellows are chosen each year. That number has averaged about 25 through the years, though for the class of 2001-2002, more than 30 people applied, Lewin said. In fact, one of the questions the Foundation asked an evaluator of the program in 1980 to examine was why the number of applicants was so low. His findings: stipends for the Fellows, $50,000 at the time, were too low; the medical centers, which nominate candidates for fellowships, were complaining that the program wasn't in line with their priorities; and, according to the medical centers, there just weren't enough strong candidates for the fellowships.

The evaluator, Daniel I. Zwick, who at the time was an independent health policy specialist, recommended an increase in the stipends and proposed that the program allow senior faculty members to serve as Fellows. The Foundation accepted both recommendations. Moreover, it took steps to expand the pool of applicants by allowing institutions without medical schools to nominate Fellows and permitting professional schools within academic medical centers to nominate Fellows (previously, academic health centers were limited to a single candidate).

In 2001, the Foundation re-authorized the Health Policy Fellowships Program for an additional three years. It agreed to expand the number of Fellows to ten by the end of the three-year authorization period and to increase the size of the award for each Fellow to $156,000 for the year in Washington plus two follow-up years. The larger grant, according to Lewin, will allow Fellows to remain on Capitol Hill until Congress adjourns, instead of having to leave just as the legislative session approaches its climax. The extra money will also give them some financial flexibility after they finish their fellowships, she added. The program will also put more emphasis on attracting minorities and health professionals with behavioral and social sciences backgrounds, Lewin said.

Achievements and Failures

Over the years, the fellowship program's methods may have remained the same, but its objectives have been adjusted as evidence accumulated that some of them were unrealistic and that at least one of them was reached with surprising ease. Much of this evidence came from Zwick's 1980 evaluation and from one in 1992 led by David Blumenthal, the chief of the Health Policy Research and Development Unit of Massachusetts General Hospital in Boston and a professor of medicine at Harvard Medical School, who is now the chairman of the Health Policy Fellowships Program's Advisory Board.

When it established the Health Policy Fellowships Program in 1973, the Foundation's board had stated that one of its purposes was "to provide health professionals who may desire a future career in government an opportunity to prepare for such service."³ It acted principally on "the perception that leading academicians were frequently tapped for senior health policy positions in the federal government but were ill-prepared to assume these roles."⁴ The Foundation officials felt that "an intensive exposure to government early in the careers of these academic health professionals would add enormously to their later effectiveness in governmental roles."⁵

As it turned out, within a few years the Foundation came to see the goal of preparing academics for policy roles in the federal government as unnecessary. Two decades later, however, Blumenthal and his fellow evaluators said that although there was no doubt that the program had failed to achieve that goal, it had succeeded in directing former Fellows "toward involvement in government and community affairs from a base in the private sector." And that was no small accomplishment, they suggested. Their survey of the former Fellows showed that almost one out of five of them had held a federal appointive job, and that most of the rest of them had become active in the health policy arena. More than 56 percent had consulted for a federal program at one time or another, almost 85 percent had stayed in touch with congressional staffs, 63 percent had lobbied Congress, 56 percent had consulted for a federal program, and 38 percent had testified before a congressional committee. Moreover, 58 percent had lobbied state legislatures and 35 percent had advised governors.

That sounds good, but how much of it can properly be attributed to the Health Policy Fellowships Program? Blumenthal and the other evaluators, Gregg S. Meyer and Jennifer N. Edwards, expanded on their survey in a Health Affairs essay⁶ published in 1994, taking a close look at the differences, if any, between the former Fellows and those who were finalists for fellowships but didn't make the final cut. Their premise was that the two groups were fundamentally alike in most respects: those who selected the Fellows told the evaluators that all of the finalists were "highly qualified."

The survey showed that "significantly more Fellows [than finalists] had participated in one or more academic health policy activities" and that Fellows were likelier than finalists to have participated in several kinds of community and professional activities. These activities included serving in a leadership position or as a health policy adviser in a professional organization, serving as an HMO executive, directing a community health center, and serving on a medical peer review organization. The former Fellows were also likelier than the finalists to be in contact with congressional staffs, to testify or lobby Congress and state legislatures, and to serve in the federal government.

So if the program hasn't succeeded in directing Fellows toward full-time government service, it has managed to point them, as private citizens, in the direction of active involvement in government and community affairs.

When the Foundation's staff first began putting together the plan for what became the Health Policy Fellowships Program, academic health centers, or AHCs, "were viewed as the center of the health and health care universe," according to Lewis G. Sandy, the Foundation's executive vice-president, and Richard Reynolds, his predecessor in that post. "The Foundation's staff and board felt that there was an imperfect fit between the mission of AHCs and the needs of the nation," they wrote. "Although not denying the importance and the value of specialty training and practice, the Foundation felt that the declining interest in primary care and the need for a health care workforce that could care for a population's health needs were critical issues not being addressed by AHC leaders." So instead of awarding grants to support biomedical research, the Foundation decided that "more leverage could be gained by fostering the public and community responsibility of AHCs. . . . From that beginning, then, emerged a series of Foundation grants and programs with the aim of influencing academic medicine."⁷

Among these programs was Health Policy Fellowships. Its designers believed that "an intimate exposure to Washington and its ways" would help future deans and chief executive officers of academic medical centers, health professional schools, and teaching hospitals to "develop the skills necessary to interact more constructively and effectively with the federal government."

But the Foundation's ambitious attempt to change the culture of the academic medical centers missed its mark. By 1992, it had become evident that the Fellows were not having the hoped-for impact on their parent institutions. The medical centers, according to the Blumenthal evaluation team, were "embedded in and wedded to a health care system that has defied every major effort at reform over the last 50 years." That is still the case today, according to Blumenthal. "I think their resistance bent but did not break under managed care, and I think that what you're seeing now is the triumph of the counterrevolution," he said in a recent interview. "With the end of managed care as we knew it, reform is still a long way away."

The goal of making academic health centers more socially responsive seemed unattainable by such a small fellowship program. As Sandy and Reynolds concluded, "single agents for change faced difficulties in altering well-entrenched organizational behavior" of the academic centers.⁸

From the Foundation's viewpoint, the biggest problem has been the unwillingness of academic health centers to confront change-or at least the kind of change the Foundation has been pressing for since the early 1970s. The Fellows, after a year in Washington, were changed, "but their old institution was still the same," Steven Schroeder, the president and CEO of The Robert Wood Johnson Foundation, wrote in 1995. As a consequence, he said, the Foundation "changed its expectations about the fellowship's impact on sponsoring institutions."⁹

Over the program's quarter-century of life, a majority of the Fellows have returned, at least initially, to the institutions for which they worked before going to Washington. This was once quite important to the Foundation, whose attempt to influence academic medicine seemed to rely on the Fellows-or at least most of them-returning to the place where they would best be able to effect change. It is less important today, and the goal has largely been set aside.

In fact, the 1992 evaluation recommended that Fellows no longer be "obligated" to return to their sponsoring institutions (though, of course, it was never a legal requirement that they return). Instead, they should be encouraged "to pursue the career option that would best develop their personal potential."

The Foundation board, however, did not accept that recommendation, deciding that it was "too large a shift," Sandy said. "We didn't want to toss the baby out with the bathwater in terms of its academic roots and the idea of a pathway from and then back to academia. Where we came out was with a 'softer' version of that recommendation, which was to be cognizant of the fact that people might not return full time to academia but would find their background applicable in other health policymaking settings."

Subsequently, the nominating procedure was changed to require the sponsoring organization to promise that the nominee would have "an appropriate" position to return to after the fellowship and to outline its plan to use the Fellow's new skills on his or her return. Nevertheless, program director Lewin said, the medical center officer who has made the promise is often gone from the institution, or at least from his or her former position, by the time the Fellow returns, or the institutions "are so strapped or have so many other pressures" that they sometimes can't keep their promises. In any case, Lewin added, those who go somewhere else often improve their job status, so that the move must be considered "a positive, not a negative," for the former Fellows.

But this begs the question that seems to have troubled the Foundation and the evaluators most: Why were the academic health centers reluctant to let their best and brightest participate in the Health Policy Fellowships Program?

For one thing, the academic health centers-all of which include a medical school, at least one other health professional school or program and at least one teaching hospital-were never delighted at the prospect that some of their mid-career faculty members would be trained, in effect, to leave the centers for government service. Zwick, writing in 1982 about his evaluation of the program two years earlier, noted that some of the centers were already worried about the increased risk of losing some of their academic stars.¹⁰ Over time, that fear does not seem to have abated, Lewin said, and "the ownership that academia has felt in this program has declined a little bit because they're not sure everyone is going to return." And as academic medical centers find themselves increasingly in a competitive financial situation, "they can't afford to lose a key health care professional who could be bringing in revenue," said Michael Rothman, the Foundation's senior program officer overseeing the Health Policy Fellowships Program.

Adding to the tension, according to Schroeder, is the fact that what the Fellows learn during their year in Washington "is not mainstream in the lives of academic medical centers," which are primarily interested in basic research and highly specialized health care delivery, not in health policy.

The prospective fellowship candidates, for their part, are worried about what awaits them if they return to the medical centers after a year in Washington. Will their old job be there when they come back? What affect might restructuring, mergers, or strategic alliances have on their prospects for a smooth return? Will their mentors have left in their absence, as happened with David Stevens at Case Western Reserve? Will their absence for a year have cost them opportunities for advancement? And if resources for new programs are scarce at their institution, will the returning Fellows be able to capitalize on what they've learned during their 12 months in Washington?

Ironically, what seemed a lesser objective when the Foundation initiated the Health Policy Fellowships Program has turned out to be one of the program's major successes: making these health professionals available for nine-month assignments at congressional committees in the health field. It is widely agreed that this has worked very well. So a program devised largely to benefit the individual Fellows and to effect change at their institutions has received praise as a tool to assist Congress as it considers health policy legislation.

The program's web site boasts that the Fellows are on the Hill "not as onlookers, but as full-time, working participants," helping to develop legislative proposals, arrange hearings, brief legislators for committee meetings and for floor debates, and working with congressional staffs in House and Senate conferences. During their time in Washington, the Fellows have helped to satisfy the congressional craving for expert medical knowledge and advice. Or so affirm congressional aides who have worked with the Fellows.

The 1992 evaluation found that some congressional aides were initially skeptical about the "amateur" status of the Health Policy Fellows. This was particularly true among majority aides to most of the major committees with health policy jurisdiction, who also insisted that they didn't have the time to train new people every year and were concerned that the Fellows wouldn't always be available and would be gone just as the legislative season reached its climax late in the year. Nevertheless, the evaluators reported, most of these doubters were "generally positive about the program as a whole," and the reluctance of majority aides to sign Fellows up for nine months seems to have diminished recently.

Aides to minority members of the major committees and those who worked on the personal staffs of members of Congress involved in health policy were much more willing to enlist the Fellows on their staffs and much more enthusiastic about their performance. That's at least in part because these legislators are less likely to have sufficient staff assistance and expertise in this area. "The fellowships are good for us and good for them," one such aide told the evaluation team. Another said of the Fellows that they provided "another pair of hands and a good brain." But some agreed with the skeptics that the Fellows were not always available when needed and that the program ended too early in the legislative session.

The Health Policy Fellowships Program was even the source of political controversy during the congressional debate over President Clinton's health care plan in 1993 and 1994. Frank Karel, the Foundation's vice-president for communications, explained that the Foundation organized community meetings to open up the process and let people tell their stories and express their views to Hillary Clinton. "Because of this, and because so many of our grantees were involved in that presidential initiative, hostile critics of the Foundation accused us of partisanship, and were widely quoted," he wrote recently.¹¹ Foundation executive vice-president Sandy added in a recent interview that the fellowship program was caught up in the "white-hot politics" surrounding the Clinton plan. "We got beat up over the Foundation's role in the planning process and the politicization of health policy," he said.

Lewin agreed that "there was some short-term anger and negative feelings," but, she added, "it blew over very quickly." Almost every year, she said, an article is published "that views the Fellows as agents of the 'liberal' Robert Wood Johnson Foundation and its agenda, but it is never taken seriously." And Paul C. Harrington, who was the majority health policy director for the Senate Health, Education, Labor and Pensions Committee until the Democrats took control of the Senate in June 2001, noted that because the Fellows were working for offices engaged in drafting controversial health legislation in 1993-94, it's understandable that they were caught up in the legislative debate. The program and the Foundation, he said, "were tarred with a brush, unfairly I think, because it didn't reflect an understanding of the role of the Fellowship program." In the years since then, he added, these suspicions have largely been "dispelled, and the Fellows are held in high esteem." After his boss, Senator James M. Jeffords of Vermont (then a Republican), became committee chairman in 1997, he picked a Fellow each year to work for the committee. The committee's new Democratic chairman, Edward M. Kennedy of Massachusetts, has also regularly selected Fellows to work for the panel.

What helped the program weather the small storm, Lewin suggested, was the fact that in its earliest days, it had "gained a unique reputation," and that "to this day, it is still considered the gold standard of health policy fellowships." The program also quite quickly became very valuable to congressional offices, she added, "and many of these offices have come to rely on these people" as sources of expert advice, especially because they have clinical experience.

In 1992, the evaluation team surveyed alumni of the program and found that 81 percent of them agreed with the statement that their fellowship experience had "changed the way I think" and that 60 percent agreed that "it changed my life." Recent anecdotal evidence suggests that those views are still widely held. "It was the most wonderful year of my life," Robert H. Miller, an ophthalmologist, and a member of the class of 1996-97, recalled in an interview. Miller, who returned to Tulane University Medical Center as vice chancellor for clinical affairs after his fellowship and became dean of the University of Nevada School of Medicine in December of 1999, said he didn't doubt that his Washington experience-he worked in the office of Senator John B. Breaux, Democrat of Louisiana-helped him get his current post, which requires intensive courting of state legislators. His fellowship, he added, taught him how the political process-whether in Washington or in the state capital-really works.

The 1992 survey of former Fellows offers statistical support for these examples. The survey found that 80 percent of the Fellows agreed that they were "highly satisfied" with the program, that 98 percent would do it again, and that 99 percent would recommend the program to colleagues. A majority said that the program had helped a lot in achieving their career goals, and more than two-thirds said that it had contributed a lot to their career satisfaction, particularly in the areas of community and government relations and academic administration rather than in academic pursuits such as teaching, researching, and publishing. Lewin, who has worked closely with each class of Fellows since she became the program's second director, in 1987, said that they have had a chance to learn how Congress really works, how difficult it is for diverse interests to achieve agreement and how democratic the system really is. "The Fellows consider it a life-changing experience," she said.

Despite the program's having had to modify its goals over the years and a sense that the program may have been too modest for its ambitious objectives, the Foundation has never balked at renewing it-most recently, in the spring of 2001. "This is an ongoing investment in people, and it's a signature program" for the Foundation, Lewin said. But she quickly added that there may well come a time when something else takes its place.

Measuring the effect even of a program that has a concrete target-reducing the number of children who lack health insurance, say, or improving the long-term care of the elderly-can be a daunting task. Evaluating a program such as the Health Policy Fellowships, whose goals have shifted over time and whose objectives have sometimes been as broad as influencing the nature of academic medicine in the United States, can be almost overwhelming.

"This is the kind of program you shouldn't try to quantify," Schroeder warned. "We're looking for qualitative signs," such as the reputation of the Fellows, the nature of their fellowship experience, what they do after it ends. "There's a certain sniff test," he added. "If you're getting people who are good, and if they go on to do good things, then it's probably worth keeping. If you're getting marginal people who don't seem to have much impact on the Hill and don't seem to have much of an impact after their fellowships, then it might not make sense to continue the program."

David Blumenthal, in a recent interview, said that the program's inability to accomplish much in the way of reforming the academic medical centers amounted to the "failure of an unrealistic goal." There continues to be "an enormous gap in culture and understanding between the academic health centers and Washington policymakers," he said. "There are some deans and academic leaders who are quite sophisticated, but it's much more common that they're not." The fellowships program, Blumenthal acknowledged, "has made a modest difference in that regard. There are a small number of deans who are graduates of that program, and they certainly have a deeper understanding of the Washington process."

Certainly the program has made its mark on Capitol Hill, if not in the academic institutions. Though winning praise on the Hill was never part of the program's goals, it might have been shut down long ago if the reviews had been negative.

According to their own testimony, the Fellows have benefited in career terms from the program. Their fellow faculty members have identified them as resources on health policy. And they've maintained their connections with people in Congress and in the executive branch.

Schroeder, in his 1995 article on the program, noted that fellowship programs are expensive (the annual cost has been more than $1 million for a class of six, and will rise to more than $2.5 million as the number of Fellows climbs to ten a year and as the grant to each Fellow increases) and, of necessity, long-term. But in addition to costs, they have "another disadvantage when competing for Foundation support," he acknowledged. They are "relatively invisible" to a foundation's staff and trustees. "The payoffs for the other programs are more immediate. It is easier to judge the quality of research and demonstration programs, the impact of a television documentary or the grandeur of a college library than it is to assess the impact of a fellowship program." Nevertheless, he wrote, The Robert Wood Johnson Foundation supports this and other fellowship programs, "stimulated by the conviction that their impact is enduring and that foundations are almost uniquely positioned to invest in such long-range projects."¹²

So what lessons have been learned about the Health Policy Fellowships Program? Lewin echoes a theme stated by the evaluation team in 1992: that the program needs to be more aggressively marketed. She acknowledged that to some former Fellows, it's an exclusive club, and "once you advertise it, it loses some of its appeal."

The evaluators had suggested marketing the program to faculty below the top level instead of relying on the institutions to act as intermediaries. But while this is clearly a way to increase the pool of applicants, it could be a risky step. Sandy, in an interview, pointed out that "the institutional sponsorship of the Fellows is part of the brand identity of the program within Washington," and said that if the fellows come without that sponsorship, "that may dilute the brand equity in the whole fellowship"and might even suggest that the Fellows have individual political agendas. That's something the Foundation would want to avoid, he said.

As to the role that the Fellows play after leaving Washington, the evaluators observed almost a decade ago that "affecting the career development of its alumni is, in fact, the most fundamental purpose of any fellowship program." They added, "If fellows are to become agents of change, they must first be changed themselves." Blumenthal, who continues to pay close attention to the program as the chairman of its Advisory Board, was asked recently if, indeed, former Fellows had become "agents of change." His response: "I think they've tried to function as agents of change. I think it's unrealistic to expect 150-odd people to change a health care system of a trillion and a half dollars."

What's in the offing, then, for this program after more than a quarter of a century?

The Foundation has come to terms with the fact that the Health Policy Fellowships Program will never achieve the ambitious goals originally set for it: preparing health professionals for careers in government and changing the face of academic medicine in America. That, as it turned out, was too much of a reach for such a relatively modest program. Yet the program has altered the professional careers of the Fellows and is perceived in Washington as valuable. It continues to be one of what the Foundation calls its "core programs." Like other core programs, such as the Clinical Scholars Program, it has been around a long time. So, despite some shortfalls in reaching all of its goals and despite its high cost, it has become part of the institutional fabric of the Foundation and is likely to remain part of that fabric for some years to come.