For the Public Good

Highlights from the Institute of Medicine, 1970–1995

Institute of Medicine Council

Washington, D.C. 1995

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 For the Public Good Highlights from the Institute of Medicine, 1970–1995 Institute of Medicine Council NATIONAL ACADEMY PRESS Washington, D.C. 1995

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 National Academy Press 2101 Constitution Avenue, N.W.Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Institute of Medicine's Council. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The Institute gratefully acknowledges the generous support of the following organizations toward its 25th anniversary activities: Albert Einstein College of Medicine of Yeshiva University, the Carnegie Corporation of New York, the Commonwealth Fund, Kaiser-Permanente, Memorial Sloan-Kettering Cancer Center, New York Hospital, the University of Rochester Medical Center, and Yale University School of Medicine; corporate benefactor—Bristol-Myers Squibb; corporate patron—Pfizer, Inc.; and corporate sponsors—Amgen, Inc., Eli Lilly and Company, Procter and Gamble, G.D. Searle and Company, Sandoz Pharmaceuticals Corporation, Schering-Plough Corporation, and the Upjohn Company. Additional copies of this publication are available in limited quantities from: Institute of Medicine Reports and Information Office 2101 Constitution Avenue, N.W. Washington, DC 20418 Copyright 1995 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 INSTITUTE OF MEDICINE COUNCIL KENNETH I. SHINE, M.D. (Chairman), president, Institute of Medicine LINDA H. AIKEN, Ph.D., Trustee Professor of Nursing and Sociology and director, Center for Health Services and Policy Research, University of Pennsylvania JOEL J. ALPERT, M.D., professor of Pediatrics and Public Health,Department of Pediatrics, Boston University School of Medicine J. MICHAEL BISHOP, M.D., director, the G. W. Hooper Foundation, and professor of Microbiology and Immunology, Biochemistry, and Biophysics, University of California at San Francisco BARRY R. BLOOM, Ph.D., investigator, Howard Hughes Medical Institute, Albert Einstein College of Medicine, Yeshiva University FLOYD E. BLOOM, M.D., chairman, Department of Neuropharmacology, the Scripps Research Institute, La Jolla, California JOSEPH A. CALIFANO, JR., LL.B., chairman and president, the Center on Addiction and Substance Abuse, Columbia University DAVID R. CHALLONER, M.D., vice president for Health Affairs, University of Florida BARBARA J. CULLITON, editor-in-chief, NATURE MEDICINE, Washington, D.C. SUZANNE W. FLETCHER, M.D., professor, Department of Ambulatory Care and Prevention, Harvard Medical School HENRY W. FOSTER, JR., M.D., consultant, Department of Health and Human Services, Washington, D.C. RUBY P. HEARN, Ph.D., vice president, the Robert Wood Johnson Foundation, Princeton, New Jersey DONALD A. B. LINDBERG, M.D., director, National Library of Medicine, National Institutes of Health, Bethesda, Maryland PHILIP W. MAJERUS, M.D., professor of Medicine, Biochemistry, and Molecular Biophysics, and director, Division of Hematology-Oncology, Washington University BARBARA J. MCNEIL, M.D., Ph.D., Ridley Watts Professor of Health Care Policy and head, Department of Health Care Policy, Harvard Medical School JOSEPH P. NEWHOUSE, Ph.D., John D. MacArthur Professor of Health Policy and Management, Division of Health Policy Research and Education, Harvard University JUNE E. OSBORN, M.D., professor of Epidemiology, School of Public Health, and professor of Pediatrics and Communicable Diseases, the University of Michigan Medical School

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 ARTHUR H. RUBENSTEIN, M.D., Lowell T. Coggeshall Distinguished Service Professor of Medical Sciences and chairman, Department of Medicine, Division of the Biological Sciences, the University of Chicago CHARLES A. SANDERS, M.D., chairman, Glaxo, Inc., Research Triangle Park, North Carolina RALPH SNYDERMAN, M.D., James B. Duke Professor of Medicine, chancellor for Health Affairs, and dean, School of Medicine, Duke University Medical Center GAIL L. WARDEN, president and chief executive officer, Henry Ford Health System, Detroit, Michigan Staff ENRIQUETA C. BOND, Ph.D., executive officer (through June 1994) JOSEPH S. CASSELLS, M.D., interim executive officer (from June 1994 to January 1995) KAREN HEIN, M.D., executive officer (from January 1995) SUE G. BARRON, executive assistant, program, Executive Office CLAUDIA M. CARL, administrative associate, report review, Reports and Information Office LOUIS E. CRANFORD, director, Administrative Office MICHAEL A. EDINGTON, director, Reports and Information Office KAY C. HARRIS, director, Development Office SANDRA H. MATTHEWS, senior executive assistant to the president, Executive Office PATRICIA A. OLENDER, executive assistant, administration, Executive Office JANA H. SURDI, director, Office of Council and Membership Services SHANA VISSER, staff assistant, Reports and Information Office

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Preface On the occasion of the 25th anniversary of the establishment of the Institute of Medicine, it is timely to revisit some of the important areas in which the Institute has made significant contributions. The purpose of this exercise is not only to identify these areas but to provide an opportunity for us to learn from the experience. In this document, Dr. Enriqueta Bond, who served as executive officer of the Institute from 1989 to 1994, has summarized some of the events that took place during the tenure of each of the Institute's presidents. Members of our staff have summarized our activities in each of six important areas, and members of the Institute have provided commentaries on these papers. They have attempted to identify the impact of our studies and programs in each area while also weighing the successes and the shortcomings of these efforts. There is much that we can learn from these commentaries, which can help us improve our performance in the future. As you recall, the Institute of Medicine completed its strategic planning activity in early 1994. This plan will be revisited in 1996. The ideas, analysis, and recommendations arising out of these highlights will provide us with a background as we revise our strategic plan. I hope that you will take the opportunity to review these highlights and to provide additional perspectives, analysis, and suggestions with regard to how we can increase our effectiveness in the future.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 As part of our 25th anniversary celebration, we have conducted a series of regional lectures, symposia, and panel discussions. The high standards of intellectual excellence and policy relevance sought by the Institute have been well demonstrated in the quality of these activities, which are conducted under the direction of our members in the various regions. A comprehensive history of the first 25 years of the Institute will be commissioned shortly. In the course of that exercise, information and ideas will be sought from Institute members, past and present committee members, government agencies, foundations, the media, industry, and many others to provide their perspectives on the Institute. I hope that you will participate in the recording of this history in the same remarkable way in which you have participated in making it. Kenneth I. Shine President, Institute of Medicine

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Acknowledgments As with the activities and achievements outlined in the chapters that follow, this volume is the product of the thoughts, advice, work, and words of a large number of people, some of whom have contributed in more than one capacity to its completion. We are grateful to each of those who have assisted in the planning and execution of For the Public Good. The idea to produce a volume detailing the history of the Institute of Medicine (IOM) first arose during the work of the planning committee for the Institute's 20th anniversary in 1990. However, the members of that committee—Roger J. Bulger, Barbara J. Culliton, Stanley B. Jones, Lawrence S. Lewin, Robert F. Murray, Jr., and Alan S. Rabson —envisioned a more in-depth document than it has been possible to accomplish to date. Work on an authoritative history of the IOM, to which the current volume is a prelude, will move forward during 1996. Integral to both For the Publc Good and the volume still to come is the solid foundation of historical materials—interviews, recollections, minutes of meetings, correspondence, and other documents—collected by Wallace K. Waterfall while he was the director of the Office of Communication. We are indebted to him for compiling this valuable resource. The chapters in this book were written by IOM staff, past and present, and IOM members. The staff, whose chapters describe key activities and areas of interest, are Enriqueta C. Bond, Marilyn J. Field, Leslie M. Hardy, Karen Hein, Marion Ein Lewin, Kathleen N. Lohr, Constance M. Pechura, and Kathleen R. Stratton; the IOM members who provided commentaries on the staff chapters are Linda H. Aiken, Stuart H. Altman, Barry R. Bloom, Robert

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 H. Brook, Avedis Donabedian, Kristine M. Gebbie, Gerald N. Grob, David A. Hamburg, June E. Osborn, Uwe E. Reinhardt, Frederick C. Robbins, and Steven A. Schroeder. Mike Edington managed the editorial and production aspects of the project. Without their dedication and committment, this book would not have been possible. Many others—IOM members and current or former IOM staff—have contributed their thoughts and efforts to planning the project and refining the materials contained herein. These contributors include Enriqueta C. Bond, under whose stewardship as executive officer the project advanced and developed; Joseph S. Cassells, who, as interim executive officer, took over the reins of control when Queta Bond departed and kept up the momentum and tightened the volume's focus; and Karen Hein, IOM's current executive officer, who brought her ideas and perspective to the project and saw it into being. Those individuals who provided information concerning events during their tenure at or involvement with the Institute include IOM's past presidents —John R. Hogness, Donald S. Frederickson, David A. Hamburg, Frederick C. Robbins, and Samuel O. Their—and former acting presidents Stuart Bondurant and Robert J. Glaser; as well as Gert H. Brieger, Roger J. Bulger, Daniel M. Fox, Gerald N. Grob, Ruth S. Hanft, Charles E. Odegaard, Charles E. Rosenburg, Barbara G. Rosenkrantz, Rosemary A. Stevens, and Adam Yarmolinsky. Other IOM staff who helped with the project or with the activities related to the 25th anniversary are: Susan G. Barron, Conrad T. Baugh, Sarah S. Brown, Claudia M. Carl, Louis E. Cranford, Kay C. Harris, Sandra H. Matthews, Patricia A. Olender, Richard A. Rettig, Jana H. Surdi, Karl D. Yordy, and Shana Visser. In addition, we are thankful for the help of our graphic designer, Pamela Reznick, and of the staff at the National Academy Press, who oversaw the transformation of the book from printouts to printed pages: James M. Gormley, Sally Groom, Dorothy B. Lewis, and Sally S. Stanfield. Kenneth I. Shine President, Institute of Medicine