To Improve Human Health A History of the Institute of Medicine (1998) / Chapter Skim
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4 Fred Robbins and the Sproull Report
4 Fred Robbins and the Sproull Report
Pages 134-178
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From page 134... ...
Ultimately, Robbins managed both to expand upon the work of David Hamburg and to reaffirm the concept of the TOM. Child health became an important area of concern for the TOM during the Robbins years; so did studies related to vaccine supply and medical technology.
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From page 135... ...
degree was "preferable but not decisive." The committee noted that a "research scientist" might be acceptable if he or she had "good rapport with" and "recognized stature in" the health professional community, implying that it was unlikely the search committee would select, for example, an economist. The IOM was about medicine and would, in all likelihood, be lead by a medical doctor, preferably one who knew something about health policy, who had pained an international perspective on the issues.
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From page 136... ...
By the end of 1979, the search committee and the Council had put Frederick Robbins at the top of the list. "Fred Robbins is clearly our first choice," William Danforth told NAS President Philip Handier, "we recommend that all efforts be made to secure his services."5 Robbins's career path resembled that of other TOM presidents.
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From page 137... ...
Unlike the personable and energetic Hogness, the intensely intellectual Fredrickson, or the charismatic Hamburg, Fred Robbins, an affable and highly competent man, would maintain what others had created. From the very beginning, he faced an uphill fight.
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From page 138... ...
Congress responded, as it did in many controversial situations, by calling for a study of the matter.~° At the beginning of 1980, Donald Fredrickson, the head of NIH, contacted David Hamburg about having the IOM do the congressionally mandated study. Although the IOM Council reacted with enthusiasm, it took many months for federal officials to decide if they wanted to enter into a contract with the TOM or whether they preferred to do the study in-house.
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From page 139... ...
subsidize medical education at the beginning of the 1970s, so it received a similar request to investigate , ~ c, .
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From page 140... ...
By the late 1970s, a substantial number of active-duty military physicians were interns, residents, or fellows, and the Department of Defense ordered the services to limit the fraction of military physicians in graduate medical education to not more than 20 percent of their authorized physician strength. All three of the uniformed services protested this
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From page 141... ...
Differences in generational outlook also figured in another of the TOM studies that Fred Robbins inherited from David Hamburg. This study, on the health-related effects on marijuana use, reflected the TOM's role as an arbiter of public health.
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From page 142... ...
The study fell into the domain of the Health Sciences Division at the TOM. Enriqueta BoncI, a talented scientist who would become an increasingly important part of the IOM's history, did much of the staff work for the project.
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From page 143... ...
"Our major conclusion," the steering committee wrote, "is that what little we know for certain about the effects of marijuana on human health and all that we have reason to suspect justify serious national concern."23 The committee worried particularly about the effects of marijuana on child development. In these ways, the marijuana study resembled the abortion study.
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From page 144... ...
Not everything that the TOM studied in the areas of public health and health sciences concerned subjects of long-standing duration. Just as Fred Robbins took over from David Hamburg, the TOM became involved in the emerging concern over toxic shock syndrome.
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From page 145... ...
The Eber! Report Circumstances forced Fred Robbins to spend a great deal of time removed from the sorts of scientific considerations that informed the marijuana and toxic shock studies and to be engaged instead in practical matters of governance.
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From page 146... ...
Even though the task force originated with Hamburg, Fred Robbins essentially took it over, and it became his vehicle for shaping the organization to his liking. When the task force met in the spring of 1981, it examined such questions as the distinctions between active and senior members and the relationship between the TOM and the Assembly of Life Sciences (ALS)
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From page 147... ...
As a corollary, the Council advised the TOM to create a resources development committee to develop a plan for raising"an adequate pool of independent, flexible funds" that would meet the Institute's long-range financial needs. The option of appointing a vice president "should remain open." More urgently, the TOM should persuade Frank Press to revise the NAS report review system and should point out to him "as forcefully as possible" the detrimental effects of maintaining so many redundant units within the Academy.3t In the fall of 1981, Fred Robbins wrote Frank Press that there was a "significant and disturbing problem of overlap in the program interests of the TOM and the ALS." The program plan, style of operation, and "general scope" of the Division of Medical Sciences "increasingly converge" with the TOM, leading to "friction, 'turf sensitivities, and confusion" in the minds of funders.
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From page 148... ...
Instead, Fred Robbins, the president of the TOM, became chairman of the Commission of life Sciences in the summer of t982.35 The resolution of organizational issues, however unsatisfactory, freed the TOM to concentrate on other pressing concerns, such as the criteria for membership and the creation of a realistic program plan. In July 1983, Robbins appointed a special task force, headed by John Hogness, to investigate the membership selection process.
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From page 149... ...
HCFA officials, it became evident, had no desire to tie the hands of the Reagan administration before it had even begun.37 The TOM never did find its niche in the area of hospital and physician reimbursement under Medicare. In 1983, Congress approved a prospective payment system for hospitals that depended on a statistical mechanism known as a "diagnosis-related group." Although the TOM had once made a similar proposal, it played no role in the development of the one that was adopted.
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From page 150... ...
The Omnibus Budget Reconciliation Act of 1981 contained a provision for the TOM to study the implications of the increasing number of physicians. With the administration less than enthusiastic, the study was never funded.40 The hostility of the Reagan administration hit the entire NAS hard, particularly after President Carter's science adviser made the transition to the Academy.
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From page 151... ...
For the TOM, the offer to Newman was similar to the one it had made to Theodore Cooper at the end of the Ford administration and indicated no disapproval of the Reagan administration. To the administration, however, which was intent on making revolutionary changes in the relationship between the government and its citizens, harboring former Democratic officeholders was a suspicious act.
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From page 152... ...
Roger Bulger, president of the University of Texas Health Science Center at Houston and former TOM staffer, came to Gray's rescue by agreeing to have his institution fund the papers.44 The bulk of the committee meetings took place in 1984, during the period in which Ronald Reagan thrashed Walter Mondale in the general election. Discussions revealed the polarized opinions that people brought to the table.
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From page 153... ...
Therefore, although the for-prof~ts eased some problems of access, they worsened others. This was a major motif of the report: deregulation in the health care industry solved some problems but created others.
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From page 154... ...
She wanted to understand how the present NTH structure had come to be and how it might be changed. The TOM put James Ebert, the biologist who had recently investigated the structure of the National Research Council, in charge of a steering committee that included, among others, the president of Purdue University, a Nobel Prize-winning biochemist from Vanderbilt, and a leading student of public administration from Harvard's Kennedy School.
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From page 155... ...
Still, there was a special sensitivity to this issue during the Reagan administration, which alone among the administrations that preceded it, appeared to hold no special brief for NTH. Simply put, the TOM had no desire to increase the Reagan administration's oversight of the National Institutes of Health.
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From page 156... ...
Behrman, dean of Case Western Reserve Medical School, agreed to chair the pane] that produced a report by the spring of 1985.52 The report, Preventing Low Birthweight, stressed that preventive measures to decrease the incidence of low birthweight babies were both cost-effective and a means of reducing infant mortality.
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From page 157... ...
Although such a practice eventually became routine for TOM reports that promised to be of wide interest, it began with the low-birthweight study, a project in which Fred Robbins took a deep personal interest. The TOM also chose to release the report in dramatic fashion.
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From page 158... ...
During the briefing, the Secretary staff did not show a lot of interest in the report; one senior staff member attended to his paperwork during the IOM presentation. After listening politely, Secretary Heckler asked Fred Robbins to remain behind at the end of the meeting.
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From page 159... ...
In May 1982, the Health Care Financing Administration announced that it wished to change some of the regulations, for example, by reducing the frequency of inspections and substituting accreditation by a private group for federal accreditation. Democratic members of the House responded by introducing a bill in the spring of 1983 that called for the TOM to study nursing home accreditation.
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From page 160... ...
. ~J Fund-Raising Despite the exhilaration of the low-birthweight and nursing home studies, the constant need to raise funds drained the energy of Fred Robbins and his staff and led to many frustrations.
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From page 161... ...
In response, the TOM actually dropped some of its fees in the Hamburg era, for example, no longer charging members to attend the annual reception. By way of contrast, Fred Robbins felt that, as an TOM committee phrased it, the "time is past due to ask more from members in the form of financial support." At the end of 1984, the TOM Council decided to charge annual dues and institute a registration fee for the annual meetings.62 User fees made only the slightest of dents in the TOM's chronic financial difficulties.
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From page 162... ...
No wonder, then, that Robert Derzon called funding the "most serious issue facing TOM" in 1984.63 The Sproull Report By the end of 1983, the consortium of foundations that supported the TOM appeared to be getting restless, dissatisfied with the TOM's progress. In January of that year, Robert Ebert, former dean of the Harvard Medical School and current president of the Milbank Memorial Fund, wrote to Frank Press, president of the National Academy of Sciences, and proposed a study of the Institute of Medicine.
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From page 163... ...
To prepare for these hearings, the TOM devoted a Council meeting in May to a discussion of its future direction. The session provided a very candid review of the organization's strengths and weaknesses, one similar in tone to the retreats that both David Hamburg and Fred Robbins had held at the beginning of their
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From page 164... ...
Private industry knew nearly nothing about the TOM, and much more could be done to interest Congress in its work; the posture of the IOM in the broad scientific community was "poor."66 When Fred Robbins appeared before the Sproull committee on June 5, 1984, he left most of the dirty linen at home. Once again, he told the group that he "welcomed" the study.
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From page 165... ...
At the same time, Sawyer, like Rogers, implied that he would like to support the TOM, even hinting that the Andrew Mellon Foundation might give the TOM a million dollars if"we saw a plan and a leadership that would address the major issues."69 Alvin TarIov, head of the Kaiser Family Foundation, said that his foundation also would like to give money to the TOM. "An aggressive, optimistic, invigorating president" could get a million dollars from Kaiser.70 Staff member Harvey Sapolsky, who had been a colleague of Frank Press's at MIT, did the bulk of the interviews for the Sproull committee.
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From page 166... ...
"It's OK to be concerned about social issues," said Shannon, in a variation of a speech he had been giving since 1969, but the TOM was "dominated by these concerns to the detriment of medical science issues." Reagan administration officials, such as Edward Brandt, the Assistant Secretary of Health who described himself as a strong TOM supporter, told the Sproull committee in direct testimony that the TOM should do its work"quicker and cheaper." Roger Bulger conceded that the "TOM had been quite close to the Carter administration." Robert Rubin, a medical doctor with an academic background who had served as Assistant Secretary of Planning and Evaluation in the Department of Health and Human Services during the Reagan administration, described the {OM's studies as "not politically balanced." For this reason and because of its slow pace and undistinguished staff, Rubin believed, the lOM's influence had declined during the Reagan administration. Karl Yordy admitted that the Reagan administration looked at the TOM as the home of failed Democrats.72 Not everything that Sproull and his staff heard was negative.
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From page 167... ...
Stuart Bondurant of the University of North Carolina Medical School said that many of the TOM reports had been "solid and several have clearly influenced health policy on important issues." Vincent Dole, senior professor emeritus at Rockefeller University, argued that the "IOM or some other leadership group with similar objectives is indispensable." Still, almost no one, in either the interviews, the direct testimony, or the many letters that the Sproull committee received, offered unqualified praise. The lingering impression was of a troubled and unfocused organization.
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From page 168... ...
Defending the Institute of Medicine Members of the TOM community reacted with concern. Karl Yordy called the report a "key event in the history of the TOM" and urged Robbins "to set a new course, not give up the ship." Using a different military metaphor, Yordy argued the need to "move rapidly to develop a defense" against the "blitzkrieg'' of NAS President Frank Press before he conquered the TOM.
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From page 169... ...
Agreeing with Omenn, Robert Butler, a Council member and the former head of the National Institute of Aging, thought the Sproull committee did "a good job and came un with some resnectahle conclusions."79 ml_ _ ~ ~ ~, Inns set up the major lines of division for an TOM Council meeting in January 1985 devoted to formulating the TOM response to the Sproull report. In general, those who wished to defend the TOM
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From page 170... ...
In this statement, the Council tried to be deferential toward the Sproull committee "a distinguished group which addressed its task sincerely ant! thoughtfully" and positive about the TOM we "want to build on the accomplishments of the past 14 years." For all of this deference, the TOM Council felt compelled to "disagree with many of their recommendations and some of their findings." The statement proceeded to object to the report's basic premise, to argue against moving the TOM's studies to the NRC, and to oppose the creation of a National Academy of Medicine.
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From page 171... ...
At a minimum, the TOM had won a reprieve without making a major concession. All it had to do was disband its presidential search committee and replace it with one jointly chosen by Frank Press and Fred Robbins.
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From page 172... ...
As the meeting wound down, Frank Press walked into the room and announced that Samuel Thier, the head of the Internal Medicine Department at Yale, would become the next president of the Institute of Medicine.86 Conclusion Although TOM members could not have known it at the time, the organization had weathered the crisis. During the era of Fred Robbins, the IOM managed to survive two threats to its existence in the form of two NAS reviews of its structure and accomplishments.
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From page 173... ...
Notes 1. IOM Council Meeting, Minutes, March 19, 1980, Institute of Medicine (IOM)
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From page 174... ...
11. IOM Council Meeting, Minutes, January 16, 1980, IOM Records; William Lybrand to Robert M
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From page 175... ...
._ 7 ~_ vat ~ ^ ~v~ v ~ ~ ~ ~ By ~ -= ~ ~$ ~ ~ Ye 37. IOM Council Meeting, Minutes, January 16, 1980, IOM Records; Karl Yordy to David Hamburg, September 2, 1980; Fred Robbins to Fred Abby, Health Care Financing Administration, December 4, 1980; and Yordy to Arnold S
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From page 176... ...
Ibid., p. 26; IOM Council Meeting, Minutes, September 17, 1984, IOM Records.
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From page 177... ...
66. IOM Council Meeting, Minutes, May 13-14, 1984, IOM Records; Charles Miller to IOM Professional Staff, May 25, 1984, Waterfall Materials.
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From page 178... ...
80. IOM Council Meeting, Minutes, January 13-14,1985, IOM Records.
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