To Improve Human Health A History of the Institute of Medicine (1998) / Chapter Skim
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1 Creating the Institute of Medicine
1 Creating the Institute of Medicine
Pages 1-49
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From page 1... ...
Walsh McDermott, a prominent practitioner of academic medicine with a deep interest in public health, believed that the organization should serve as a forum where physicians and other professionals concerned with health policy could work toward the solution of health-related social problems. Although profound differences divided these three men, they concurred in the belief that the organization should do more than bestow an honor on its members.
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The Association of American Medical Colleges, a similarly venerable organization that was in the process of transforming itself from a "congenial 'deans' club' into a powerful lobby for academic medicine," represented the interests of academic health centers, not the medical profession. Few other organizations were large or influential enough to speak for the profession.
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These aspects of Page's career illustrated the influence of German models on American science and demonstrated that in the prewar era, support for medical research came as much from private philanthropy as from government grants. Working at the Rockefeller Institute between 1931 and 1937, Page became interested in the phenomenon of high blood pressure.
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. is to decide who deserves the honor." "Let us proceed slowly and thoughtfully, but let us proceed," Page concluded.4 In private, he told a colleague that no one needed to be pushed "but if the thinking about it is open and moves along, the whole thing will gel."5 In public, he wrote another editorial for Modern Medicine that appeared in March 1965.
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Similarly, federal support of medical research, although lavish, bred its share of problems among members of Congress, the executive branch, and representatives of medical schools. In June 1966, President Johnson convened a meeting of his top health policy officials and asked them whether "too much energy was being spent on basic research and not enough on translating laboratory findings into tangible benefits for the American people." The mere fact that the President posed the question, according to Stephen Strickland, "fell like a bombshell" on NTH officials and created a ripple of panic among the scientists in medical schools.7 Not long after this meeting, Science printed an item in which it attributed a desire to create a National Academy of Medicine to "reform-minded top officials of the Department of Health, Education, and Welfare." The new organization "would supply the profession with another set of spokesmen and provide the government with a more congenial source of authoritative advice."8 Only a short time after President Johnson's meeting with his science advisers, Page used his local connections to secure a grant of $6,000 from the Cleveland Foundation that enabled a group of leading physicians to travel to Cleveland, Ohio and discuss strategy.
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. to any who want to listen." Above all, Page stressed the fact that advice on medical questions could no longer be left to amateurs: medicine's growing scientific base and its increasingly complicated relationship with the government necessitated the creation of a group that could mobilize the best professional opinion in the country.~° Although Page dominated the meeting, James Shannon also made his presence felt.
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Still, he wondered, as had dames Shannon, whether the group should proceed on its own or whether it should "come under the umbrella of a chartered organization such as the NAS." In fact, the Cleveland group was already in contact with the NAS. After the first meeting, Shannon and Ivan Bennett had arranged a Washington conference with Frederick Seitz, president of the NAS.
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In 1967, he served as the vice president of medical affairs at the Commonwealth Fund, an important dispenser of funds for medical research and public health. Highly regarded as a scientist, MacLeod, like dames Shannon, was a member of the National Academy of Sciences.~3 Watsh McDermoN and the Board on Medicine As {van Bennett noted, the prestige of the National Academy of Sciences, with its federal charter and its proud history that stretched back to the presidency of Abraham Lincoln, was beyond dispute.
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Seitz told the Executive Committee of the NAS Council that he had already talked with Bennett and Shannon and suggested the creation of an advisory board on medicine.
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His choice was Walsh McDermott, a 56-year-old professor of medicine and public health at Cornell Medical School who recently had been elected to the Academy. McDermott belonged to Page's discussion group, although he had missed both meetings and told Page of his ambivalence toward a National Academy of Medicine.2i The appeal of his selection lay not only in his familiarity with the movement to create a National Academy of Medicine but also in his unquestioned prominence as a doctor and a public health official.
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that the Board would develop into "a widely respected voice of American medicine." He proceeded to negotiate with Seitz over other members of the Board. They agreed that Ivan Bennett, Colin MacLeod, James Shannon, and Irvine Page, the prime movers behind Page's efforts to launch a National Academy of Medicine, should all be members.
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Joseph Murtaugh, chief of the Office of Program Planning at NTH, represented the interests of dim Shannon. Keith Cannan, who worked for the Division of Medical Sciences of the National Research Council, attended as an NAS staff member.
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He urged fellow Board member dim Shannon to keep "our ultimate objectives in mind" and informed Shannon that Walsh McDermott "is an extremely capable and nice person but ~ do not think he is in a class with you." Indeed, Page hoped Shannon would become the first president of a National Academy of Medicine. As these sentiments implied, Page had many criticisms of the way in which the National Academy of Sciences handled the Board on Medicine.
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James Shannon noted the profusion of groups already concerned with medical care and policy and compared the result to a "floating crap game." The Board.on Medicine should bring institutional stability to this situation and should make it less of a game of chance and more a matter of putting the best minds in contact with the hardest issues. Adam Yarmolinsky, a lawyer by training with a strong interest in problems related to poverty, noted that his prior contacts with medicine were primarily those of a patient, yet he hoped the Board would address the distribution of medical care in the inner cities.
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The operation, quickly followed by others performed in the United States, captured public interest at a time when much of the other news, such as the beginnings of the Tet Offensive in South Vietnam, was depressing. Eugene Stead, the Board on Medicine member from Duke, called McDermott and told him that the American Heart Association was prepared to issue a guideline on the use of heart transplants.
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Creating the Institute of Medicine 17
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"Don't Try Heart Transplants too Soon, Scientists Warn," read a typical headline.38 The statement made a deep impression on intellectuals who followed the transplantation debate and on government officials responsible for funding medical research. In April 196S, the Saturday Review printed the statement in full.39 Senator Lister Hill(D-Ala.)
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To put it more bluntly, the head of the Stanford Medical School had helped draft a statement saying that complicated operations such as heart transplants should be done only in places
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As if this were not enough, the Board had some direct connections to the foundation world. Colin MacLeod, the same person who pleaded the Board's case to the NAS Council, worked for the Commonwealth Fund, which became an early supporter of the Board.
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One, on medical education, came at the urging of Jim Shannon, who sought nothing less than a major redesign of medical education to incorporate changes in science into the curriculum. McDermott asked {van Bennett to head a five-person subcommittee charged with developing a proposal.
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Comroe, a blunt man, did not hide his feelings from Walsh McDermott. "l think that it is very nice for 22 men in a wide variety of disciplines to meet once a month and move at a relatively slow pace toward solution of major problems," he told McDermott, "but the work could go very much faster .
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He decided to appoint a subcommittee to investigate the matter. Headed by Irving London, a summa cum laude graduate of Harvard and a Harvard-trained doctor who chaired the Department of Medicine at Albert Einstein College of Medicine, the group contained six other Board on Medicine members.
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the academy is the only position to take," Page replied. He attributed opposition to the NAM to "public health people" and those "concerned with economics" who believed that "if medicine had the upper hand, we would all revert to our antediluvian days of which they are so highly critical."62 Walsh McDermott, whom Page would have classified as one of the public health people, refused to be stampeded.
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It seemed to him that the Board represented the best hope of interdisciplinary collaboration, in which physicians could work with social scientists on such problems as the reform of medicine and medical education. An Academy of Medicine would develop a tendency to be overprotective of the medical profession and to shy away from the most critical problems.63 In a rebuttal to Walsh McDermott, Page charged that McDermott had stacked the intellectual deck.
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From page 26... ...
This meant it had to overcome the stereotype that physicians always acted in their self-interest, desired nothing more than a trade union, and exhibited no concern for the country's future.66 Irvine Page aptly summarized the situation at the end of 1968. In an unguarded moment, he wrote that "there have been many, many arguments over the past year and a great deal of soul searching going on and there is no way of knowing how it is going to come out." To Dwight Wilbur, Page's friend and ally on the Board, it appeared that Walsh McDermott was "doing his best to fan the flames in his direction or on his behalf."67 As Wilbur's comment suggested, the Page faction spent much of the next year and a half in a state of frustration.
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From page 27... ...
~,< ~ _ _ ~ _ ~ Academy of Medicine that included members who would serve for no more than 10 years; it would have an initial membership of 250 people, a balance of three to one between medical professionals and others, and a full-time elected president.72 Although Murtaugh could not have known it, he had, in fact, written the first draft of a plan for the Institute of Medicine. At first glance the London panel's report appeared to be a victory for Irvine Page, who favored the creation of a National Academy of Medicine, and a defeat for Walsh McDermott, who opposed it.
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Walsh McDermott presented the Board's plan to the Executive Committee of the NAS Council at the end of March. The NAS officers asked him a lot of pointed questions.
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As far as Philip Handier and the NAS Council were concerned, the matter was far from settIed.75 In the course of the May discussions of the Board, Walsh McDermott confided that he was having his own crisis of confidence. Although he would do his best to argue the case for a National Academy of Medicine to the Council in June, he still had doubts about the wisdom of this approach.
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From page 30... ...
The National Academy of Sciences might then become so diluted that its prestige would disappear. Wallace Penn, a physiologist who worked at the University of Rochester's medical school, thought it would be much better to expand the Academis Medical Sciences Section and the NRC's Division of Medical Sciences than to create a new academy.
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From page 31... ...
Such a division might preempt the campaign to create a National Academy of Medicine.8i Although Joseph Murtaugh called the Council's reception of the Board on Medicine "cordial," the proposal for a National Academy of Medicine came at a sensitive time in NAS history.82 The resulting dispute reflected in part the differences in outlook between the hard and applied sciences. The physicists, chemists, and mathematicians who made up the bulk of the National Academy of Sciences regarded most social problems as too imprecise to define in a meaningful way.
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From page 32... ...
In the Nixon era, with both academia and the undirected nature of scientific research under attack, preserving the Academy as a sanctuary from ephemeral politics seemed all the more important. When the Executive Committee of the NAS Council met on July 19 in the Academy's facilities at Woods Hole, Massachusetts, to make a final decision on the Board's proposal, HandIer's views prevailed.
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If Fred Seitz were still the NAS president, things would have turned out differently. McDermott tried to move beyond the anger and get the Board to decide on what to do now.
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From page 34... ...
Walsh McDermott did all he could to soften HandIer's position through a series of phone calls and telegrams. Working closely with McDermott, Handier drafted a letter in which he offered McDermott a chance to participate actively in the NAS committee charged with reorganizing the National Research Council.
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From page 35... ...
Page described HandIer's mood as "flippant" at some times and "fairly harsh" at others. McDermott, he felt, sparred with the Board and represented it "very poorly indeed." Julius Comroe thought that "we are witnessing a last-ditch struggle to retain Walsh McDermott in the leadership (or controlling)
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Ivan Bennett mentioned that the Board had failed to advance the torch that the Pare group had handed it. and (untrod pacer cne olame on Walsh McDermott.
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For one thing, {van Bennett met with the members of the Long committee and came away impressed. Although he had been an outspoken critic of Walsh McDermott, he began to believe that some sort of accommodation with the NAS might be possible.
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Laser and Irving London had gone "over to the other side completely." "I suppose in common decency that we have to wait," Page advised.~°° As Joseph Murtaugh cleared off his desk before leaving the Board on Medicine, he too detected some progress. The Board had decided to turn its energy toward examining the implications of national health insurance for medicine, medical education, and health services.
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Soon after the Institute started, it would have about 100 members, and ultimately it might grow to 260 members.~03 Walsh McDermott and a delegation from the Board on Medicine presented this "draft charter" to the NAS Council on June 5, 1970. Yarmolinsky, the principal writer, hastened to reassure Council members that the Charter marked a revision of, but not a departure from, the Board on Medicine.
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The next step was for Irving London, Adam Yarmolinsky, Walsh McDermott, and James Shannon to present these documents to the NAS Council on August 24. In the meantime, Handier offered his suggestions.
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As Page put it, the Carnegie Foundation and Commonwealth Fund planned to let the Institute "have a try and fail before big money will be available for NAM."~°8 Conclusion Between 1967 and 1970, the Board on Medicine spent most of its time trying to reconcile the conflicting points of view of its members and negotiating with the National Academy of Sciences. As a consequence, it completed few studies and gained fame only for a short statement that it issued on heart transplants.
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From page 42... ...
Page, "More on a National Academy of Medicine," Modern Medicine, March 15, 1965, pp. 89-90; materials in File IOM: 1965, Box 1, Page Papers.
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From page 43... ...
Walsh McDermott, June 28, 1967, and McDermott to Seitz, July 22, 1967, NAS, Committee and Boards, Board on Medicine, General, NAS Records, NAS Archives.
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30. "Summary Minutes of the Second Meeting of the Board on Medicine, Washington, D.C.," December 14 and 15, 1967, File Board on Medicine Meetings: Minutes 1967-1968, Board on Medicine Files, NAS Records, NAS Archives.
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Dr. Francis Moore to Walsh McDermott, March 14, 1968, File Transplant Statement: Correspondence, Board on Medicine Records.
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57. Julius Comroe form letter, July 8, 1968, in Meeting July 22, 1968: Agenda, Attendance File, Board on Medicine Records; Comroe to Board on Medicine, July 26, 1968, in Agenda Book, Background Materials on Further Institutional Forms for the Board on Medicine, Board on Medicine Records; File July 22, 1968, Meeting Transcript, p.
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From page 47... ...
75. Walsh McDermott to Fred Seitz, March 24, 1969, NAS Council, Executive Committee Meeting, March 29, 1969, NAS Records; McDermott to Board on Medicine, May 22, 1969, NAS Records; McDermott to Irving London, April 15, 1969, NAS Records; Minutes of NAS Council, April 26-27, 1969, NAS Records.
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From page 48... ...
Abelson et al., August 1, 1969, "Background Materials," September 9-10, 1969, Meeting of the Ad Hoc Committee on Further Institutional Forms of the Board on Medicine, Board on Medicine Records; Telegram from Walsh McDermott to Philip Handler, August 5, 1969, National Academy of Medicine Proposal File, 1969, Board on Medicine Records; Handler to Joseph Murtaugh, August 5, 1969, McDermott Files, Board on Medicine Records; Handler, memoranda for file, August 12 and August 13, 1969, NAS Records.
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From page 49... ...
105. NAS Press Release, June 10, 1970, NAS Records; Philip Handler to Walsh McDermott, June 10, 1970, NAS Records.
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