The Institute of Medicine Begins Operations
Early in 1971, Philip Handler, the president of the National Academy of Sciences (NAS), wrote one of his correspondents that ''the Institute of Medicine [IOM] is, at the moment, largely a paper organization, but the members of our Board on Medicine are busily engaged in fleshing it out."1 Four and a half years later, after two IOM presidents had come and gone, Roger Bulger, a key IOM staff member, noted that it had never "been our expectation that we would become a household word across the United States of America. We have never felt that we would become, at least in the first years, an opinion maker at the level of the individual citizen."2
As Bulger indicated, the Institute of Medicine attracted little national attention during its first five years of operations. This was because its work did not directly engage the questions that animated the public, such as the passage of national health insurance, nor did its leaders seek to become political celebrities who testified often before Congress. Instead, the IOM maintained a low profile and focused on relatively technical, but nonetheless important, questions related to health policy and conduct.
The new organization faced internal pressures that mitigated against its undertaking more ambitious projects. Members expected to shape the organization's agenda and participate in its activities, yet the IOM depended heavily on Washington-based staff, attuned to the nuances of public policy and accustomed to taking the lead on research projects, to guide its work. The action-oriented IOM formed part of the National Academy of Sciences and had to adapt to its culture. This meant an insistence on intellectual rigor attained by close peer review of Institute reports, combined with a relatively passive attitude toward obtaining grants and contracts. The National Academy of Science's leaders believed that Washington should come to them, an outlook that the Institute of Medicine, a younger, less established organization with a direct dependence on external funds,
could ill afford. These differences in institutional outlook between the NAS and the IOM often took the form of personal confrontations between I presidents John Hogness and Donald Fredrickson and NAS President Philip Handler.
Even as Hogness and Fredrickson dealt with these constant pressures, they faced the more mundane task of running the IOM on a daily basis. The invention of routines that would guide the new organization through its first five years fell to them. Much of their work centered on the task of recruitment. They had to hire staff members who would set the tone for the Institute's subsequent development, select members who would initiate key committees such as the Program Committee, and make vital contacts with the foundation officers and public officials whose decisions on funding grant proposals held the key to the Institute's very survival.
Neither of these presidents served for a long time. John Hogness spent three years in office before leaving to become president of the University of Washington; Donald Fredrickson stayed at the IOM for less than a year, much of it spent in distracting and ultimately successful negotiations with federal officials over whether he would become the head of the National Institutes of Health (NIH). The turnover made the difficult endeavor of starting the IOM that much harder. Because Hogness and particularly Fredrickson left so quickly, the organization failed to establish a sense of continuity. Those in the foundation and health policy communities in positions to fund the IOM and increase its visibility found it difficult to gain a "fix" on the organization's identity. Nonetheless, Hogness and Fredrickson both made enduring impressions on the Institute of Medicine's history. Under their leadership in the years between 1971 and 1975, the IOM perfected its form of governance through establishment of the IOM Council and experimented with different ways of influencing health policy. IOM leaders came to realize that the organization possessed the means of convening the nation's leading experts to consider important issues in health policy. As a result, the IOM influenced President Nixon's war on cancer and established an important methodology for estimating the costs of medical education. By the end of the period, the IOM, if not a household name, had become known to the Washington health policy community as an organization with the potential to serve as a useful and influential source of impartial advice.
After Philip Handler declared the IOM open for business in December 1970, the first task was very basic: the members of the old Board on Medicine, now reconstituted as the IOM Executive Committee, had to pick the initial members of the new Institute of Medicine. This task, like many others in the period between the end of 1970 and the spring of 1971, fell on acting President Robert J. Glaser, a witty man and an accomplished physician, who proved quite adept at the delicate task of getting the organization started. He had been present at the first, tentative NAS meetings that had given birth to the Board on Medicine, and he was a veteran of the long discussions that had led to the Institute of Medicine. During the often contentious sessions that followed, he managed to retain the goodwill of Walsh McDermott, Irvine Page, and Julius Comroe.
Like McDermott, Page, and Comroe, Glaser came from the world of academic medicine. Raised in St. Louis, he went to Harvard at a time when that school was just beginning to accept students from the Midwest and West who lacked a fancy prep school background. Graduating from a Harvard class that also contained John F. Kennedy, Glaser continued his studies at Harvard Medical School. This enabled him to embark on a career that included a series of distinguished academic appointments. At Washington University, he headed the Division of Immunology. In 1957, he moved to the University of Colorado, where he became one of the nation's youngest medical school deans. Six years later, he returned to Harvard, where he held the university's first chair in social medicine. Then, in 1965, he arrived at Stanford to become dean of the medical school. Five years later, Glaser accepted a job as vice president of the Commonwealth Fund, which enabled him to make occasional trips from New York to Washington to handle IOM business on a part-time basis.3
Glaser chaired what was known as the Initial Membership Committee. Ivan Bennett, Walsh McDermott, and Eugene Stead also served on the committee that began its work even before the formal creation of the Institute and made many of the important decisions about the terms of IOM membership. Discussions centered on the appropriate age, proper geographic distribution, and right mix of medical specialties, other health professionals, and nonmedical fields. Although the process went smoothly, disagreements with the Executive Committee (the old Board on Medicine) arose over how to treat people who were approaching age 60. The Membership Committee wanted to exclude them; the Executive Committee
disagreed, hoping to attract as much talent to the Institute as possible. 4 As a compromise, Glaser's committee decided to apply an age limit of 64. This meant that the IOM would not necessarily be an organization of young men, even though the Charter called for people to become senior members when they reached age 66. Nor would the IOM necessarily be an organization with many active members, although it did work out this way and willingness to work was defined as one of the conditions of membership. The initial Membership Committee decided not to consider whether a person was already overburdened with other commitments before asking him or her to become a member; those asked to join were allowed to make up their own minds about whether they could find time to serve.5
Having set the basic ground rules, the Membership Committee proceeded to generate a list that contained nearly twice as many people as necessary to bring the total membership to 100. Board on Medicine and NAS members who belonged to the Section on Medicine received automatic invitations. This left 77 positions to fill. In January 1971, the committee nominated 48 people for membership from a list of 85, and in March the committee selected the final 29 nominees. In contrast to later years when the Institute of Medicine would hold a formal membership election, in 1971 the nominees were selected by a committee, approved by the Executive Committee and Philip Handler, and then asked to join. Glaser presented the final list to Handler in April. Letters to newly selected members went out toward the end of May 1971, and the NAS made the formal announcement in June.6
The National Academy of Sciences protected the Institute of Medicine from the more overt forms of lobbying that accompanied the membership process. Ever since the formation of an Institute of Medicine had become a real possibility, Philip Handler had received a stream of letters from organizations arguing that they deserved representation in the IOM. Psychiatrists, pharmacists, toxicologists, veterinarians, dieticians, and rehabilitation doctors all wrote to Handler. To his credit, he kept these letters to himself and did not pressure the IOM to accept anyone merely as a representative of a particular profession or medical specialty. He preferred that merit predominate.7
To be sure, the IOM Executive Committee and the NAS Council did not agree completely on the criteria for membership. Although the NAS Council approved the list, some Council members complained that key scientific fields, such as demography and epidemiology, did not receive enough representation. The IOM, for its part, worried about the lack of practicing physicians, who constituted only 10
percent of the initial membership. In a variation of a discussion that had gone on since 1967, Glaser told Handler that practicing physicians were "essential for the Institute to carry out its obligations," even though their accomplishments could not be measured by publications or membership in prestigious professional societies. Glaser even admitted that in the absence of these academic criteria, the selection process for practicing physicians was less rigorous than for other members. Identifying physicians engaged in the private practice of medicine who had national reputations proved a difficult task. Some of the physicians who were chosen, such as one who practiced near the NAS's unofficial summer headquarters in Woods Hole, Massachusetts, owed their selection to the fact that key IOM and NAS officials knew them. In addition to the concern over finding enough private physicians with sufficient distinction to merit IOM membership, Glaser worried about the geographic tilt of the final list. A disproportionate number of members came from the Northeast, mid-Atlantic, and West Coast regions—a taint of elitism that bothered the IOM far more than it did the NAS.8
Charter Members of the Institute of Medicine
The group did better in selecting members from a broad array of fields. Glaser identified 19 different fields in the initial membership group, including administration, basic sciences, engineering, community medicine, dentistry, nursing, and nutrition.9 It was, by any sort of measure, an impressive group. It contained two future IOM presidents, Donald Fredrickson and David Hamburg. It featured people who practiced medicine in very different settings: a family practitioner from Hampton Highlands, Maine, and the dean of the Harvard Medical School; the chairman of the Johns Hopkins Department of Pediatrics and a nurse-midwife from New York Downstate Medical Center. The physician-in-chief at Beth Israel Hospital, the general director of Massachusetts General Hospital, and the head of Blue Cross-Blue Shield all made their way to the Institute of Medicine. Only four people, who were not directly involved in health policy and had corporations or other large organizations to run, turned down the IOM's offer of membership.10
At the same time that Robert J. Glaser orchestrated the talent hunt for IOM members, he also coordinated the search for the first permanent IOM president. In December 1970, Glaser himself was on a short list of eight candidates, but he made it known that he was not interested; he preferred to launch the organization and do his work at the Commonwealth Fund. Like Glaser, all of those on the list were white, male medical doctors who worked in an academic or a research setting; indeed, everyone who headed the IOM in its first quarter century fit this description. Because each person on the list held a prestigious position such as chief of medicine, chairman of a medical school department, or medical school dean, Glaser realized it would require salesmanship to interest one of these individuals in the IOM job.
On January 20, 1971, Glaser reported to Philip Handler on a meeting with John Hogness, former dean of the Medical School at the University of Washington and current director of the university's Health Sciences Center. ''I got the feeling," Glaser noted, "that John is extremely interested and that the chances are very good that he will be interested in taking it on." Two months later, Handler made a formal offer to Hogness to serve a five-year term beginning on July 1, 1971. On March 30, 1971, the Academy announced Hogness's selection. "With the appointment of Dr. Hogness, the Institute of Medicine becomes a reality," said Handler.11
On the same day, the New York Times made John Rusten Hogness its "Man in the News," indicating a high level of interest in the IOM and its affairs. The piece featured a picture of Hogness, stethoscope around his neck, intently performing a medical examination. His hair slicked back, Hogness looked a bit like the television reporter Mike Wallace. The head and shoulders shot gave no indication of Hogness's height—6 feet, 4 inches—"the size of a tackle," according to the Times, nor did the grainy black-and-white photo capture the blondish cast of his hair. Physically imposing, Hogness related well to people and used his self-deprecating sense of humor to soften what the Times described as "his vigorous and innovative way of doing things."12
Although Hogness later wondered what factors played a role in his selection as IOM president, he was a natural enough choice. His selection helped to bridge some of the gaps between the McDermott and Page factions of the Board on Medicine. Although he came from an academic background at the University of Washington, he had maintained a private practice in Seattle for most of the 1950s. Leaving private practice in 1959, he plunged into the administration of the academic medical center at the University of Washington, serving first as medical director of the newly opened university teaching hospital, next as dean of the School of Medicine, and finally as executive vice president of the University of Washington at a time when the disruptions caused by the Vietnam War made it a trying proposition. He persevered and developed a reputation as an excellent university administrator, one who received regular offers from large research-oriented universities to serve as president. Not only had he been in private practice, he had served as secretary-treasurer of the local medical society. Not only had he done research in endocrinology, he had also chaired the Board of Health Sciences at the University of Washington and come to know the members of other health professions. He therefore had connections with both the nationally oriented academic and the locally oriented private practice sides of medicine and with its scientific and clinical aspects. In selecting Hogness, the IOM touched all bases.13
Born in 1922, Hogness was only 48 at the time of his appointment as IOM president, a young man to lead a young organization. He came from a distinguished scientific family. His father, a physical chemist, had taught at the University of Chicago and played a key role in the Manhattan Project that led to the development of the atomic bomb. His brother became a distinguished biochemist at Stanford, and John himself took his undergraduate degree in chemistry. This pedigree no doubt was reassuring to Philip Handler, who could assume that Hogness knew how to function in a community in which scientific
achievement was paramount. The physicians at the IOM, for their part, could take comfort in the fact that Hogness had received topflight training at the nation's best medical schools, including the University of Chicago and Columbia, before coming to Seattle in 1950 as a chief resident at King County Hospital, a teaching hospital for the newly formed University of Washington School of Medicine.14
"At last we have a pope," one waggish doctor remarked on learning of Hogness's selection.15 Even as Hogness spoke ex cathedra of the IOM and its mission, he realized that the new organization was far from becoming the "established church" in its field. The IOM resembled a movie set with a glossy front and the illusion of depth. Stripped of all the promises about what it would become, the IOM consisted only of a group of members and a president who had the services of one staff member. It would be up to Hogness to make something of an organization that had spent most of its time arguing about its role in the Academy and relatively little time on concrete projects that would, in the end, determine its reputation.
Speaking to anyone who would listen, Hogness tried to interest people in the IOM. He described his new job as "one of the most important jobs in the health field," as head of an organization that "alone in the health field will speak ... without an axe to grind." Members, who were at the peaks of their careers, would marshal the scientific wisdom of the United States and make recommendations "widely recognized as authoritative."16 It was important that the organization not play politics, because it could not favor one side over the other and still speak with an impartial sense of authority. In this regard, the IOM would investigate and arbitrate far more than it would assert or advocate. At the same time, the IOM would not be passive and wait for disputes to come to it. Instead, it would seek out problems, looking for significant matters of national policy. "When there are major issues and concerns before the American public, we are more apt to be involved in those areas.... We will be able to foresee future problems, rather than deal with them after they have reached crisis proportions," said Hogness,17 who promised ''one hell of a show.''18
Staffing the Institute and Bureaucratic Routines
Despite this bravado, Hogness told the Executive Committee at the end of 1971 that he had traveled widely in the past year and found few people who were even aware of the Institute's existence.19 In part, the IOM's anonymity resulted from Hogness's preference to
get his own house in order, by hiring the IOM's core staff and establishing its bureaucratic routines, before he reached out to the external community. In September 1971, Hogness announced his intention to hire a senior professional to serve as his deputy. He had in mind Roger J. Bulger, associate director of medical education for allied health at Duke University, with whom he had developed a rapport and who brought distinct skills to the job. If the IOM president came from the West Coast, his executive director would come from the East. 20
In fact, the careers of Bulger and Hogness were closely intertwined. Bulger, a major figure in IOM history from 1972 to 1976, received his undergraduate degree from Harvard in 1955. After a year in England, he returned to Harvard as a medical student. Bulger took much of his postgraduate training at the University of Washington, serving as chief resident in medicine in the 1964–1965 academic year and, significantly for the IOM, meeting John Hogness. His medical education and postgraduate training in science prepared the way for an academic appointment at the University of Washington. In 1970, he left for Duke, where he held the title of professor of community health sciences and associate professor of medicine. Still only 38 years old, he came to the IOM with a wealth of experience. More importantly, he had a quiet competence and an easy manner that made the work of the IOM go smoothly. He served as the inside man who ran the store while the IOM presidents made outside appearances.21
After hiring Bulger, Hogness appointed the members of the IOM's standing committees. In September 1971, he announced the formation of a Program Committee, headed by Irving London, to oversee requests for studies and establish priorities among them. The work of this committee became so important that Hogness decided that it required its own staff. He hired Karl Yordy, the associate administrator for program planning and evaluation at the Health Services and Mental Health Administration, for this purpose. Yordy, who would remain in positions of authority at the IOM from the era of John Hogness until the era of Ken Shine, soon became indispensable not only to the Program Committee but to Hogness and Bulger as well. As for other committee assignments, Dr. Clifford Keene, president of the Kaiser Foundation hospitals, agreed to head a Finance Committee, and Hogness convinced Robert J. Glaser to continue as head of the Membership Committee.22
With the basic structure in place, Hogness, turning to the most important committee of all, decided that the Executive Committee was too large to function in this capacity. He renamed it the IOM
Council, and it became the organization's central governing body. From the IOM Council, Hogness drew members who would act as a Report Review Committee, once the IOM began to issue reports. The Executive Committee, meanwhile, was transformed into a much smaller group of only five members.23
Hogness realized that one of the most important tasks he and the Council faced was to make plans for the IOM's first annual meeting. The bylaws stipulated that there be such a meeting, and even without a specific mandate, the need for it was obvious. Members required a forum in which they could meet one another, discuss the IOM's program, and become a part of the organization. Hogness set the meeting date for the middle of November and put Samuel Nabrit, Irvine Page, and Eugene Stead in charge of coming up with a program. They devised panels on the founding of the IOM and on "medical care as related to scientific research." In an offhand comment that said a great deal about gender relations at the time of the IOM's founding, the program planners announced that "there will be no special program for wives, and no plans for their attendance at the banquet."24
Science reported with some optimism that "the institute seemed to be satisfactorily en route toward establishing an identity of its own" at the November 1971 meeting. The journal reported, however, that the IOM was new and had practically no business to transact. It filled the void with speeches. Walsh McDermott recounted the founding of the IOM. Victor Sidel, head of the Department of Social Medicine at Montefiore Hospital in New York, discussed his recent trip to China. In a concluding speech, John Knowles, general director of Massachusetts General Hospital, offered what was described as an "iconoclastic" analysis of health policy, urging the Institute to get involved in modern problems and not become a "status organization." 25
For Hogness, the main objective was to keep the members active and involved. Without much of a scientific product "to offer the membership," he thought it important "to put on a good program and have an outstanding reception." So Hogness and his staff laid on an "very elaborate, excellent buffet." In the years that followed, the IOM fall reception, which attracted a unique crowd of researchers, practitioners, members of Congress and their staffs, and health policy officials, became a key social, professional, and political gathering. With tongue only slightly in cheek, Hogness later wrote that ''if, in the first years of our existence, we were not yet too well known, at least we ate well."26
If the IOM were to succeed, it had to do more than host a pleasant cocktail party. It required a substantive program, something that had largely eluded the Board on Medicine. One of the organization's first opportunities to contribute to medical policy came during the "cancer wars" that dominated the medical news in 1971. President Richard Nixon's decision to declare war on cancer shook up the medical research establishment. Senators Edward Kennedy (D-Mass.) and Jacob Javits (R-N.Y.), neither of whom enjoyed warm relations with the administration, introduced a bill to create a National Cancer Authority, which received wide support from such organizations as the American Cancer Society. The potential issue for the IOM was not whether the federal government should support cancer research but rather how to organize this research. Kennedy and Javits hoped to separate the cancer effort from the rest of the National Institutes of Health in an effort to give it more visibility and free it from the red tape that supposedly hindered NIH efforts. Many IOM members and their colleagues in universities and medical centers felt that such a separation would seriously undermine the NIH and medical research in general. Each special disease or cause would ask to be elevated above the rest of NIH, and soon the entire organization, which had put so much money in medical school coffers, would disintegrate. Nor did creation of a separate National Cancer Authority appear to be conducive to good science. As several IOM members noted in March, "there is the mistaken belief that equates a separate agency with curing cancer." 27
Philip Handler, whose own background was in biological research that took place in a medical school, felt strongly enough about the issue to write Kennedy and Javits a letter advising against the National Cancer Authority. Handler urged the IOM to move on the issue, but with the organization still so new and eager not to make a mistake in handling its first big political issue, IOM leaders hesitated to make a public stand.28
When the political action shifted from the Senate to the House, John Hogness received a request to testify before Congressman Paul Rogers (D-Fla.) and his Subcommittee on Public Health and Welfare. Hogness also was wary of establishing a bad precedent, in this case by testifying as an individual. He preferred to reserve his congressional appearances for times when he would be able to present the results of an IOM report or study.29 In this case, however, he decided to break his own rules. The cancer agency, he told a reporter, was "a little different because it went to the nature of health research." On
October 4, 1971, Hogness testified before Rogers, and he continued to work behind the scenes with the Congressman to create a compromise measure that gave priority to the cancer effort but left the National Cancer Institute within the National Institutes of Health. During the debate on the House floor, Rogers announced that "the presidents of the National Academy of Sciences, as well as the Academy of Medicine of the National Academy of Sciences, have stated strong support of this approach."30 Rogers got the name wrong, which would be a continuing problem for an organization so closely associated with the National Academy of Sciences, yet whose name sounded so much like the National Institutes of Health. His remarks, however, indicated that the IOM had made an impression on him and on the policy process.
Having played a role in the creation of the cancer program, Hogness looked for a way to influence its subsequent development. The opportunity came in 1972 when the NAS received a request from the Office of Science and Technology in the White House to review the National Cancer Program for the National Cancer Institute (NCI). The idea was for the IOM to evaluate the process by which the NCI developed scientific recommendations and to examine the NCI's management plans. The Institute of Medicine persuaded Dr. Lewis Thomas, a distinguished scientific writer, cancer researcher, dean of the Yale Medical School, and IOM member, to chair the panel that was to write the review.31
Working quickly, Thomas and his committee produced a draft report by the end of November. In general, the report praised the National Cancer Program Plan, although it cautioned against leaving the impression that a cancer cure could be programmed in the same way as a mission to the moon. The plan occasionally gave the impression that "all shots can be called from a central headquarters, that all, or nearly all, of the really important ideas are already in hand, and that given the right kind of administration and organization, the hard problems can be solved. It fails to allow for the surprises that must surely lie ahead if we are really going to gain an understanding of cancer." In other words, Thomas and his colleagues wanted to leave the door open for unprogrammed basic research.32
The report was unlikely to spark much opposition from the National Academy of Sciences, yet it led to a conflict between the two organizations that reflected the uncertain lines of authority between them. Hogness realized that the report, like all of the reports that the IOM hoped to produce, would have to be reviewed by the Institute. He appointed a committee led by Walter Rosenblith, a professor at the Massachusetts Institute of Technology (MIT) and former Board on
Medicine member who held the distinction of belonging to the NAS, the IOM, and the National Academy of Engineering, to perform this review. Rosenblith's committee posed no objections to releasing the report. The sticking point came over whether the NAS Council would also have to review Thomas's report. Technically, it had such a right, but it often waived that right for something already reviewed by another part of the organization. Hogness hoped that this would be the case with the Thomas report. The decision, Hogness was led to believe, lay with NAS vice president George Kistiakowsky. When Hogness heard that Kistiakowsky thought that formal review could be eliminated, he was relieved, because the IOM faced a tight deadline to get the report to the White House.33
Hogness then learned with dismay that Philip Handler had reversed Kistiakowsky's decision. "I still sense a need for review by a Report Review Committee," Handler told Hogness. In a view that reflected his high aspirations for the NAS, Handler wanted to be sure that the IOM group had measured the National Cancer Program Plan against the national interest. He saw the report as establishing an important precedent for the National Academy of Sciences: "The Cancer Plan will surely be followed by the Heart Plan, a Neurological Disease Plan.... "Hogness had no alternative but to yield.34 In the future the report review process would be a major factor in delaying the release of IOM reports, even if it sometimes provided a beneficial check on the reports' quality.
The internal cancer wars at the NAS did not end there. Hogness and Handler then battled over who should transmit the report. Handler thought it was an NAS report and should be transmitted by him. Hogness believed in no uncertain terms that as an IOM product it should be sent to the White House over his signature. "It is essential to the Institute of Medicine that we be recognized as the agency that performed the review and therefore as the responsible agent," he argued. "It is very important that the Institute of Medicine have a distinct identity—that it be regarded as a separate branch of the National Academy of Sciences ... with its own capabilities and not as the equivalent of another division of the National Research Council." 35
Hogness won this battle. After he confronted Handler in his office and said that it was simply unacceptable for the report to be anything other than an IOM report, Handler realized that Hogness might resign over the issue. Although Handler yielded, the incident led to a breach between the two men that was never fully mended.
Entitlement and Health Contrasts
Disputes between the National Academy of Sciences and the Institute of Medicine were only one of many reasons that an IOM study might not be completed. Some studies, such as those on collective bargaining in the health care sector or medical responsibilities in criminal processes, languished for lack of funds, despite considerable effort on the Program Committee's part to refine and promote them. Other ideas, such as a request from the National Research Council's (NRC's) Division of Medical Sciences that the IOM study the legal and medical dimensions of "brain death," met with a negative reception by the Program Committee. Still other proposals made it past the Program Committee only to be turned down by the IOM Council.36
As the process of selecting studies for the IOM unfolded, it became apparent that the IOM would handle things differently from the Board on Medicine. In the Institute of Medicine, the views of social scientists, who were experts in research design and the testing of hypotheses, carried more weight than they had in the Board on Medicine. The Board on Medicine relied on outside consultants to conduct its research because it was small and compact and had almost no staff at its disposal. Because the IOM aspired to be larger and more comprehensive, it had the potential of using internal staff, rather than external consultants, to undertake a broad range of studies. It also hoped to be agile and quick enough to do studies that were relevant to current policy concerns. Achieving these various goals proved very elusive, as the rise and fall of the entitlement study demonstrated.
The Institute of Medicine inherited the entitlement study from the Board on Medicine. Board members had recognized national health insurance as one of the most important concerns of health care policy and wanted to do something about it. Negotiations with federal authorities for a contract to study the subject stretched into the period after the founding of the IOM. Only then did Paul Sanazaro, director of the National Center for Health Services Research and Development—a federal agency in the Department of Health, Education, and Welfare that was started at about the same time as the Board on Medicine and for many of the same reasons—ask the IOM to undertake "a study in depth of universal entitlement" to health care. Such a study would consider "fundamental questions and issues related to the structure and implementation of a national program of entitlement."37
This mandate was breathtakingly broad. It amounted to nothing less than planning a program of national health insurance and explaining what effects it would have on the nation's health. It reflected the sense in the early 1970s that passage of national health insurance was inevitable, and therefore the more rational, dispassionate planning that preceded it, the better. The study was part and parcel of the Board on Medicine's outlook that it should engage broad social questions.
Although Sanazaro's request was made in January 1971, it took until June for the IOM to obtain a small planning grant, designed to produce a larger, more elaborate proposal, from the Department of Health, Education, and Welfare (HEW).38 There was considerable interplay between Philip Handler and the leaders of the IOM in the process. The trouble was that much of the work for the project was to be done by Leon White, a professor of operations research and management at MIT. In March 1971, when Bryan Williams, the Dallas physician and former Board on Medicine member, went before the NAS Council to explain the project on behalf of the IOM, he met with a barrage of criticism so fierce that Handler felt compelled to apologize to Robert J. Glaser. Handler told Glaser that "it will not do to have the study conducted as an all MIT affair; somehow a multidisciplinary committee of the Institute must be involved in the planning, participate in some part in the conduct of the study, and take absolute responsibility for the final report." Glaser said that he understood the problem and reassured Handler that White would be carefully supervised and controlled, both by Bryan Williams in Dallas and by Rashi Fein, Walter Rosenblith, and Irv London, who were on the scene in Boston.39
White, it became clear, wanted the study to be done in a manner similar to the Carnegie Commission Study on the Future of Higher Education. He expected a commission to be formed by the IOM that would authorize the conduct of specific research projects. Hogness told White that the NAS was very "leery about subcontracting when the subcontract implies a policy making activity or judgment activity on the part of the subcontractor." "I share this reservation completely," Hogness added.40
The planning group for the entitlement study, headed by Bryan Williams, met for the first time in August. By September, the group had come up with a proposal for a full-fledged study that would cost $2 million. The IOM Executive Committee approved the proposal by a mail ballot, although not everyone appeared to be in favor of pursuing the study. Dwight Wilbur, former president of the American Medical Association and a distinguished private practitioner, thought that the
18 months allotted to such a large study was insufficient. He hoped that the private sector would be emphasized as much as the public sector. Rashi Fein, an academic economist and avowed partisan of national health insurance, was concerned that planning for national health insurance would be suspended for the life of the study, thereby delaying passage of the measure.41 These comments revealed that the project had begun to encounter the polarized politics of national health insurance.42 Nonetheless, the NAS Council joined the IOM Executive Committee in approving it.
Just as this proposal was ready for public distribution, the IOM's Program Committee began to meet. When it took a fresh look at the proposal, more doubts began to surface. For one thing, members felt they should have been consulted. If they had been, there might have been more in the proposal about the place of health technology and the role of health manpower. For another, there was a sense that the study was too broad.43 Among the most vocal critics of the study was David Mechanic, a leading figure in the sociology of medicine who had entered the IOM in the summer of 1971. He said that the project would inevitably result in disappointment because it promised more than it could reasonably deliver. The proposal attacked "almost every issue in the health services research field, many of which are unanswerable at this time."44 At base, Mechanic criticized the IOM for displaying a naivete about social science research.
In February 1972, a group headed by Irving Lewis, a professor of community health at the Albert Einstein College of Medicine, met in Boston to see if the proposal could be saved. William Schwartz, chairman of Tuft's Department of Medicine, stressed again that the study was attempting to address too many questions. He questioned whether IOM members would have the time to supervise such an ambitious study. Julius Richmond, the head of the Judge Baker Guidance Center in Boston who was destined to play a major role in IOM history, asked whether the study would force the Institute to take a position on national health insurance. Roger Bulger replied that Hogness hoped, at the very least, that some general principles for national health insurance would emerge. This posed a further dilemma. If the study was broad, it would require a long time to complete. If the study was to be relevant to the political debate, it would have to be finished quickly. After the meeting, Lewis conceded to Hogness that "I just do not see how we can proceed with the present scope of work."45
Because the members did not seem to want the study, Hogness decided to kill it. Martin Feldstein, the prominent Harvard economist and an IOM member, concurred in this decision, advising Hogness
that if the IOM had done the study, it would have risked becoming a "political body hiding behind some not very good analytical work." Feldstein's low opinion of the proposal reflected his lack of confidence in the analytic skills of the Institute staff and the Program Committee. Neither, Feldstein believed, could "judge the quality of prospective social science research." According to Feldstein, the IOM proposal would not have been approved by the National Science Foundation, which funded work in economics and other social sciences.46 If Hogness's decision to kill the project marked a response to internal IOM intellectual politics, it also marked a response to the external political environment. Hogness knew it would be difficult to obtain funding for a broad study of health insurance because the administration had submitted a health insurance proposal of its own. The National Center for Health Services Research and Development, a creature of the Great Society, had long since fallen out of favor with the Department of Health, Education, and Welfare. Hogness learned from a high-ranking HEW official that the department had no desire to sponsor a study that might contradict what it already had done. The window for the IOM to influence the debate was closed.47
The study on universal entitlement taught Hogness two important lessons. First, IOM studies would have to be closely supervised and not entrusted to outside contractors. "As you know," Hogness wrote Feldstein, "we inherited the Universal Entitlement Project from the Board on Medicine, and they had a somewhat different attitude about the role the Institute members should play in supervising such studies." Second, the organization would have to develop the technical capability to critique proposals, particularly in the social sciences areas.48 As a first step toward implementing the lessons, Hogness decided to rid the Institute of the inventory of old Board on Medicine projects and to proceed with new ones. These would of necessity be smaller in scope than the old projects and would rely more on the Institute's medical, rather than social science, expertise. If the IOM should undertake a large study, it would do so with its own staff, rather than subcontracting the bulk of the work to outsiders.
The chief legacy from the Board on Medicine was a series of studies conducted by David Kessner, an internist from Yale University. These studies examined contrasts in health status between the rich and the poor, showing how differences in health outcomes were related to differences in health care delivery. Financed by the Carnegie Corporation and other foundations interested in problems of poverty, the project involved, among other things, field studies in which teams of doctors examined children living in low-income Washington neighborhoods. Walsh McDermott saw this
project in typically grandiose terms. It would ''appraise the extent to which the health problems of the disadvantaged are a consequence of economics, race, failure of the delivery system and a failure of the other related systems in society." Although the results were much more limited, the study did yield useful methodology for using certain conditions, such as anemia and middle-ear infections, as statistical "tracers" that could be employed to compare the effectiveness of different health delivery systems. The project also mined data sets such as a record of live births and infant deaths in New York City in 1968 to show that differences in infant deaths between whites and blacks could be somewhat reduced through "easily obtained personal and medical information.''49
The health contrast studies resembled the sort of work that a faculty member might do in a school of public health. In sponsoring them, the Institute of Medicine put its imprimatur on a research project that was largely conducted by outsiders. The Institute did not use the studies to make authoritative statements on health policy questions, in part because IOM Council members such as Harvard statistician Fred Mosteller urged the IOM to be cautious about pushing its conclusions beyond the reach of the data.50
Health Effects of Abortion
In contrast to the entitlement and health contrast studies, the abortion study showed how the IOM could contribute to health policy debates, even on a controversial topic. This project stemmed from the famous January 1973 Supreme Court decision in the case of Roe v. Wade that states could not ban abortions during the first trimester of pregnancy. In the fall, David Hamburg and David Mechanic, both of whom were IOM Council members, suggested that the IOM might want to examine the health impact of legalizing abortion. The idea captured the imagination of the IOM Council and won the approval of the Program Committee, the Council, and NAS authorities.
In February 1974, John Hogness invited Dr. Mildred M. Bateman, director of the West Virginia Department of Mental Health, to chair the steering committee created for the abortion study. Ten others joined her, including seven IOM members. All came with imposing titles: the head of the Obstetrics and Gynecology Department at Meharry Medical College, the chief of the Epidemiology Department at Harvard's School of Public Health, the dean of the Medical School at Case Western Reserve University, the president of the Social Sciences Research Council.51 The committee's pedigree testified to the
IOM's unique ability to assemble an interdisciplinary panel of distinguished medical and social sciences practitioners.
To run the study, the IOM needed to raise money from outside funders. It turned to a group of private foundations, each of whom made small grants of about $10,000. For the seven groups that said yes, at least as many said no. This made fund-raising a time-consuming, frustrating activity that continued throughout the project. When the project began, no one knew if the money would hold up long enough for it to be completed.52
Unlike the entitlement and health contrast studies, the steering committee for the abortion study made no effort to perform original research. Instead, it saw its mission as synthesizing and critiquing the existing literature. Every two months, committee members flew into Washington, D.C., for meetings. Nearly all of them, burdened with busy schedules, missed a meeting or two. Inevitably then, the steering committee looked to Martha Blaxall, an IOM staff member who held a doctorate in economics, to draft the report. She functioned as an adjunct of the steering committee, not as an independent contractor, as David Kessner had on the health contrast studies. In the parlance of medical research, she was not the principal investigator who ran the study as much as the talented postdoc working in someone else's laboratory. Just as science was a collaborative endeavor, so the line between the steering committee and the staff on an IOM project was difficult to draw. Although the steering committee reviewed Blaxall's work carefully and came to its own conclusions, the study nonetheless depended very much on her efforts.53
Because the steering committee met infrequently and internal clearances were necessary for any IOM report, the report on legalized abortion was not released until May 1975. At the very beginning, the committee made it clear that the report would not deal with the ethics of abortion. It would, instead, treat the health aspects of the subject, an area in which its credentials were unquestioned. For many combatants in the debate, this posture resembled mounting a production of Hamlet without the character of Hamlet. From the IOM's perspective, the decision showed a newfound ability to limit its work to those aspects of public policy on which it could speak with authority. For the members of the steering committee the ethics of abortion were, in any case, beside the point. They believed that whether or not abortions were legal, women would seek them. The committee concluded that "legislation and practices that permit women to obtain abortions in proper medical surroundings will lead to
fewer deaths and a lower rate of medical complications than restrictive legislation and practices."54
In a manner typical of IOM study groups, the steering committee conceded that many things about abortion remained unknown. Hence, in what would become a cliché in IOM reports, the group called for further research on the consequences of abortion on health status. The highest priority, according to the committee, was for studies of the effects of abortion on mental health.
Although this IOM lacked the money for wide distribution of the report, it nonetheless elicited considerable public reaction. The Center for the Study of Moral Order condemned the committee for not taking a stand on the moral and ethical issues and urged the IOM to "disavow the ethically neutral behavioral movement of social numbers theory." 55 Wire services wrote stories about the report that led to newspaper articles from coast to coast. The report's summary and conclusions made their way into the Congressional Record on June 3, 1975. The National Abortion Action League and the Religious Coalition for Abortion Rights distributed reprints from the Congressional Record.56 In this manner, although the study contained nothing surprising and tended to reinforce the conventional liberal wisdom, it made a definite impression on the public debate. The study showed that the IOM could work in a modest manner and still get results.
The IOM also experimented with small-scale policy statements on timely issues. These were short reports done quickly. One of the first came about as a result of a provision in the Social Security Amendments of 1972 that awarded health insurance coverage through Medicare to people with end-stage renal disease (ESRD). The idea was to have the federal government pay for kidney dialysis. The IOM quickly convened a group to consider whether this disease-by-disease approach to national health insurance made sense.
In a sense, the composition of the group predetermined its outcome. At least three of the members followed Social Security policy closely and objected to the way in which Congress had handled the ESRD provisions. Robert M. Ball, a scholar in residence at the IOM who served as Social Security Commissioner from 1962 to 1973, acted as a consultant to the committee. He, too, opposed the ESRD parts of the 1972 law. Not surprisingly then, the panel, chaired by political
scientist Herbert Somers of Princeton University, concluded that "coverage of discrete categories of diseases would be an inappropriate course to follow in the foreseeable future for providing expensive care on a universal eligibility basis."57 In other words, the study reaffirmed the convictions that panel members brought to the task—a potential danger inherent in all IOM reports and, for that matter, in all NAS reports.
The IOM intended the health maintenance organization (HMO) study to function in a manner similar to the categorical approach report. It would be a modest effort that would produce what John Hogness called a "background paper on health maintenance organizations." Hogness discovered, however, just how hard it was for the IOM to stay current with breaking events.
The committee for this project, headed by Paul Ward, executive director of the California Committee on Regional Medical Programs, met for the first time on January 9, 1973. Everyone realized that federal legislation in aid of HMOs was under consideration in Congress. Despite the possibility that the committee's work might be overtaken by events, the group decided to proceed. The committee produced a preliminary draft by October; President Nixon signed the HMO Act of 1973 into law at the end of December. The law implemented some of the committee's suggestions, yet the committee continued to see the merits of issuing its own report.58
The theme of the report was that health maintenance organizations should be given what the committee called a "fair market test." Such a test would "do more to improve the functioning of the American health care delivery system than any other policy step which could be taken in the near future."59 IOM members who reviewed the report were less than impressed with it. One reviewer called the timing of the report"... peculiarly unfortunate. It is both too late and too soon.'' The IOM could no longer influence the content of the law, nor could it appraise the law's impact. Furthermore, the committee's fair market test, according to the reviewer, came complete with numerous regulatory suggestions that amounted to a "high degree of protection." Such criticism led to further delays in releasing the report. One federal official had to plead with the IOM's Karl Yordy to get the report released. "Let's get the Report published and let's forego any further nitpicking,'' he said. When the report appeared in May 1974, it had only a minimal impact on public policy.60
The Costs of Education Study
The reports on HMOs, end-stage renal disease, and abortion required a large expenditure of staff time with comparatively little return. The reports were on disparate topics and failed to bring a sense of coherence to the IOM's efforts. If the IOM were to survive, it required a large sustaining project that brought in enough money to cover not only the costs of the project itself but some of the Institute's other operational costs as well. The study of the costs of educating health professionals served as just such a project for much of 1972 and 1973.
In November 1971, John Hogness received a letter from Merlin K. DuVal, Assistant Secretary for Health and Scientific Affairs at the Department of Health, Education, and Welfare, mentioning the fact that Congress was about to pass the Comprehensive Health Manpower Training Act of 1971. DuVal had managed to insert a provision in the act that mandated a study of the "national average annual cost of educating students in each of the health professions." DuVal made sure that the Institute of Medicine would be asked to perform the study.61
The study concerned a subject in which IOM members took a vital interest. At stake was the way in which the federal government would subsidize medical schools as well as schools of dentistry, osteopathy, nursing, veterinary medicine, pharmacy, podiatry, and optometry. In the past, much of the support was indirect, through mechanisms such as research grants, which by 1968 amounted to nearly 42 percent of medical school revenues; construction grants for teaching faculties; and special grants for schools in financial distress. With federal research funds declining and medical school enrollment expanding, Congress sought a better system for aiding schools. One idea was to make grants to the schools based on the number of students. Not ready to make a final decision on how to implement such a system, Congress fell back on the old device of requesting new data. It wanted to know how much it cost to educate a medical student and how much variation existed from school to school. It also asked for a way in which costs per student could be calculated and for any recommendations that the IOM might have on the way the federal government could use educational cost data to determine the appropriate amount of capitation grants to health professional schools.62
The assignment required the IOM to come up with hard data in a manner similar to the studies on health contrasts that had been conducted by David Kessner. This necessitated hiring a large staff
with technical competence and the ability to complete the study by the June 1974 deadline imposed by Congress. Hogness put Ruth Hanft, the IOM's senior research associate, whom he had hired in March 1972, in charge. He had met her during his service on the HEW Secretary's Task Force on Medicaid and had come to admire both her technical skills and her Washington savvy. Hanft was, in fact, a distinguished figure in health services research who, among other things, enjoyed a close working relationship with HEW Secretary Elliott Richardson and had played a key role in designing the Nixon administration's health insurance proposal. Hanft, in turn, supervised the hiring of a staff that eventually numbered 20 people, as well as consultants from five different consulting firms.63
The costs of education project was a $2 million undertaking that involved reviewing data from previous studies, coming up with a methodology for estimating costs, gathering the data necessary to make the estimates, interpreting the data, and producing a final report. Hanft and her study team decided to appoint eight professional advisory panels, one for each of the professions being studied. This necessitated holding meetings with each of them. The most time-consuming aspect of the project involved visiting a representative sample of the schools and then asking faculty members to record their activities for a week of their time. In this way, the project staff hoped to determine exactly how much of a faculty member's time went into teaching and other educational activities and how much went into providing care or performing research. The approach raised complex methodological issues. How could one reasonably divide the time of a resident who both supervised medical students and interns and performed clinical procedures on patients? How could one be sure that faculty members reported their time accurately or participated in the survey at all? Where, exactly, did teaching stop and research begin, when the research was often conducted with students and when the products of the research informed faculty members' teaching?64
Julius Richmond headed the IOM steering committee that tried to advise Hanft and her staff on these issues and formulated the final recommendations. The committee also included Eli Ginzberg, a professor of economics at the School of Business, Columbia University, and one of the nation's leading experts on manpower issues. Almost alone of the members of the steering committee, he devoted a substantial amount of his time to the committee's work and closely critiqued the staffs methodological approach. Others on the committee had direct experience with administering a school concerned with the health professions—for example, James Kelly,
former vice president for administrative affairs at Georgetown University; Alvin Morris, vice president for administration at the University of Kentucky; Martin Cherkasky, director of Montefiore Hospital; and David Rogers, former dean of the Johns Hopkins Medical School and current president of the Robert Wood Johnson Foundation.
Inevitably, the steering committee ceded a lot of ground to Hanft and her staff, both because committee members could not hope to get involved in the finer points of data collection and because Hanft was an accomplished expert in her own right. Indeed, she would become an IOM member after her service on the IOM staff. When it came to making recommendations, however, the steering committee played a central role.
The climactic meeting of the steering committee took place in September 1973. The central issue concerned whether to restrict the report to hard data, such as a statement that the total cost of educating a medical student was $4,821, or to broaden the report to include a philosophical statement on the government's role in health education. Daniel Tosteson, the chair of the Department of Physiology and Pharmacology at Duke, hoped to stick close to the data. David Rogers disagreed. He argued that the "climate of the times" demanded the report go beyond costs. The figures were important to support the committee's position, but "if the Institute of Medicine doesn't take a lofty view of Federal subsidy to health professionals, no one will." He concluded that ''Congress wanted more than data; they want strong, constructive guidelines.'' Eli Ginzberg agreed that the report should convey the fact that federal subsidies for educating health professionals were "in the national interest.65
The final report, like nearly all IOM reports, amounted to a compromise between these two positions. It included a great deal of data and even a technical appendix. It also contained a series of broad philosophical recommendations, for example, that "health professional schools be regarded as a national resource requiring Federal support." The group endorsed a capitation grant program as "an appropriate Federal undertaking to provide a stable source of financial support for health professional schools" and recommended that capitation grants ranging between 25 and 40 percent of net educational expenditures "would contribute to the financial stability of the schools and would be an appropriate complement to other sources of income."66
When it came time to brief the Subcommittee on Health and the Environment of the House Interstate and Foreign Commerce Committee, Hanft, rather than Julius Richmond, did the talking. She dwelled on the methodological aspects of the study and presented the
congressmen and their staff with tables of data. She mentioned the group's recommendations last, in contrast to the formal report, which listed them first.67
The report on the costs of medical education illustrates some of the problems that the IOM faced in its early years. The study, although large and lucrative, lasted only a short time and originated in Congress, not in the IOM itself. It was not a project that IOM members would have chosen to do on their own. The National Academy of Sciences had a long tradition of responding to requests for advice from the federal government and expected the IOM to do the same. The IOM, for its part, hoped to maintain an independent agenda that reflected professional and societal concerns. The costs of education study furthered this agenda but only indirectly. It concerned a limited and highly technical point of policy, not a major policy initiative. Furthermore, the restricted duration of the study meant that it provided only temporary financial relief to the IOM. The large staff recruited for the project would not be able to move on to other IOM projects. Finally, the project was staff-driven. Steering committee members did little to influence the study methodology, which could as easily have been done by a Washington think tank or consulting firm as the IOM.
What the IOM added to the costs of education study and to health policy more generally was the ability to convene groups of experts to serve on the steering and advisory committees. The appeal to Congress was that the IOM represented a broader interest than the medical and other health professions schools. In this regard, the IOM differed from the Association of American Medical Colleges or other groups that had done studies on the costs of medical education.
In the end, however, the Institute of Medicine contained a core constituency of faculty members and administrators from academic medical centers. On the 10-person steering committee, only Eli Ginzberg, a Columbia professor, and Morton Miller, executive vice president and chief actuary of the Equitable Life Assurance Society, were not directly involved with medical education. The other eight, with the possible exception of foundation executive David Rogers, depended on federal subsidies to medical, nursing, or dental schools for their livelihoods. Hence, the general principle of federal aid for medical education never came under heavy attack. Although Hanft might have preferred to stick with the data and not take any philosophical positions, she was overruled. In the ensuing discussion, there was no conservative ideologue who could hold his or her own with former medical school dean Rogers or federal manpower program advocate Ginzberg. Nevertheless, the IOM delivered an innovative
and technically competent report on time. When Senator Edward Kennedy offered amendments to the Health Professions Educational Assistance Act of 1974, he described the IOM study as the "best and most reliable data ... on the educational costs of schools of the health Professions." 68
The Program Committee
Beyond the Washington Beltway and beyond the large medical centers, few people worried about reliable data on an arcane subject. As a consequence, the costs of education report did little to increase the IOM's general visibility, nor did it help unify the IOM's program. The study, in short, was not the sort of project that Hogness favored as a model for the IOM. He preferred that the Institute not conduct research but rather that it be concerned with "broad and basic issues of national health policy."69 His advisers concurred in the recommendation that the "Institute concentrate more on policy analysis than on the gathering of original data."70 In this vein, Hogness and the IOM Council reacted with skepticism to a proposal that the IOM function something like the Brookings Institution. If the IOM were to be a think tank, it would be a staff-driven, not a member-driven, organization, which appeared to violate one of the IOM's main organizing principles. 71 Neither Hogness nor the IOM Council wanted to leave the IOM to the mercy of external clients, even those of such obvious influence and importance as the U.S. Congress, and make it, in the Washington vernacular, a "job shop." Instead, Hogness recognized the need for the organization to focus its efforts on important issues of its own choosing. He looked to the Program Committee to provide the necessary focus. In this manner, he followed the plan set down by the Institute's founders who mandated that the IOM president create a Program Committee and use it to prepare a program of studies.
The Program Committee under the direction of Irving London and with the staff support of Karl Yordy held frequent meetings not only to consider specific proposals but also to produce a general framework for the IOM's work. As a first cut, the committee divided the proposals into 10 general categories. These categories failed to satisfy everyone. James Shannon, still following the IOM's activities with interest, said that the categories gave short shrift to science and medical education. He saw in the committee's work "the reflection of a progressive detachment of the drive of medical schools from a biomedical science base to softer social considerations." Shannon, in
other words, was still conducting the war that he had waged in the Board on Medicine against Walsh McDermott. For Shannon, there was too much on "legal and ethical issues" (category 10), "health maintenance" (category 6), and "environmental influences on health" (category 2). Philip Handler found himself in full agreement. Science always came first with him. Roger Bulger conceded that the categories were rather loose but thought it important just ''to get started." Even the Program Committee did not regard the categories as fixed. After consulting with members, for example, the committee realized that ''government regulations and health administration" (category 9) intersected with nearly all the other categories and would have to be dropped.72
At the end of 1972, the Program Committee took the process a step further and issued a general statement that suggested four basic principles to guide the IOM program. These followed directly from the deliberations that had led to the IOM's founding. The organization should rise above "any particular interest, viewpoint, or profession" in favor of "the protection and advancement of the health of the public." The Institute's program should involve its members in its work. The IOM should recognize a "fundamental unity of health policy issues" and not attempt to attack them piecemeal. Finally, the "Institute should initiate activities as well as respond to external requests." There followed a long laundry list of projects that the IOM might undertake, such as an "analysis and redefinition of health manpower functions and roles" or a "study of the interaction between the physicians and the FDA on drug utilization."73
A fundamental lack of money kept the IOM from following its general principles and undertaking these specific projects. Fund-raising, so vital to the IOM's survival, became a source of considerable anxiety during the IOM's first 15 years. "The financial support of the Institute of Medicine was, to put it mildly, a bit shaky at first," Hogness recalled.74 In time, however, Hogness attracted a core group of five foundations that came to the IOM's aid. For the first few years, the IOM included a statement in each of its studies that it received its principal funding from the five foundations and listed them by name.
During the long period of discussion with the National Academy of Sciences, the Board on Medicine had put its fund-raising efforts on hold, with the result that the IOM had little to spend in its first
months of operation. Through the end of the 1972 fiscal year, the National Academy of Sciences covered most of the IOM's $2,000 in administrative expenses. Only the studies on health contrasts and the costs of medical education brought in much external money, and most of this went to pay specific project expenses, leaving nearly nothing for activities that might lead to the IOM's expansion.75 As a consequence, the IOM maintained a versatile yet small and rudimentary staff.
Hogness realized that much more money was required. He estimated that the IOM would need at least $700,000 just to sustain its central activities including staff salaries and money to pay the travel expenses of the members of the IOM Council and the IOM Program Committee.76 Although those who served on IOM committees did so without compensation, they still generated bills for transportation and lodging. Looking to the foundation community to support the IOM, Hogness made the rounds of foundations that took an interest in medicine and medical policy.
One of his first stops was the Robert Wood Johnson (RWJ) Foundation. At the end of 1971, Hogness told the head of this foundation, which was just getting organized, that he planned to make a formal proposal at the beginning of the next year. At the time David Rogers, who was himself an IOM member and regarded Walsh McDermott as an important mentor, would become the president of the foundation. Hogness and Rogers were on a close, first-name basis, with Rogers even relying on Hogness to make suggestions for appropriate people to staff the foundation. Although foundation officials asked many hard questions about the IOM's focus and fund-raising plans, the RWJ Foundation decided to make a major grant of $750,000, to be spent over a three-year period. The foundation predicted that the IOM would "make a contribution of the first importance to the outcome of the difficult and decisive policy decisions confronting the nation's health enterprise." The grant, the sixth largest that the foundation awarded in 1972, represented a substantial vote of confidence in the IOM. The foundation and the IOM hoped, in effect, to work together in establishing themselves as important entities in the world of health policy.77
Support from the Robert Wood Johnson Foundation had an immediate effect on IOM activities. In fiscal year 1973, RWJ money amounted to more than the amount contributed by NAS to the organization. The IOM used the money to defray some of the expenses that it could not charge to project accounts, such as the $157,000 it spent on salaries for "IOM direction and support," the $40,000 required to fly the Council to Washington, D.C., for meetings, and the
$46,000 that it hoped to spend on public information and reports.78 All in all, the IOM used $200,000 of the foundation's money in 1973. Hogness credited the RWJ Foundation with making it possible for the IOM to expand from 5 to 12 professional staff members.79
The W.K. Kellogg Foundation, which had a long-standing interest in public health, provided another target for Hogness's philanthropic outreach. Here again, it took substantial effort for the IOM to satisfy the foundation. A proposal calling for $643,420 over five years was rejected by the Kellogg Foundation and led the IOM to write a second proposal, asking Kellogg to give the IOM $100,000 a year for five years. IOM officials estimated that this amount would cover 40 percent of the basic operating expenses. Only a month after the RWJ award, the Kellogg Foundation board elected to give the IOM $100,000 a year for three years, a grant that was not as long in duration as the IOM had requested but one that paid just as much each year. The foundation hoped the IOM would use this money to plan its major studies and to develop "authoritative statements on major health policy issues." Hogness reported that this "flexible support" would enable the Institute "to take the initiative'' on such issues as the "training and distribution of health manpower.'' The IOM used the money to fund short-lived member "survey" committees to assist the Program Committee, such as one on science policy for medicine and health, and to pay for staff papers on such subjects as the Nixon administration's 1974 health budget.80
The Richard King Mellon Foundation became the third foundation to come to the IOM's aid in 1972. Robert J. Glaser, who worked at the Commonwealth Fund, reminded John Hogness that during the Board on Medicine days, Irvine Page had gone to see a member of the Mellon family and asked for "a massive amount of money to set up an independent academy." Glaser urged Hogness to visit George Taber, director of the Richard King Mellon Trust, and tell him that the IOM was the direct outgrowth of Page's efforts. Hogness followed through on Glaser's suggestion, and this yielded a grant of $300,000, to be spent over three years, in support of the IOM's budget for central activities. Most of the money went to pay staff salaries.81
By 1975 two more foundations, the Commonwealth Fund and the Andrew Mellon Foundation, had joined the core group of major contributors to the Institute of Medicine. Getting money from both required intensive efforts on the part of Hogness and his staff. Commonwealth turned down an initial request for $1 million. Hogness persisted, submitting another application at the end of November 1973. The Commonwealth board, which included IOM members Quigg Newton and Robert Glaser, deliberated over this
proposal until May. During this period, IOM officials made numerous visits to Commonwealth and talked with its officials by telephone. The effort paid off in the form of a grant of $200,000 a year for three years.
Cultivating the Andrew Mellon Foundation proved similarly arduous. There, Hogness dealt with Nathan Pusey, the former president of Harvard, and John Sawyer, the former president of Williams. He asked Mellon for a "spendable endowment grant of $1,000,000." Mellon officials were not interested in this. Their foundation tended to focus on the humanities, rather than the sciences. In time, the IOM developed a proposal to establish a program in health care ethics, something that fit the foundation's mission and had been on the IOM's agenda from the beginning. In December 1974, Pusey informed Philip Handler that the foundation would give the IOM $750,000 for its program of "examining the competing political, economic, and social values inherent in decisions pertaining to health care policy."82
Although preferable to receiving money from the federal government to perform a specific task, foundation funding carried its own drawbacks. For one thing, foundation officials—some of whom were IOM members and hence entitled to kibitz for that reason alone—enjoyed a relationship with the IOM not unlike that between New York financiers and Hollywood producers during the studio era. In return for their money, the foundations expected to exercise a certain degree of oversight or, in the language of philanthropy, stewardship. It therefore mattered when a high official of the Commonwealth Fund criticized the IOM for taking a "shotgun" approach to health policy issues or an official from the Kellogg Foundation said that the IOM did not do enough to disseminate the results of its studies.83 There was, in other words, no free lunch.
It also took considerable industry to "scrounge up" the lunch. Most of the philanthropic contacts that Hogness made went nowhere. With such an illustrious group of members, the IOM could get in touch with nearly any foundation and meet with a cordial reception. Often, however, the IOM received exquisite courtesy and nothing else. The case of the Ford Foundation was typical. Adam Yarmolinsky knew McGeorge Bundy, head of the Ford Foundation, through both his Washington and his Harvard connections, and he set up a meeting with Bundy; Ford vice president "Doc" Howe, a former commissioner of education; and IOM officials. "My guess is that ours is not the particular bank at which they will be most likely to find anything but good wishes," Bundy told Yarmolinsky. At the meeting, Bundy offered only a glimmer of hope, advising the IOM that the Ford Foundation
was not in medicine, gave no money for endowments, and was not feeling rich. For the next eight months, IOM staff members kept plying Bundy with invitations to IOM events and updates on IOM activities. Then the Ford Foundation politely but firmly said no.84
Perhaps the most difficult thing about foundation grants was that they had to be renewed. When IOM officials received a foundation grant, they spent, rather than invested, the money. This meant that within a few short years, they had to return to the foundation or find another one to take its place, a situation that did not make for financial stability. In the common parlance, foundations provided soft, not hard, money. "I am still concerned about the long-range financing of the Institute. Foundations tend to be fickle in their support," wrote William Danforth, a physician, IOM member, and president of Washington University, in 1975.85
Even with foundation support, the Institute of Medicine could do only a few of the things it wanted to do. To create a sense of community, the Institute looked to activities that were under its control. Of all the organization's rituals, members took the most interest in the annual election of new members, although the results never pleased all of the IOM's constituencies. The elections between 1972 and 1975 were typical in the way that so many members participated and so many were discontented with the results. In 1972, the members made 150 formal nominations for 50 available positions, and the Membership Committee reduced the number to 84. The election yielded 53 new members, including former HEW Secretary Wilbur Cohen, philosopher and medical ethicist Daniel Callahan, distinguished sociologist Elliot Freidson, and noted health statistician Dorothy Rice. With the results in, the IOM Council analyzed them to identify areas that had to be strengthened. Its analysis showed that only 4 of the 17 practicing physicians nominated, compared with 10 of 11 academics, made it into the Institute, and that only 4 basic scientists were elected. Less than half of the 25 new members had an M.D.; 12 were members of minority groups, including 10 blacks. The results stirred up Irvine Page, who complained that the IOM was becoming a "sociological forum far from the needs of medicine.... We are increasingly being looked upon as academicians of strong political and social hue."86
Hogness agreed that more practicing physicians and more basic scientists were needed. Although the Institute made a concerted effort
to elect more basic scientists in 1973, fewer scientists were picked than any other group. This agitated Philip Handler, who suggested that there be "fixed quotas of relatively non-overlapping categories" in order to balance the membership. The Membership Committee came up with a new set of categories, including clinical and fundamental scientists, that resulted in the election of a few more scientists. This, in turn, irritated social scientists such as David Mechanic, who complained that only one of the 33 candidates listed as a fundamental scientist—economist and NAS member Kenneth Arrow—was a social scientist. No psychologists or anthropologists made it on the list. In succeeding years, the Membership Committee continued to adjust the categories and created a ballot that set quotas on each category. In 1975, for example, the categories included natural scientists, social scientists, health administrators, clinical practitioners, and others. Members were urged, although not compelled, to vote for a specified number of candidates in each category, up to a total of 40.87 The result was that the proportion of fundamental scientists rose from 14 to 15 percent of the membership, but practitioners declined from 9 to 8 percent.88 The search for the proper mix of members continued.
If elections provided a common bond among Institute members, the presence of visiting fellows helped to create a sense of community in IOM central offices in Washington, D.C. Most came with outside money and sought only a congenial place in which to work. At the beginning of April 1973, former Social Security Commissioner Robert Ball moved in as a more or less permanent fellow. He remained at the Academy until the beginning of the Reagan era, using his time to write a book on Social Security and Medicare and to play an active role among Social Security and Medicare policymakers. With his tremendous set of Washington connections and extensive administrative experience, he served as an informal adviser to at least four IOM presidents. As an IOM member in his own right, he also took a more formal part in governance, serving as a member of the Council and of the steering committees for IOM studies.
Dr. Robert Q. Marston, former director of NIH, became a fellow at the same time as Robert Ball. Although his stay was brief, his mission was important.89 He directed the Robert Wood Johnson Health Policy Fellowships program, which became the longest-running regular activity of the IOM. It began with a $710,000 grant from the foundation to the IOM, intended to "offset severe shortages of faculty members in the nation's academic medical centers who are specifically qualified for research, teaching, and service in the complex field of health policy."90 The idea was to bring a small number of academic physicians and other health professionals to
Washington and have them work for congressional committees and other agencies involved in making health policy. Cooperating with the American Political Science Association, the IOM ran the program through a special Fellowships Board that took the lead in selecting the fellows. The Institute announced the selection of the first group of six fellows, who had been culled from 43 nominations, and 12 finalists, in the spring of 1974. These fellows spent the 1974–1975 academic year in Washington, starting with an orientation at the IOM and then moving into temporary assignments on Capitol Hill. David Banta, an assistant professor at Mount Sinai School of Medicine's Department of Community Medicine, with both an M.D. and a master's degree in public health to his credit, worked for Paul Rogers's health subcommittee in the House and for Edward Kennedy's health subcommittee in the Senate. He thought enough of the experience to accept a permanent Washington assignment.91
Although foundation officials worried that having the fellows succumb to Potomac fever defeated the purpose of the enterprise, they recognized the fellowship program as an important endeavor that deserved their continuing support. In 1976, the RWJ Foundation renewed the basic grant and raised its level to more than $1 million. The fellows, meanwhile, had become a regular part of IOM life. They received standing invitations to the IOM annual meetings and other activities.92 Despite occasional squabbles over budgetary levels and administrative details, the fellowship program exemplified an almost seamless collaboration between the RWJ Foundation and the IOM, with few of the drawbacks of other forms of soft money.
Relations with the National Academy of Sciences
If annual meetings, elections, and visiting fellows provided a sense of continuity to the IOM's activities, so—in a perverse way—did the continuing efforts to define an appropriate relationship between the IOM and the NAS. Discussions on this subject continued throughout the first four years of IOM history. The desire to maintain a distinctive identity apart from the rest of the Academy helped unify IOM members. They examined communications from the NAS with the same suspicion and apprehension that eighteenth century American colonists reserved for letters from the King of England.
Philip Handler had a tendency to treat the IOM in an imperial manner. Indeed, John Hogness later claimed that Handler had never wanted the Institute to be created in the first place, but his other priorities prevented a major confrontation. These consisted of
reorganizing the National Research Council and defining the relationship between the NAS and the National Academy of Engineering (NAE). Handler's relationship with Clarence Linder, the NAE president, was far worse than his relationship with John Hogness. In fact, both Linder and Handler used Hogness as a sounding board, each complaining about the other.93 Despite the often prickly personalities involved, Handler persisted with his reorganization efforts. During 1971, he tried to enlist Hogness's help in reorganizing the National Research Council so that many IOM activities, particularly its ability to initiate studies, would be moved to the NRC. Hogness offered Handler little aid, telling him that IOM members would never go along with the changes. The IOM Executive Committee decided in November 1971 not to acquiesce in the reorganization plan. "IOM is a bastard organization. It does not fit properly anywhere," confessed Hogness to Handler.94 For the next two years, Handler pursued the more sensitive negotiations with engineers. Then he told Hogness that his long years of bargaining with the NAE had produced an agreement that was adopted with enthusiasm by all of the parties involved, and it was a matter of "considerable urgency" to reach a similar agreement with the IOM.
Faced once again with a request that the IOM incorporate many of its activities into the NRC, the IOM Council responded by reasserting its basic principles. The Institute wished to retain its organizational structure, one that combined the characteristics of an honorary society and a working organization. The Council therefore rejected the notion that the IOM should become a purely honorary academy, with an "Assembly of Medicine" in the NRC as its "operating arm." The IOM also wanted to retain its multidisciplinary character, examining the "social science issues of medical care," as well as policies related to ''health professional education and the biomedical and behavioral sciences basic to health." Although the Institute of Medicine agreed to be represented on the governing board of the National Research Council, it concurred in none of Handler's other suggestions, and for the moment at least, the NAS Council did not press the issue. In effect, the NAS accepted the fact that the IOM would differ in significant ways from the National Academy of Sciences and the National Academy of Engineering. Only one substantive change came about as the result of the 1973 reorganization effort: the authority to approve IOM projects was transferred from the NAS Council to the Governing Board of the NRC. ''In essence," as John Hogness put it, "the present organizational situation is basically a good one and should be reaffirmed."95
When John Hogness reaffirmed the soundness of the IOM structure, he did so as someone who was about to leave the organization. Appearing before the IOM Council on May 10, 1973, he announced that he would assume the presidency of the University of Washington, the one job he felt he could not refuse, in the late spring of 1974. A search committee headed by Walsh McDermott moved quickly to select a successor. The committee chose Donald Fredrickson, who had the distinction of being a member of both the Institute of Medicine and the National Academy of Sciences.96
Two years younger than Hogness, Fredrickson had followed a different route in his career. He began his undergraduate studies at the University of Colorado, but the war interrupted them. After serving in the U.S. Army, he finished his undergraduate degree at the University of Michigan and remained in Ann Arbor for his medical degree. Between 1949 and 1953, he completed his training in hospitals and laboratories that were associated with Harvard. Beginning in 1953, he worked at the National Heart Institute, serving as its director from 1966 to 1968. In 1973, when the IOM search committee approached him, he was the director of intramural research at the National Heart and Lung Institute. Of all the IOM founders, his career resembled most closely that of James Shannon: the focus was on research, rather than on clinical practice.
Fredrickson had joined the IOM with the initial membership group in 1971, quickly becoming involved in it activities. In the fall of 1971, he received a phone call from Julius Comroe, who wanted another basic scientist to serve on the IOM Council and asked Fredrickson to run. Agreeing, Fredrickson became a Council member in 1972 and found it to be an engaging experience. "There was a rich mixture of the dialects and ethics operative in the world outside the laboratory walls," he recalled, that offered "an unparalleled view of the complex field of human health." When the search committee approached him in the fall of 1973, he was interested.
On November 20, 1973, Philip Handler invited Donald Fredrickson to his office. "The Council of the IOM thinks I ought to talk to you about John's job," Handler said. Fredrickson told him that the prospect of becoming president of the IOM was not unattractive but that he worried about how the NAS reorganization would affect the Institute. He defended the IOM practice of mixed membership, saying that "ecumenism" was important in such a complicated area as health. He announced that he would not consider the job unless the disagreements between the NAS and the IOM were settled. This
provided a spur to Handler and Hogness and accounted in large measure for Handler's acquiescence to the IOM position. After some hesitation, Fredrickson accepted the offer of the IOM presidency on January 18, 1974.
The members' meeting in the spring of 1974 served as an inauguration of sorts for Donald Fredrickson. He spoke of bridging the worlds of science and medical practice, arguing that the IOM's commitment was to "lend the scientific method to the direction of a whole social movement." Noting that the IOM's success rested upon the "essence, not merely the appearance, of nonpartisan objectivity," he predicted that the same sort of satisfaction he had found in the laboratory could also be found at the Institute of Medicine.
However, Fredrickson faced a rude sort of culture shock. Perhaps the most jarring element was the need to visit the IOM's major funders, reassure them that the organization remained strong, and initiate the process of reapplying for support. As an official of NIH, Fredrickson had given away, not requested, money. Fund-raising in the federal government took the form of appealing to the Bureau of the Budget and Congress, a far different exercise than going to New York and meeting with foundation officials.
One exercise that the leadership of NIH and the IOM held in common was the need to provide sufficient office space for staff. The IOM staff was simply too large to be housed in IOM headquarters, nor could it secure enough space in an auxiliary building on Pennsylvania Avenue. Therefore, the IOM rented space in the Watergate office complex that had previously been occupied by the Democratic party. Indeed, Fredrickson's office turned out to be the same one used by Lawrence O'Brien, the very site of the Watergate break-in, which monopolized the headlines during this period surrounding President Nixon's resignation. As a consequence, IOM staffers often found their work interrupted by curious tourists seeking out the "stuff of history."
Fredrickson never had time to sink his teeth into the job as president of the IOM. Almost as soon as he arrived in the late spring of 1974, he began to receive phone calls from federal officials warning of dissension in the upper ranks at NIH. Some of these officials wanted to know if he would be willing to return to Bethesda as head of the National Institutes of Health. Early in January 1975, Fredrickson learned that he was on a short list of candidates for both Assistant Secretary of Health and director of NIH. He met with administration officials on January 9, 1975, a year to the day after he had received a phone call from Handler offering him the job as IOM president. On January 24, he told the IOM Council that he had been approached by the administration to serve as head of NIH and that he
"would not refuse to consider this position" if it were offered to him. That morning, over breakfast, Adam Yarmolinsky had tried to dissuade Fredrickson from considering the position, arguing that he could do more good as head of the IOM. Fredrickson explained that as he had told Philip Handler, the NIH was "not a job; it's a cause." Realizing that something had to be done, the IOM Council moved to designate a vice chairman pro tem who would take over in Fredrickson's absence. It eventually selected Julius Richmond for the post.97
On April 19, 1975, HEW Secretary Caspar Weinberger announced the nomination of Donald Fredrickson as director of the National Institutes of Health. On May 5, Fredrickson addressed a letter to all members of the IOM telling them he had accepted President Ford's offer and that he would be leaving IOM in June. He said that the choice was difficult but he had chosen NIH because its needs seemed more critical. He realized that although changing presidents twice in four years created great potential for harm, he was confident that the IOM would "survive its president." He owed his confidence to his faith that Julius Richmond and Roger Bulger would preside effectively over the Institute during the transition period. He also took solace in the fact that the Robert Wood Johnson and Kellogg Foundations had renewed their core grants to the IOM and that the IOM would be able to maintain a budget of from $3.5 million to $4 million in fiscal year 1976.98
"In retrospect the time you have spent with us now seems to have been extraordinarily short," Handler wrote to Fredrickson.99 Indeed, Fredrickson had only a few months to concentrate on the IOM. The rest of his short tenure was spent in negotiations with administration officials over the state of the National Institutes of Health. This left him with too little time to change the IOM's basic direction or to infuse the IOM with the funds that would make it truly self-sustaining. Of six major projects that the IOM had hoped to initiate during Fredrickson's tenure, only two had received any sort of outside funding.100
During the traditional August lull in 1975, Roger Bulger, who had been running the IOM on a daily basis since Fredrickson's departure, dictated a thoughtful letter to Larry Lewin, a Washington consultant who had worked on the IOM's costs of education study. The letter provided Lewin, who was hired to make recommendations on how the
IOM should be structured and managed, with an overview of the IOM's four-year history. It was an exceptionally candid look at the organization.
Bulger noted that the problems of the IOM began with its name. People mistook it for the National Institutes of Health. When the IOM did something newsworthy, its activities became confused with those of the National Academy of Sciences. As for the IOM's program, the organization had often been concerned with issues that were "very philosophic, sometimes ethical, often quite political, and frequently not as quantitative or analytical as may people would like." Still, most people knew of the organization only because of the large, data-collecting studies, such as the costs of education study. The problem was that it was possible just to collect data, without getting at underlying policy issues. Hogness and Fredrickson had both believed that much of the valuable activity at the IOM took place outside the formal studies. If nothing else, the IOM served to "broaden the horizons of each of its members." Many of its best conversations and activities took place in Council meetings and meetings of the Membership Committee. These discussions were themselves contributions to health policy.
Although the IOM had its headquarters in Washington, D.C., it was not a typical Washington organization. The IOM president did not make regular appearances on Capitol Hill or serve as a sort of "health policy guru." In this regard, the IOM differed from the American Association of Medical Colleges, whose president, John Cooper, had become a major player on the national scene. Some people thought that the IOM should try to play a more visible role in the policy process. Part of what inhibited the IOM was the inability to distribute the results of its studies. Bulger thought it sad that the IOM could not provide copies of its costs of education studies to every medical school in the country. Nor did the IOM spend much on publicity, depending on the "kindness of strangers" to let the world know of its accomplishments.
As a way to overcome some of these problems, John Hogness had "utilized the development of a staff as a combination of acquiring expertise and analytic abilities with extending the points of contact for the Institute throughout the health establishment." The members of the staff complemented one another. Bulger had experience with the allied health professions, Karl Yordy with the government, and Ruth Hanft with health services researchers. The IOM used its visiting scholars and residents to fill in the gaps. Every such request was scrutinized with an eye toward the potential "contribution to the general environment of the Institute and its possible contribution to
the staff." The result, according to Bulger, was a "reasonable level of staffing." "We have a very wholesome interdisciplinary thing going,'' he added, "such that I am comfortable as a health professional with the whole range of staff people.''
Bulger concluded his long letter by saying that "as we have developed more of track record and more people have taken notice of us, we have also attracted our share of jealousies and legitimate concerns. It is important that in this city of Washington, those people who might look to us for advice and who might be able to use us should think of us as competent and able to deal with the problems."101 Hogness and Fredrickson had made a start in this direction, in particular by raising funds from foundations and establishing the basic routines of IOM governance and IOM studies. Still, as Bulger had noted, the organization remained invisible to mainstream Washington and the general public. By the time Jimmy Carter became president in 1977, this condition would change.