- Email: [email protected]
Institute of Medicine: A brief look at a controversial body
Institute of Medicine: A brief look at a controversial body L o ca ted in W ashington, a city filled with govern m ental and qu asigovem m en tal agen cies, bu reau s, and com m issions that populate the na tio n ’ s capital and contribute to the running o f the co u n try ’ s busin ess, is that som etim es co n trover sial b o d y, the Institute o f M edicine. L ittle know n to the general public, the IO M fun ctions as an independent investigative body that provid es analysis, a d v ice, and judgm ent on the quality and d elivery o f health care in the U nited States. It w as chartered in 1970 by the N ation al A c a d e m y o f S cien ces to enlist distin guished m em bers o f the m edical and other pro fessio n s fo r the exam ination o f p o licy matters pertaining to the p u b lic’ s health. T h is it does by acting under both the a ca d em y ’ s 1963 congres sional ch arter responsibility to be an adviser to the federal governm ent and under its ow n initia tive to identify issues o f m edical care, research, and education. A ctin g on a contractual basis at the behest o f either the fed eral governm ent or o f a private foundation or group, the IO M m akes studies and recom m endations in six m ajor areas: biom edical research priorities and sources o f support; health m anpow er educational and utilization policies; health care organization and financing; health care quality and its assessm ent; the prevention o f disease: health, so cial, and environm ental factors; and ethical and legal issues arising from n ew scientific know ledge. T h e co n tro v ersy that o cca sio n a lly surrounds 812 ■ JADA, Vol. 91, October 1975
the institute basically concern s w hat health pro fessio n als think about its activities. S in ce the IO M v e ry often tackles such m atters as abor tion, quality assurance and p eer review , and health m aintenance organizations, it has found som e u nfavorable com m ents falling on its shoul ders o n ce its reports have been issued. T h e co n ditions and recom m endations surrounding a health p olicy m atter w hich m ay h ave been brought to light h ave at tim es received less than an enthusiastic response from those health pro fession als w h o w ould be directly a ffected by them . T h is situation is com pounded by the fa ct that today any con troversial subject or p o licy m atter, w h eth er it has anything to do with health care or not, is going to be painted by m any observers in either “ lib eral” or “ co n se rv a tiv e” co lo rs. In the opinion o f John I. Ingle, the o n ly dentist on the IO M staff, “ T h e IO M has acquired a repu tation for being liberal b ecau se it takes up con troversial subjects. P eop le w ould sim ply like to ignore controversial issues in the hopes that they will go a w a y, but that n ever happens. A n d if the health profession als w h o are alarm ed by our re ports w ould only stop and think, they w ould realize that it is to their advan tage to have im portant issues exam ined and an alyzed o b je c tiv e ly , so that som ething can be avoided or changed w here n e cessary before it gets out o f c o n tro l.” Furtherm ore, according to D r. Ingle, the in
stitute does not formulate health policy at all. “ What we do, simply, is evaluate the current lit erature and thought dealing with a particular subject—for example, the costs of health pro fessions education—and then put together a re port describing our findings.” Sometimes this report will go to the federal government if a fed eral agency (such as HEW) sponsors the study. More frequently, studies are being undertaken for private foundations interested in health mat ters (such as the Robert Wood Johnson Founda tion of Princeton, NJ). No doubt labels will continue to be attached to the IOM and its reports. The findings of a par ticular study are going to provoke controversy of one sort or another, partly because of an individ ual topic and partly because of the reputation in the professional community—favorable or otherwise—that individual IOM members have. I O M m em bership
The Institute of Medicine’s charter provides for a membership of not more than 400, at least 25% of which “ shall not be from the health profes sions.” Currently, slightly more than that per centage have been drawn from such fields as the social and behavioral sciences, law, and public administration, while the greater portion, of course, comes from various health disciplines. A spring balloting raised the membership to 306, and it is expected that in two years the institute will arrive at its chartered complement. Nine dentists have been elected to the Institute of Medicine. They are: Noah C. Calhoun, Wash ington; Clifton O. Dummett, Los Angeles; Don ald J. Galagan, Lakeview, Ark; I. Lawrence Kerr, Endicott, N Y; Alvin L. Morris and Jeanne C. Sinkford, Washington; Max Schoen, Port Jefferson, N Y ; Joseph Volker, Birmingham, Ala; and C. Gordon Watson, Chicago. Doctors Kerr, Watson, Calhoun, and Sinkford were el ected to membership in the spring balloting. An individual nominated for membership in the IOM can be elected by the entire body to serve a five-year term, with the possibility of one additional term. The basis for membership con sists of professional achievement in one’s field, with relevance to issues in health care and med icine; a demonstrated interest in, concern with, and involvement in critical matters of health pol icy, disease prevention, research, or health pro fessions education; and a willingness to devote a significant amount of time to exploring these matters while working within the IOM without any compensation.
Any organization that perpetuates itself by electing its own nominees, of course, can eas ily tend to develop into a group comprised of individuals who think similarly and have gen erally the same approach to issues. The IOM is no different in this regard, as its critics have pointed out and as certain institute members themselves have reportedly recognized. To pro vide a more balanced membership, one that is representative of the entire spectrum of the health community, the IOM staff has said that recommendations have been made to the insti tute’s governing council to change the current method of nominating and electing new mem bers, especially with an eye toward increasing the number of those with a background in pri vate practice. But defenders of the institute’s membership, on the other hand, have responded to the criti cism regarding similarity in thinking by pointing out that the IOM membership consists not only of those individuals prominent in their respec tive professions but also of nonprofessionals concerned with and actively involved in the en tire realm of health policy. Thus, they say, there are bound to be individuals known as “ activists” as members, according to an IOM staff mem ber, simply because their “ activism” was one of the reasons for their election. I O M projects
It was the activism of IOM members that pro duced such studies as the “ Costs of education in the health professions,” a highly regarded report performed under contract with the De partment of Health, Education, and Welfare pursuant to provisions of the Comprehensive Health Manpower Training Act of 1971. The accelerated pace of health legislation in recent years had brought with it an increased demand by the Congress for such an in-depth study. This investigation was undertaken to determine the average annual costs of educating students in schools of dentistry, medicine, osteopathy, optometry, pharmacy, podiatry, nursing, and veterinary medicine. Such information, of course, had a great deal of impact on subsequent health legislation. In addition to this study, there are other proj ects that touch on the dental profession and dental health care. Pending is a quality assur ance study, which is looking into care delivered by health maintenance organizations. Dental care delivery will be examined in this study, along with that of medical care. Another project INSTITUTE OF MEDICINE ■ 813
focuses on the impact of Medicare and Medicaid payments on the operation of hospitals, espec ially on the payment of interns and residents. Oral surgery interns and residents probably will be affected by this investigation. The specialty and geographic location of foreign medical grad uates also will be examined. Other IOM projects: —A privately funded study that is currently on the IOM’s agenda is a long-range look at the prevention of disease. The approach here is two pronged: specific diseases will be investigated and all the literature dealing with their preven tion will be evaluated. Also, various “preventive measures” will be examined to see how they can be applied more effectively in disease preven tion. —An investigation of health manpower in pri mary care delivery is under way. It will attempt to determine what can be done about increasing the number of general practitioners. Further, the institute has performed such ac tivities as: —conducting a review, at the request of the executive branch, of the five-year strategic plan for the National Cancer Program; —holding three national invitational confer ences (1) to explore curricular collaboration toward preparing students to function as mem bers of a health care “team” ; (2) to assess the new ethical problems posed for health profes sionals by changes in society’s values and ex pansions in medical technology; and (3) to exam ine regulation in the health industry and its impli cations for the cost of health care; and —initiating three policy studies concerning the organization and financing of health care: impli cations of the catastrophic illness approach to national health insurance, health maintenance organizations, and the supply of hospital beds for acute care.
814 ■ JADA, Vol. 91, October 1975
The Robert W. Johnson Health Policy Fel lowships, established by the IOM with a grant from the Johnson Foundation, are another activ ity. This program is designed to provide a bet ter understanding of major issues in health policy and a knowledge of how federal health programs are established. Two dentists, in fact, are among six fellows chosen for the 1975-1976 year which began in September. Chester Douglass of the University of North Carolina and Michael J. Till of the Uni versity of Minnesota are currently participating in orientation programs before assignment to the staffs of a senator or a representative for rotating four and a half month stints with each House of Congress. T h e I O M and the future
With the formation in 1972 of the Congressional Office of Technology Assessment, it would ap pear that future study projects mandated by law may be performed by that body rather than by the IOM. But such a development does not mean a diminished influence for the IOM, since more and more of its investigations are now privately funded by the larger foundations. For in addition to the Robert Wood Johnson Foundation men tioned, support comes from the Commonwealth Fund and the W. K. Kellogg, Andrew W. Mel lon, and Richard King Mellon foundations. Thus, with these groups utilizing the resourc es of the IOM to investigate sociomedical issues of concern to them as well as to encourage addi tional studies in related areas, the institute will probably be around for quite some time, con tinuing its analyses of those issues that have an important effect on the nation’s health care pol icies.
T h is a r tic le w a s p r e p a r e d b y t h e A D A W a s h in g to n O ffic e .
the institute basically concern s w hat health pro fessio n als think about its activities. S in ce the IO M v e ry often tackles such m atters as abor tion, quality assurance and p eer review , and health m aintenance organizations, it has found som e u nfavorable com m ents falling on its shoul ders o n ce its reports have been issued. T h e co n ditions and recom m endations surrounding a health p olicy m atter w hich m ay h ave been brought to light h ave at tim es received less than an enthusiastic response from those health pro fession als w h o w ould be directly a ffected by them . T h is situation is com pounded by the fa ct that today any con troversial subject or p o licy m atter, w h eth er it has anything to do with health care or not, is going to be painted by m any observers in either “ lib eral” or “ co n se rv a tiv e” co lo rs. In the opinion o f John I. Ingle, the o n ly dentist on the IO M staff, “ T h e IO M has acquired a repu tation for being liberal b ecau se it takes up con troversial subjects. P eop le w ould sim ply like to ignore controversial issues in the hopes that they will go a w a y, but that n ever happens. A n d if the health profession als w h o are alarm ed by our re ports w ould only stop and think, they w ould realize that it is to their advan tage to have im portant issues exam ined and an alyzed o b je c tiv e ly , so that som ething can be avoided or changed w here n e cessary before it gets out o f c o n tro l.” Furtherm ore, according to D r. Ingle, the in
stitute does not formulate health policy at all. “ What we do, simply, is evaluate the current lit erature and thought dealing with a particular subject—for example, the costs of health pro fessions education—and then put together a re port describing our findings.” Sometimes this report will go to the federal government if a fed eral agency (such as HEW) sponsors the study. More frequently, studies are being undertaken for private foundations interested in health mat ters (such as the Robert Wood Johnson Founda tion of Princeton, NJ). No doubt labels will continue to be attached to the IOM and its reports. The findings of a par ticular study are going to provoke controversy of one sort or another, partly because of an individ ual topic and partly because of the reputation in the professional community—favorable or otherwise—that individual IOM members have. I O M m em bership
The Institute of Medicine’s charter provides for a membership of not more than 400, at least 25% of which “ shall not be from the health profes sions.” Currently, slightly more than that per centage have been drawn from such fields as the social and behavioral sciences, law, and public administration, while the greater portion, of course, comes from various health disciplines. A spring balloting raised the membership to 306, and it is expected that in two years the institute will arrive at its chartered complement. Nine dentists have been elected to the Institute of Medicine. They are: Noah C. Calhoun, Wash ington; Clifton O. Dummett, Los Angeles; Don ald J. Galagan, Lakeview, Ark; I. Lawrence Kerr, Endicott, N Y; Alvin L. Morris and Jeanne C. Sinkford, Washington; Max Schoen, Port Jefferson, N Y ; Joseph Volker, Birmingham, Ala; and C. Gordon Watson, Chicago. Doctors Kerr, Watson, Calhoun, and Sinkford were el ected to membership in the spring balloting. An individual nominated for membership in the IOM can be elected by the entire body to serve a five-year term, with the possibility of one additional term. The basis for membership con sists of professional achievement in one’s field, with relevance to issues in health care and med icine; a demonstrated interest in, concern with, and involvement in critical matters of health pol icy, disease prevention, research, or health pro fessions education; and a willingness to devote a significant amount of time to exploring these matters while working within the IOM without any compensation.
Any organization that perpetuates itself by electing its own nominees, of course, can eas ily tend to develop into a group comprised of individuals who think similarly and have gen erally the same approach to issues. The IOM is no different in this regard, as its critics have pointed out and as certain institute members themselves have reportedly recognized. To pro vide a more balanced membership, one that is representative of the entire spectrum of the health community, the IOM staff has said that recommendations have been made to the insti tute’s governing council to change the current method of nominating and electing new mem bers, especially with an eye toward increasing the number of those with a background in pri vate practice. But defenders of the institute’s membership, on the other hand, have responded to the criti cism regarding similarity in thinking by pointing out that the IOM membership consists not only of those individuals prominent in their respec tive professions but also of nonprofessionals concerned with and actively involved in the en tire realm of health policy. Thus, they say, there are bound to be individuals known as “ activists” as members, according to an IOM staff mem ber, simply because their “ activism” was one of the reasons for their election. I O M projects
It was the activism of IOM members that pro duced such studies as the “ Costs of education in the health professions,” a highly regarded report performed under contract with the De partment of Health, Education, and Welfare pursuant to provisions of the Comprehensive Health Manpower Training Act of 1971. The accelerated pace of health legislation in recent years had brought with it an increased demand by the Congress for such an in-depth study. This investigation was undertaken to determine the average annual costs of educating students in schools of dentistry, medicine, osteopathy, optometry, pharmacy, podiatry, nursing, and veterinary medicine. Such information, of course, had a great deal of impact on subsequent health legislation. In addition to this study, there are other proj ects that touch on the dental profession and dental health care. Pending is a quality assur ance study, which is looking into care delivered by health maintenance organizations. Dental care delivery will be examined in this study, along with that of medical care. Another project INSTITUTE OF MEDICINE ■ 813
focuses on the impact of Medicare and Medicaid payments on the operation of hospitals, espec ially on the payment of interns and residents. Oral surgery interns and residents probably will be affected by this investigation. The specialty and geographic location of foreign medical grad uates also will be examined. Other IOM projects: —A privately funded study that is currently on the IOM’s agenda is a long-range look at the prevention of disease. The approach here is two pronged: specific diseases will be investigated and all the literature dealing with their preven tion will be evaluated. Also, various “preventive measures” will be examined to see how they can be applied more effectively in disease preven tion. —An investigation of health manpower in pri mary care delivery is under way. It will attempt to determine what can be done about increasing the number of general practitioners. Further, the institute has performed such ac tivities as: —conducting a review, at the request of the executive branch, of the five-year strategic plan for the National Cancer Program; —holding three national invitational confer ences (1) to explore curricular collaboration toward preparing students to function as mem bers of a health care “team” ; (2) to assess the new ethical problems posed for health profes sionals by changes in society’s values and ex pansions in medical technology; and (3) to exam ine regulation in the health industry and its impli cations for the cost of health care; and —initiating three policy studies concerning the organization and financing of health care: impli cations of the catastrophic illness approach to national health insurance, health maintenance organizations, and the supply of hospital beds for acute care.
814 ■ JADA, Vol. 91, October 1975
The Robert W. Johnson Health Policy Fel lowships, established by the IOM with a grant from the Johnson Foundation, are another activ ity. This program is designed to provide a bet ter understanding of major issues in health policy and a knowledge of how federal health programs are established. Two dentists, in fact, are among six fellows chosen for the 1975-1976 year which began in September. Chester Douglass of the University of North Carolina and Michael J. Till of the Uni versity of Minnesota are currently participating in orientation programs before assignment to the staffs of a senator or a representative for rotating four and a half month stints with each House of Congress. T h e I O M and the future
With the formation in 1972 of the Congressional Office of Technology Assessment, it would ap pear that future study projects mandated by law may be performed by that body rather than by the IOM. But such a development does not mean a diminished influence for the IOM, since more and more of its investigations are now privately funded by the larger foundations. For in addition to the Robert Wood Johnson Foundation men tioned, support comes from the Commonwealth Fund and the W. K. Kellogg, Andrew W. Mel lon, and Richard King Mellon foundations. Thus, with these groups utilizing the resourc es of the IOM to investigate sociomedical issues of concern to them as well as to encourage addi tional studies in related areas, the institute will probably be around for quite some time, con tinuing its analyses of those issues that have an important effect on the nation’s health care pol icies.
T h is a r tic le w a s p r e p a r e d b y t h e A D A W a s h in g to n O ffic e .