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Like all of my predecessors, I havespent a substantial amount of timeduring my year as President reviewingthe addresses delivered by my extraor-dinarily distinguished predecessorsand wondering how I could possiblysay anything new, different, or in anyway memorable. Like my more recentpredecessors, my concerns about thequality of my Presidential Addresswere either compounded by, or per-haps attenuated by, the uncertainty asto whether anyone would come to ourmeeting to hear my remarks. The goodnews is that attendance at these meet-ings has stabilized, with this year’s reg-istrants at slightly over 500.

The flip side is that, in our attemptto keep the meeting compact, the tim-ing of my address is most suitable forweekend insomniacs who are hopingfor an entertaining warm-up for thismorning’s main event — the presenta-tion of the Kober Medal to our distin-guished winners, Mike Brown and JoeGoldstein, by Dan Foster and GeneWilson. Is it my imagination or, sinceGeorge W. became President, is every-body from Texas?

As I looked through the variousaddresses given both by AAP Presi-dents and by speakers at our annualdinner, I must admit that I ultimatelyfound my favorite, a talk whosemetaphorical relevance to academicmedicine has stood the test of time. Asa prelude to my own thoughts, whichI hope will be equally metaphoricalbut less cynical, let me begin by pre-senting an abridged version of theremarks of Dr. Richard Johns severaldecades ago (1).

The title of Dr. Johns’s address was“How to swim with sharks: theadvanced course.” Without ever specif-ically mentioning academic medicine,Dr. Johns emphasized that the worldwas dangerous, and that as one movedfrom the small backyard pond to try-

ing to compete successfully in the larg-er ocean of academic medicine, onehad to face a number of potentialadversaries. At a time when these meet-ings revolved around the presentationof scientific abstracts, these competi-tive instincts were upregulated by avariety of chemokines that incitedinflammatory responses against newdata that challenged establisheddogma or questions that were designedto display the relative prowess of thequestioner, potentially at the expenseof the presenter. Oftentimes, thesedebates were the intellectual highlightof our meeting; sometimes, however,they degenerated into arguments ascreaky as the protagonists’ joints, prov-ing the old adage that “in academicmedicine the fights are so fiercebecause the stakes are so small.”

In any case, back to Dr. Johns. Hisfirst piece of advice for his audience atthe AAP meetings was that, whenswimming, you should assume that allunidentified fish are sharks. Regard-less of their initial appearance, uniden-tified fish not only cannot be consid-ered friendly, but, in fact, must beconsidered predators until definitiveevidence to the contrary is available.

Second, since sharks are stimulatedand reinforced by the sight and smell ofblood, when potentially faced with ashark, it is critical that you do not bleed.Although our detailed knowledge ofthe coagulation pathway has advancedover the past several decades, this basicprinciple remains intact. For those ofyou taking prophylactic aspirin, thiswarning is more pertinent than ever.

Third, although some would sug-gest that the “meek shall inherit theearth,” when faced with a shark, it iscritical to counter any aggressionpromptly. Think humeral immunityand hyperacute rejection, not delayedhypersensitivity, tolerance, or chimeraformation.

The usual model for physicians is torush to the aid of the injured. In themidst of a shark attack, however, Dr.Johns’s advice was just the opposite:get out if someone is bleeding! Forshark attacks, there is no effectiveactive or passive immunity, so themedical response becomes simple: per-sonal evacuation and quarantine.

The key principle of host defenses isto fight off foreign substances whilenot inciting an autoimmune response.The presence of high levels ofimmunoglobulins in the gut and respi-ratory tract are consistent with Dr.Johns’s next admonition, which is thatwhen faced with a shark, do not wait foran overt attack, but rather use anticipa-tory retaliation. This recommendationis consistent with the general principlethat the primary prevention of diseaseis always preferable to having to treatthe disease after it develops.

Fortunately, sharks are typically soli-tary predators, but, if one shark is dan-gerous, nothing could be worse than abunch of sharks, especially if, contraryto their natural instincts, they acttogether. Therefore, when faced withthe potential of multiple sharks, Dr.Johns warned that it is vital to disor-ganize an organized attack. In doingso, one may be able to fight off thesharks one at a time, whereas it wouldnot be possible to defeat them allsimultaneously.

If Dr. Johns captured, albeit cynically,some of the flavor, excitement, and rel-evance of this organization and of theTri-Societies’ meetings in which he par-ticipated, then the theme song oranthem of academic medicine wouldhave been the musical score from themovie Jaws. But what now? I standbefore you today as a different kind ofpresident in at least two ways. One isthat I am the only living, breathingpresident of the AAP who never went toa meeting in Atlantic City. Since I grew

AAP Presidential Address

Covering all the bases in academic medicine

Lee GoldmanAddress correspondence to: Lee Goldman, Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, California 94143-0120, USA. Phone: (415) 476-0909; Fax: (415) 502-5869; E-mail: goldman@medicine.ucsf.edu.

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up in southern New Jersey, I rememberthe boardwalk (for this organization,remembering the boardwalk is almostthe moral equivalent of rememberingthe Alamo), but I remember it as ayoung child on vacation and not assomeone who gawked at the giants ofmedicine as they watched the jumpinghorse and judged the horse flesh of theyoung presenters who displayed theirwares as potential future faculty. It is,however, too soon to paraphrase JohnKennedy and to claim that “the torchhas been passed to a new generation,”tempered by the battles of managedcare, because several of my successors aspresidents of the AAP do, in fact, recalltheir times at Atlantic City meetings.

A second reason that my views may besomewhat different is that I am the firstAAP President in many years who neverdid wet laboratory research. Rather, asyou all know, I am a clinical epidemiol-ogist who has focused on studyingpatients who see physicians, especiallythose with common problems, such asacute chest pain or a need for noncar-diac surgery, and then have performedrandomized trials of interventions,studies of prognosis, and analyses ofoutcomes such as quality of life, cost,and cost-effectiveness. Of note is thatalthough my research focus has notbeen in the mainstream of the last gen-eration of this Society, it fits remarkablywell with our historic roots. The centerof gravity of the AAP has been investiga-tions performed by full-time faculty indepartments of medicine, using the lat-est methodologies across whatever spec-trum of science can advance our under-standing of normal human biology, thebasic mechanisms of disease, how peo-ple react to these diseases at levels rang-ing from the subcellular response to thepopulation-wide impact, and how bestto alter the disease process in ways thatbenefit the individual and society. TheAmerican Society for Clinical Investiga-tion was created for these same purpos-es and to extend honorary status to ayounger generation of clinically-activeinvestigators, the “young turks” whowould hopefully aspire to subsequentmembership in the AAP. It is importantto emphasize that neither Society wasenvisioned as a society of molecularbiology or of any particular scientificemphasis that may have preceded mod-ern molecular biology. The breadth ofexcellence to be encouraged was verynicely epitomized by the requirements

for the Kober medal, the AAP’s highesthonor, whose charter emphasizes thatit is to be given to recognize “outstand-ing contributions in the medical sci-ences or preventive medicine.”

Another memorable AAP addresswas delivered by my good friend HollySmith, who was a predecessor as Chairof Medicine at UCSF, as Editor of theCecil Textbook of Medicine, and as Presi-dent of the AAP. Holly correctly fore-casted that the rise of the subspecial-ty society meetings was a bad omenfor the future of these meetings. Withhis unparalleled humor and prescientwisdom, Holly made it clear that tra-dition and nostalgia could not standin the way of progress.

In the context of world events, therisks of bioterrorism, and the interfaceof medicine and public health withthese events, as evidenced so beauti-fully by Dr. Henderson’s remarks lastnight, the fate of the AAP and its sib-ling organization, the ASCI, hardlyseems like a critical issue. Rather thantalk nostalgically about the distin-guished traditions of our organiza-tion, academic medicine, and depart-ments of medicine, I thought I wouldtry to borrow from the model of Dr.Johns and talk about something elsethat has indisputable metaphoricalrelevance. I therefore decided to talkabout another topic that drips withnostalgia and reverence for the past:America’s pastime, baseball.

This metaphor, though perhapsinane or ridiculous to some of you, hasrelevance to me, because growing up inPhiladelphia, my dream was tobecome the general manager of thePhiladelphia Phillies. In an era inwhich baseball players needed winterjobs in order to make ends meet, myfather advised me, in part for financialreasons, to go into medicine instead. Ifonly he was as prescient as HollySmith! Then again, no matter whatyou think of me as an academic physi-cian and chair of a department ofmedicine, if you have ever seen me playbaseball, you would probably agreethat, at least on this issue, there was noquestion but that father knows best.

But back to baseball. Let medescribe to you some of the keyaspects of baseball, including some ofits traditions, some of its rules, andhow to build a winning team.

Many baseball fans have looked backwith great nostalgia to an earlier era

when great stars made baseball Ameri-ca’s pastime. In describing those bettertimes, however, it is often overlookedthat initially all of the players werewhite men. Subsequently, amid greatfanfare, baseball was finally integratedby Jackie Robinson, and now the U.S.major leagues include a diverse groupof players of different ethnic back-grounds such as Sammy Sosa from theCaribbean and Ichiro from Japan. In allendeavors, this policy of finding thebest talent is always critical to success.More recently, women have assumedroles in administration and even asumpires, further testimony to thediversification of the sport. Despitethese diversifications, however, base-ball is frequently criticized, not inap-propriately, for not having doneenough to broaden its leadership.

In baseball, there is an annual draft inwhich the best young talent is rankedby the various teams, so that all the topprospects are matched with individualorganizations. These young playersthen become part of a minor leaguefarm system, in which they receivementoring, instruction, and guidance,while playing before relatively smallcrowds. Only the best can expect to bepromoted to the major leagues.

It was formerly common for playersto play their entire careers with oneteam, but since Curt Flood became thefirst baseball free agent, the most tal-ented players are the objects of biddingwars, so that free agents such as AlexRodriguez may be enticed with unbe-lievable packages to join a new team.Free agency makes it hard to keepone’s own best players, but also makesit possible for entrepreneurial andaggressive teams to accumulate sub-stantial talent.

In baseball, players are listed both inthe batting order and by their posi-tions in the field. In the field, eachposition is important, yet very differ-

Figure 1Positions in the field of academic departments.

ent. Every team focuses on strength upthe middle (pitcher, catcher, shortstop,second base, center field), with thegeneral rule of thumb being that ateam cannot succeed unless it is strongin these positions (Figure 1). Success-ful teams, however, also rely criticallyon power at the corners, first base andthird base, where it may be less impor-tant to have all-around players andmore important to have individualswho have particular power and skill attheir respective positions.

In little league, being positioned inthe outfield, especially right field orleft field, implies a relative lack of skill.Hence the common aphorism “out inleft field.” By the time one gets to themajor leagues, however, being out inleft field does not imply second-ratestatus, but rather it is a position thathas been played by some of the bestbaseball players of all time, such as TedWilliams and, most recently, Barry

Bonds, who are just two of the best-known left fielders. So, at the majorleague level, even outfielders play crit-ical roles on a well-rounded team.

In baseball, it was often said that sin-gles hitters such as Ty Cobb driveChevrolets because no one pays muchto come see them, while home run hit-ters such as Mark McGwire, often calledheavy hitters, drive Cadillacs becausethey draw the fans and fill up the park.Everyone wants to be Babe Ruth and hita home run, and each hopes to hit ahome run each time he is up to bat . Allbaseball fans are familiar with thosewho have been well publicized for hold-ing season records for home runs, suchas Ruth, Maris, McGwire, and Bonds,and we all know that home run hittersget lots of good press in leading publi-cations (Figure 2). For those who holdcareer home run records, such as Ruth,Hank Aaron, and Sadaharu Oh, therecognition transcends their own leagueor even country to reach internationalstature (Figure 3).

All baseball players hope that theircareer accomplishments may result intheir election to the CooperstownBaseball Hall of Fame, but honorssuch as this are reserved for the verybest as judged by experts (Figure 4).Of note is that the Hall of Fame rec-ognizes outstanding contributions byplayers at different positions in differ-ent eras. What is usually expected issuperb performance over an entirecareer, but the Hall of Fame may alsorecognize brilliance over a shorterperiod of time. The recent emphasison relief pitchers led to the creation ofa new statistic, the save, and to the cre-ation of new awards to recognize thisnew breed of player.

Most baseball players play only oneposition after they reach the majors,but some change positions as theircareers progress. For example, BabeRuth started as a pitcher and became aright fielder, and Pete Rose started as asecond baseman and later played anumber of other positions. Baseballgeneral managers must be careful notto pigeonhole their players premature-ly, but rather to allow them the oppor-tunity to evolve their careers over time.

To afford to recruit new free agentsand to keep their own best players,baseball teams must fill up their sta-diums by selling tickets, they musthope that the fans buy a lot of conces-sions, and, ideally, they try to sell their

broadcasting rights at top dollar. Theimportance of revenue sources fromplaying the game on a daily basis (Fig-ure 5), from satisfying happy cus-tomers (Figure 6), and from majoroutside sources (Figure 7) is criticalfor generating the resources needed tobuild a winning team.

And every fan wants a winning team,especially a team that will win theWorld Series. Although there is alwaysdebate and subjective argumentregarding which is or was the bestteam (Figure 8), there also are objectivemeasures and statistics that help settlethese debates. Of course, individualsuccess is also important in baseball,whether one is a pitcher, for whom theCy Young award is the highest honor,or a position player, for whom themost valuable player award is mostcoveted. Baseball clearly understandsthe importance of recognizing out-standing performance multipledomains (Figure 9 and Table 1).

Baseball is a good metaphor for aca-demic medicine and departments ofmedicine because baseball requiresstrong individual performances as wellas some degree of teamwork. Only oneperson pitches, bats, catches, or throwsat a time, but the team also benefitsfrom relays and coordination. In base-ball, the number of individual statisticsthat are tracked is almost endless, andthe individual rewards substantial; nev-

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Figure 2Where the heavy hitters publish. Nature cover(Volume 385, Number 6619, Copyright 1997)reproduced with permission from MacMillanPublishers Ltd.; Science cover (Volume 290,Number 5494, Copyright 2000) reproducedwith permission from The American Associationfor the Advancement of Science; The New EnglandJournal of Medicine cover (Volume 345, Number14, Copyright 2001.) reproduced with permis-sion from the Massachusetts Medical Society.

Figure 3Three members of the Association of AmericanPhysicians who are also Nobel laureates.

Figure 4Academic Medicine’s Halls of Fame.

Figure 5Even in academia, substantial revenue is gener-ated from the daily practice of medicine. Muchof this revenue supports the academic mission.

ertheless, every player wants to be on awinning team. Sacrifice bunts and sac-rifice flys are rewarded, and some willsacrifice personal goals or rewards to beon a World Series championship team

In any address, it is always difficultto find the right balance among vari-ous themes: acting as a cheerleader forthe organization one loves, blamingunenlightened outsiders for any unre-alized aspirations, or introspective self-reflection. The latter, of course, runsthe risk of creating controversy, gener-ating disagreements among friends,even swimming with sharks.

As demonstrated in our bench-to-bedside talks yesterday, one researchparadigm that currently characterizesthis society could be depicted symboli-cally as finding candidate genes fromseverely affected individuals or families,cloning the gene, breeding a transgenicmouse to confirm the relationshipbetween the genotype and the pheno-type, and correcting the problem by giv-ing the protein (or inserting a gene toproduce it), or by suppressing an excessprotein, or by blocking its effect. This isa wonderful model, and we saw exam-ples yesterday of how it has alreadymade a difference in some diseases andholds great promise for the future.

But let me now describe a somewhatdifferent paradigm, which begins byunderstanding one of the great tri-umphs of modern medicine, which isthe marked decline in mortality fromstroke and coronary heart disease inthe past 50 years or so (2). Mortalityfrom stroke has declined consistentlyand dramatically, by about 60%, since1950. For coronary heart disease, therewas an increase until the mid 1960s,followed by an equally steep decline.Of note is that noncardiovascularmortality has declined, but much lessimpressively over the past 50 years.

What are the reasons for this declinein coronary mortality? In analyses per-formed by us and others (Table 2),about a third of the decline can beattributed directly to reductions inserum cholesterol levels, reductionspartly due to drugs, especially statins,which derive directly from the extraor-dinary research of today’s Kobermedalists (3). But most of the nationalreductions in cholesterol levels thatexplain the decline since 1965 antedat-ed the widespread use of these drugsand can be attributed most directly todietary changes that were very modeston an individual basis, but have a pro-found effect when multiplied by 250million Americans. Reductions insmoking and blood pressure have alsobeen important, with risk factor reduc-tions accounting for about 50% of thedecline in coronary mortality. Improve-ments in the case fatality rate afteracute myocardial infarction (MI) andin the medical and surgical treatmentof chronic coronary disease account forabout 40% of the decline.

To make my point, consider mortal-ity from acute MI. Over just the past20 years, mortality rates after acute MIhave fallen by more than 75% in per-sons under age 65, by about 50%between ages 65–84, and by a moremodest 7% in patients over age 85 (4).

For acute MI, an amazing range ofpotential interventions have been sub-jected to large-scale randomized con-trol trials. For example, in these ran-domized trials, aspirin is associatedwith about 0.8 odds ratio for death,meaning that it reduces the odds ofdeath by about 20% (5). In the acutesetting, beta blockers are also associat-ed with a favorable odds ratio,although the pooled trials yield a con-fidence interval that overlaps 1.0. Forthrombolytics and especially primary

PTCA, the benefits are clear. For ACE-inhibitors, the benefits are modest butsignificant in the acute setting, and, ofcourse, we know that they are muchmore beneficial chronically after theMI, as are beta blockers. Calciumchannel antagonists have an adverseeffect and should not be used routine-ly. Anticoagulants appear to be mar-ginally beneficial, principally whenused with thrombolytics or primaryPTCA. Lidocaine, which was shown ina number of randomized trials toreduce the risk of primary ventricularfibrillation, actually appears toincrease the risk of death. Magnesiumwas beneficial in a number of small tri-als but showed no benefit and evensome harm in the largest trials.Nitrates may be marginally beneficial.The data on secondary PTCA andcoronary bypass graft surgery are sug-gestive in the acute setting, but theodds ratios for all the pooled data con-tinue to overlap one.

As a result of these data, the use oftherapies for acute MI has changeddramatically over the past severaldecades. Aspirin use has increased sub-

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Figure 6Happy customers fuel medical philanthropy.Photo reproduced with permission fromhttp://www.dmc.org/donor/donation.html.

Figure 7The NIH is a key outside source of revenue foracademic departments.

Figure 8The rankings of medical schools generate sub-stantial debate and fan interest. Best GraduateSchools cover (1st edition, Copyright 2002) repro-duced with permission from U.S. News and WorldReport.

Table 1Recent Kober Award Recipients of the AAP

1992 E. Donnall Thomas1993 Arnold S. Relman1994 David M. Kipnis1995 Alexander Leaf 1996 Robert G. Petersdorf1997 Helen M. Ranney1998 Eugene Braunwald1999 Jean D. Wilson2000 J. Claude Bennett2001 Kurt J. Isselbacher2002 Michael S. Brown/

Joseph L. Goldstein

stantially, as has the use of beta block-ers, thrombolytics, ACE-inhibitors,and even, more recently, primaryPTCA (5). By comparison, the use ofcalcium antagonists increased untilthe randomized trial data appeared,and then the use rates subsequentlydecreased. Similarly, the use of lido-caine increased when it was thought tobe beneficial for primary ventricularfibrillation but decreased substantial-ly when its detrimental effects becameobvious. For urgent coronary bypassgraft surgery and nonprimary PTCA,there has been a modest increase,again consistent with the data.

We can also estimate how thesechanges in therapies have contributedto the reduction in 30-day mortalityfrom acute myocardial infarctionbetween 1975 and 1995 (5). Aspirin, inmany ways the lowest technologyintervention, is estimated to beresponsible for 30% of the decline inmortality from acute myocardialinfarction. The increased use ofthrombolysis, heparin, primary PTCA,beta blockers, and ACE-inhibitors hasalso contributed. Reductions in theuse of lidocaine have been beneficial,as have the increased use of otherPTCA, nitrates, and coronary arterybypass graft surgery. Overall, there isan impressive linkage among datafrom randomized trials, changes in theuse of therapies as a result of these tri-als, and reductions in mortality.

In fact, evidence-based advances incardiac care have had an extraordinaryeffect on medical practice and out-comes (Table 3). Here are just twoexamples of changes in therapies fromthe time that I was a cardiology fellowin the 1970s to the current time. ForST-elevation acute MI, the approach inthe 1970s was prophylactic lidocaine,bed rest, and perhaps warfarin for anti-coagulation. In 2002, standard thera-py includes thrombolysis or primaryPTCA for recanalization, aspirin inessentially everyone, and beta blockersand ACE-inhibitors in those who areeligible for them. The benefits of thesechanges are substantial. But also con-sider congestive heart failure. In the1970s, the cornerstones of therapywere diuretics, digoxin, and bed rest.The newly available beta blockers wereto be avoided. By 2002, diureticsremain a key therapeutic option, but itis ACE-inhibitors, beta blockers, andspironolactone that have been shownto improve survival. Digoxin is a sec-ond-line therapy that reduces hospi-talizations but does not reduce mor-tality. Bed rest has been replaced byexercise rehabilitation programs.

Without in any way denigrating theparadigm of cloning genes and devel-oping transgenic mice, please considerhow these reductions in coronary mor-tality have been achieved. First, virtual-ly every improvement began with epi-demiologic and clinical epidemiologicresearch that identified the key risk fac-tors (Table 4). Interventions were devel-oped to reduce these risk factors. Someof these interventions were derivedfrom basic science research, but others,such as smoking cessation, came fromthe behavioral sciences literature andthen were supplemented by physiolog-ic interventions, such as nicotinereplacement therapy. In cardiology, vir-

tually every intervention has been test-ed in large-scale randomized clinicaltrials, which resulted in the abandon-ment of many widely accepted thera-pies and the adoption of therapies pre-viously thought to be contraindicated.Once therapies were shown to be effec-tive, their implementation dependedon whether they were also cost effectivebefore making changes in the deliverysystem (such as re-engineering hospi-tals to provide primary angioplasty). Itwas important to develop guidelinesand protocols, to help physicians andhospitals implement these strategies,to develop mechanisms for monitoringphysicians’ performances and helpingthem improve them (such as by com-puterized order entry), to determinewhy patients and physicians may notbe compliant with effective recom-mendations, and finally, to be sure thatthese interventions have actually hadthe impact on morbidity and mortali-ty in the real world that they were pro-jected to have based on clinical trials.Of course, this paradigm does notreplace the genetic paradigm Idescribed earlier; in fact, the two arecomplementary, with the hope thatbeneficial therapies will be targeted to

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Figure 9Top doctors. Recognizing excellence in the clin-ical domain. Guide to Top Doctors cover (1st edi-tion, Copyright 2000) reproduced with permis-sion from The Center for the Study of Services.

Table 2Explaining the decline in CHD mortality: 1980-1990

Primary prevention Secondary prevention Total

Cholesterol lowering 15% 17% 32%Smoking reductions 3% 3% 6%Blood pressure reductions 6% 7% 13%

Total risk factor 24% 27% 51%

MI case-fatality rate - 14% 14%Medical/ 27% 27%surgical treatment

Total 24% 68% 92%

CHD, coronary heart disease. MI, myocardial infarction. Adapted from reference 3 with permission.

Table 3Evidence-based advances in cardiac care

1970s 2002

ST-elevation MI lidocaine thrombolysis

bed rest primary PTCA? warfarin aspirinβ-blockers ACE inhibitors

CHF diuretics diureticsdigoxin ACE inhibitorsbed rest β-blockersavoid β-blockers spironolactone

MI, myocardial infarction; PTCA, transluminal coro-nary angioplasty.

individuals with appropriate geneticprofiles and avoided in those who willnot benefit or may even developadverse effects.

My point is that in departments ofmedicine and other clinical depart-ments, we must value and rewardphysicians whose science is applied ateach of the steps of each of these, andother, paradigms for scientific medicaladvancement. A senior leader in aca-demic medicine once said to me thatclinical trials were not really science; allthey required was a bunch of trainednurses. I obviously disagree and willturn once again to my baseball dia-mond. We must never forget that ourdepartments’ efforts in education, clin-ical as well as scientific, represent ourunifying mission, just as pitching issaid to be 70% of baseball. For a depart-ment to succeed, we need outstandingindividuals, hopefully all-stars, in eachof these positions. Not every depart-ment will be able to be strong in everyposition, especially if one tries to havethis type of breadth within every divi-sion or subspecialty. Some individualsuccess and even team success can beachieved despite weaknesses in some ofthese positions. The best departments,however, will cover all the bases and bestrong in the outfield as well. Ourdepartments should not be purely clin-ical, but it also is not, in my opinion,desirable to aspire to have a depart-ment that is so focused on basic sciencethat it is tilted out of proportiontoward third base. Academic medicine,like baseball, is played by individualswho strive for individual success, butthe entire team benefits from multi-disciplinary research, coordinationbetween clinicians and researchers, andthe commitment of everyone towardtraining and education.

I must emphasize in the strongestpossible terms my belief that both the

ASCI and the AAP must continue toexpand their horizons about the typeof scientific contributions that war-rant election into our halls of fame. Inmy nine years on the AAP Council, Ibelieve that my colleagues have livedup to the symbolic commitment theymade when, under Gene Wilson’s pres-idency, someone with my backgroundwas invited to the Council to broadenthe perspective of the membershipdebate. I am confident that RalphHorwitz, who is an extraordinaryresearcher and leader, will continueand build upon this diversificationeffort. The AAP continues to see anoutstanding group of nominees, and Ibelieve a substantial reservoir of won-derful future members remains.Therefore, we can be confident abouta consistent stream of worthy mem-bers for the near future.

However, I would be remiss if I didnot share with you my dismay aboutthe election policies of the ASCI.Whereas the AAP has elected its maxi-mum number of members even inyears in which the nomination num-bers were comparatively low by histor-ical standards, the ASCI has recentlyfailed to fill its full complement ofpotential new members year after year.Although the ASCI has elected anoccasional nominee with absolutelysuperlative credentials in clinical epi-demiology and clinical research, Ibelieve it has adopted an election pol-icy that no longer follows the basic“center of gravity” approach of focus-ing on finding the best investigatorsof all types, primarily in departmentsof medicine but extended whenappropriate to other clinically activephysicians, up to the full complementof electees allowed by the bylaws.Although it is true that there may befewer physician scientists performingsome types of research than in prioryears or generations, there are plentyof physicians who are performingclinical investigation. My honest con-cern is that the ASCI is on an apop-totic course, in which its election poli-cies have not subtly discouragednominations across a broad spectrumof clinical investigation and made theorganization increasingly irrelevant tothe departments of medicine thathave served as the core for both theASCI and the AAP. I urge my col-leagues on the ASCI Council immedi-ately to adopt a radical change in their

selection process: to encourage appli-cations explicitly rather than to dis-courage them implicitly; to elect thefull complement of members allow-able by the bylaws each year; and todiversify the membership to cover thisfull spectrum of research performedin departments of medicine. Withoutthis change in ASCI election policies,these meetings are surely doomed.The AAP will find it increasingly diffi-cult as well, and these societies willbecome irrelevant in clinical depart-ments of medicine, even those that areresearch intensive. To my friends inthe ASCI leadership, I apologize forthe bluntness of these remarks, butthey are no different in substancefrom what I have shared with many ofyou privately.

The Baseball Hall of Fame includesoutfielders who have hit more than700 home runs and shortstops whohave hit fewer than 20. It includesplayers whose lifetime career statisticsdemonstrate their aggregate accom-plishments as well as stars with briefercareers that were nevertheless note-worthy for their substantial impact. Inshort, it looks at achievement in thebroadest sense and in the context ofboth the position that someone playedand the era in which that personplayed. And it always remembers it isthe Baseball Hall of Fame, not thethird baseman’s hall of fame, the hit-ter’s hall of fame, or the strikeoutartist’s hall of fame.

Why have I spent so much time talk-ing about departments of medicine ata scientific meeting? My belief is thatthe future of our honorary societies iscritically dependent on whether or notwe can find a way to reposition ourmeetings as a cornerstone of academicmedicine. In the past several years,these meetings have reached a newmetastable state, with attendance hov-ering around 500. The attendees areprimarily the new members, the peo-ple who nominated them, the officersof our societies, our invited speakers,and a loyal but increasingly aging baseof members dedicated to science inmedicine. Of course, there are somehonorary societies whose meetings areperpetuated by this model. However,in the Atlantic City era, these societiesand the AFCR represented the core ofacademic internal medicine. That corehas shifted, undoubtedly because ofthe broad spectrum of research that I

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Table 4Methods underlying advances in modern car-diac care

Epidemiology Identify risk factorsDevelop interventions Basic science

Behavioral sciencePhysiologic research

Test interventions Randomized trialsImplement interventions Cost-effectivenessRe-engineering Guidelines, protocolsAssess real-life impact Compliance

have described. The meetings alsoalways have had some smaller num-bers of pediatricians, neurologists, der-matologists, and physician scientistsfrom other departments, but they werecoming because their interests andoutlook were oftentimes more syn-chronous with departments of medi-cine than with their own departments.

My hope is that we can test thewaters again by beginning to developlinks to societies that focus onpatient-oriented research, and per-haps outcomes research as well. Just asit is often said that it takes as long toget better from asthma or heart failureas it took to get worse, it will likelytake us at least as long to reformulateour meeting as it took for the meetingto involute. And some people neverget better from heart failure. Never-theless, I urge my successors on thecouncils of both of these organiza-tions to look outward, not inward, tothink about the broader definitions ofscience in clinical departments, and

especially departments of medicine,and to be increasingly inclusive notonly in our membership, but also inthe way our meeting is structured andour allies are defined.

I also realize that, as a clinical epi-demiologist, I have, in many ways,been on the lunatic fringes of both ofthese societies. Lunatics or radicalsrarely change society; they just softenit up until the establishment beginsto change. It took Nixon to go toChina, and it may take a molecularbiologist to change these societies inthe direction that I am describing. Iurge all of you to give serious consid-eration to where we are going andwhere we want to go.

Anyone who says anything thatchallenges the primacy and centralityof basic science in departments ofmedicine runs the risk of beinglabeled an “anti-scientist.” Althoughthe department of medicine that Ichair has more dollars of NIH grantresearch than any other department

in the country, I obviously am not alaboratory scientist. So, let me makeit clear that I value and embrace basicscience research in departments ofmedicine. We encourage it; we nur-ture it; we emphasize it. But I hope wewill also always encourage, empha-size, and nurture the full spectrum ofactivities that cover the entire playingfield of academic medicine.

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2. Goldman, L., et al. 2001. The effect of risk factorreductions between 1981 and 1990 on coronaryheart disease incidence, prevalence, mortality,and cost. J. Am. Coll. Cardiol. 38:1012–1017.

3. Hunink, M.G.M., et al. 1997. The recent declinein mortality from coronary heart disease, 1980-1990: the effect of secular trends in risk factorsand treatment. JAMA. 277:535–542.

4. Goldberg, R.J., et al. 1998. Worcester Heart AttackStudy. Age-related trends in short- and long-termsurvival after acute myocardial infarction: a 20-year population-based perspective (1975–1995).Am. J. Cardiol. 82:1311–1317.

5. Heidenreich, P.A., and McClellan, M. 2001.Trends in treatment and outcomes for acutemyocardial infarction: 1975–1995. Am. J. Med.110:165–174.

The Journal of Clinical Investigation | Volume 111 S7