First published November 3, 2008 - More info
Dr. Swain, Council members, and members of the AAP, thank you for this singular honor. It is a particular pleasure to have the Medal presented by Denny Ausiello. Denny, who was once my student, is now my chief, which is about as appropriate a sequence as I can imagine. I have titled my response “Wandering.” Wandering aptly describes my career, as Denny so well documented. I have been privileged to have moved easily across geography and professional responsibilities. Wandering is also the title of a small book by one of my favorite authors, Hermann Hesse. In this book, he describes pleasures, insights, and excitement that can come when one crosses boundaries. Those boundaries, as in my case, can be real or metaphorical. Hesse also wrote my favorite book, The Glass Bead Game (Magister Ludi). My father gave me the book when I finished my residency, and after reading about 50 pages of it, I told him it was boring and I didn’t know why he thought I would enjoy it. He told me that I probably was not grown up enough, nor did I have enough responsibilities to appreciate the book, but that perhaps some time in the future I would. As was so often the case, my father was right. When I reread the book a few years later, I understood that it was about Hesse’s concern that the utopian, intellectual, insulated academic community that he had long sought could not survive if that community was too isolated from social responsibility. By the time he published the book in 1943, he had seen the rise of Hitler and what he perceived to be the impotence of the detached intellectual community in combating that rise.
I have always thought that our real challenge is to provide adequate protection for independent, creative intellectual activity while assuring that those who receive that protection in education or health care understand their social responsibilities. So as I have wandered through my professional career, I have always tried to value creativity and responsibility equally.
After a very fine public high school education in Brooklyn, I went off to Cornell and found a much broader intellectual community than I had previously experienced. One of my early misjudgments was to go to medical school after 3 years, forfeiting what would have been a far more broadening opportunity in a senior year at the university. Nonetheless, I loved medical school. Almost everything that I studied excited me, and I felt that this was what I was meant to do. Mine was a small, state medical school in upstate New York with about 70 students in a class; sadly, only 5 were women and not one was a minority. On a more positive note, I was fortunate to have dedicated teachers, excellent classmates, and, of course, a wide variety of patients.
From medical school, I went to my internship at the Massachusetts General Hospital in a department led by the remarkable Walter Bauer. A larger cultural transition could hardly be imagined. The MGH was the epitome of excellence, of great traditions, and it had a history of training leaders in medicine such as Holly Smith and Frank Austen. I remember arriving to start my internship and was then asked when I would interview at the NIH. I asked my colleagues what the NIH was and they explained it, so I went for an interview and was fortunate enough to be selected as a clinical associate. It turned out that almost everybody on the medical house staff at the MGH spent 2 or 3 years doing research between their second and third years of residency.
My time at the NIH was an eye opener. I was very fortunate to work for Stanton Segal. He was an almost perfect mentor, highly intelligent, widely informed, and very patient. NIH provided me with a unique view on how one might insulate individuals sufficiently to produce outstanding research, while also providing access to an experience in translational research. While at the NIH, I also formed a working relationship with one of my longest-standing colleagues and friends, Leon Rosenberg. Returning to the MGH after 2 years, I completed residency and fellowship and joined the Renal Unit. While the MGH was a great institution in which to train, it was a far more challenging one in which to be a junior faculty member. I had begun to form my own views about the relationship of clinical research to clinical practice and to medical education. Sadly, the MGH was not willing to be risk taking in those areas at that time.
But I then had one of the most exciting opportunities of my career, and that was being offered the chance by Bud Relman to come with him to Penn to help rebuild the department there. The time at Penn with Bud was spectacular. He was always open to new ideas, he had a clear plan of what a Department of Medicine ought to be and wonderful taste in the people he recruited. He was also very generous with giving people responsibility and credit for what they did. It was my time with him that made it possible for me to be considered for the chairmanship of Yale. Bud did not get everything done at Penn that he envisioned for a modern Department of Medicine, but that was more a function of resistance to change in other departments than it was of his vision.
While at Penn, I had the opportunity to reconnect with Stan Segal and to continue research in his lab. In addition to responsibilities in the department, I chaired the Curriculum Committee for the medical school and I began to be more active in national organizations. One particular treat at Penn was that I was part of a renal group run by Marty Goldberg that was almost certainly one of the best such groups ever assembled. In that group was Donna McCurdy, the finest teacher of medicine that I have ever known.
Given the opportunities at Penn and the visibility Bud allowed me, I began to be asked to look at Chairs of Medicine. And then in January of 1975, I became the Chairman of the Department of Internal Medicine at Yale. Bob Berliner was the dean, and he had long been one of my heroes in medicine and physiology. Lee Rosenberg chaired the Genetics Department and was always a strong supporter. Three people in particular made it possible to develop the department. They were Phil Felig, Bob Donaldson, and Dick Root. We faced almost none of the resistance to change that Bud had faced at Penn. It became possible to build a department which spanned from scientists appropriate to have joint appointments in the very best basic science departments to those with interest in translational and clinical research to those who were clinical teachers and consultants equal to the best the community could provide or could use. This mix of talents was ideal for stimulating and training young physicians. At Yale, we were able to develop a regional hospital network for medical education that we used as a resource to place our graduates and to develop a collaborative relationship across the southwestern part of the state. I also had the opportunity to lead an effort to establish a school-wide faculty practice plan. During the Yale years, I continued activities at the national level and served on the Directors Advisory Committee at the NIH as a member of Institute of Medicine and as Chairman of the American Board of Internal Medicine.
The Yale years were as fulfilling as anything I could imagine, but I felt strongly that after more than 10 years as Chairman, that for my own growth and for Yale’s sake, change in leadership would be appropriate. At that time, there were innumerable changes in health policy, research funding, and attempts at cost control, all of which were well intended but put tremendous pressure on academic health centers. Therefore, rather than moving to a position in health center leadership, I took advantage of the opportunity to serve as President of the Institute of Medicine, where I gained an understanding on how health policy was actually made. I was very fortunate during my time at the Institute of Medicine to have Frank Press as President of the National Academy of Sciences. He was intellectually gifted and understood the political scene as well as anybody I have ever worked with. At the IOM, I had the opportunity to build a financial base that would allow the Institute to take more control of its own agenda. After an initial study addressing the AIDS epidemic established the IOM as a timely, trusted source of policy advice, we began to be consulted on a vast array of health policy issues.
While at the Institute of Medicine, I had the opportunity to sit on the Oversight Group for the Government-University-Industry Research Roundtable and began to appreciate how each of these sectors contributed to the conduct of research. I came to understand how the balance that has been established between the sectors in this country must be protected if we are to maintain a prominent position in the generation of intellectual property for health. Through the contacts from that Roundtable, I found myself being nominated for university presidencies. Ultimately, I chose to return to Boston, to Brandeis University. Brandeis was a wonderful, small, research university, which, though it did not have a medical school, had outstanding life sciences, and it was possible for me to establish clinical outlets for teaching at Sheldon Wolff’s department at New England Medical Center and at the Department of Medicine at the Mass General. I loved teaching undergraduates at Brandeis, and I still do so today with Stuart Altman.
At the end of 1993, I was asked to consider coming back to the Mass General, first as president of the institution, and almost certainly as a part of leadership of the then-being-discussed merger between the Mass General and Brigham and Women’s Hospital. I found it emotionally difficult to say no when asked to take on the MGH position, remembering that the direction of my entire professional and teaching career had changed from the time that I arrived at the Mass General as an intern. So not only was it payback time, but the MGH was about to behave in a way I had not seen it do earlier — that is, to be really risk taking in reorganizing the way health care would be delivered in our area. The formation of Partners and a chance to work with Dick Nesson in getting it started was a superb opportunity late in my career. The lessons learned from trying to bring those 2 institutions together and to have them nucleate an integrated health care system are beyond the time of this presentation. Nonetheless, the opportunity to work with Jack Connors as Chairman of the Board and to recruit Jim Mongan to be my successor were particularly important parts of that experience.
I also had the opportunity to work on corporate boards such as Merck and Charles River Laboratories. I served on foundation boards such as the Commonwealth Fund, on university boards, and on the Board of the Federal Reserve Bank of Boston. If that doesn’t qualify as wandering, I don’t know what does.
If you don’t want to wander aimlessly, it helps to have a guide and companion, and of course, I had and have Paula. She has been with me every step of the way, offering advice and sometimes direction. She has been infinitely patient with my machinations, but I think she secretly enjoyed some of the excitement of being in motion. She is also almost single-handedly responsible for how our 3 daughters, of whom I am so proud, turned out. They and their families continue to be a great source of pleasure for us.
Let me close by reflecting on how fortunate I have been in the people I have worked with and the opportunities I have had and again thanking the Association for this honor.