FACING THE FUTURE IN MEDICINE

BY
C. EVERETT Koop, MD
SURGEON GENERAL
AND
DEPUTY ASSISTANT SECRETARY FOR HEALTH

PRESENTED AS THE JOHN WARNER DUCKETT LECTURE
BAYLOR UNIVERSITY MEDICAL CENTER
DALLAS, TEXAS
MARCH 30, 1983
(GREETINGS TO HOSTS, GUESTS)

I'M DELIGHTED TO BE YOUR GUEST TODAY AND I'M ESPECIALLY HONORED TO
SPEAK IN A FORUM THE BEARS THE NAME OF “JOHN WARNER DUCKETT.” BOTH MEN
-- FATHER AND SON -- ARE SPECIAL PEOPLE AND. IN MY MIND AND. I'M SURE,
IN THE MINDS OF THE THOUSANDS OF COLLEAGUES AND PATIENTS WHO HAVE KNOWN
THEM -- THEY EPITOMIZE WHAT GOOD MEDICINE IS SUPPOSED TO BE ALL ABOUT.

MY FIRST MEETING WITH WARNER DUCKETT TOOK PLACE SOME YEARS AGO. IT
WAS AN ODD INTRODUCTION, BUT, AS I WAS TO LEARN IN THE YEARS SINCE, IT
WAS ALSO CHARACTERISTIC OF HIS INDEPENDENCE OF MIND AND SPIRIT. IT
HAPPENED IN PITTSBURGH AT A PROFESSIONAL MEETING.

I WAS AT THE ROSTRUM OF ONE OF THE SESSIONS, DISCUSSING. AMONG
OTHER THINGS, THE PROBLEMS POSED BY BILIARY ATRESIA IN INFANTS AND
YOUNG CHILDREN. BILIARY ATRESIA WAS, WITHOUT DOUBT, ONE OF THE MOST
FRUSTRATING OF PEDIATRIC DISEASES BECAUSE THE NUMBER OF SUCH LESIONS
AMENABLE TO SURGICAL CORRECTION WAS SQ SMALL, COMPARED T0 THE
INCIDENCE OF THE PROBLEM.
-?-

AT THAT TIME, THERE WERE A HALF DOZEN PEOPLE IN THE COUNTRY WHO
CALLED THEMSELVES “PEDIATRIC SURGEONS.” I WAS ONE AND I THOUGHT I KNEW
WHO ALL THE OTHER FIVE WERE. BUT WHEN I HAD FINISHED MY PRESENTATION
AND WAS TAKING QUESTIONS FROM THE FLOOR. A CERTAIN DISTINGUISHED
LOOKING GENTLEMAN IN THE BACK OF THE ROOM -- A TOTAL STRANGER TO ME --
GOT UP AND PROCEEDED TO TELL THE ASSEMBLED COLLEAGUES THAT HE HAD HAD
BUT THREE PATIENTS IN THE PAST YEAR WITH BILIARY ATRESIA...HE HAD
TREATED ALL THREE...AND ALL THREE HAD BEEN SUCCESSFUL.

THIS WAS QUITE UNUSUAL, BECAUSE A SURGEON MAY COME ACROSS MANY
PATIENTS WITH BILIARY ATRESIA...BUT IN AN ENTIRE CAREER, A SURGEON
WILL SEE ONLY TWO OR THREE CASES IN WHICH THE ATRESIA CAN BE
SURGICALLY CORRECTED. IN FACT, IN MY OWN 35-YEAR CAREER AS A
PEDIATRIC SURGEON I HAD ONLY FIVE SUCH PATIENTS.

I MADE IT MY BUSINESS TO TALK WITH THIS GENTLEMAN AFTER THE
MEETING. AND HE WAS INDEED A PRACTICING PEDIATRIC SURGEON, ALTHOUGH
NOT A PURIST. AND THAT CONVERSATION WAS THE BEGINNING OF A LONG AND
WARM FRIENDSHIP WHICH HAS CONTINUED WITH THE NEXT “JOHN WARNER
DUCKETT.”
-3-

AS MANY OF YOU KNOW, I HAD THE GOOD FORTUNE OF MEETING UP WITH
YOUNG JOHN AND WAS INSTRUMENTAL IN BRINGING HIM TO THE CHILDREN'S
HOSPITAL OF PHILADELPHIA AS DIRECTOR OF PEDIATRIC UROLOGY. HE IS THE
WORLD'S OUTSTANDING PRACTICING PEDIATRIC UROLOGIST. EXHIBITING THE SAME
KEEN INTELLIGENCE AND INDEPENDENT SPIRIT THAT HAS CHARACTERIZED HIS
DISTINGUISHED FATHER.

ALL THAT IS BY WAY OF SAYING THAT I AM DEEPLY HONORED -- AND JUST
A BIT INTIMIDATED -- AS I PREPARE TO DELIVER A LECTURE THAT BEARS THE
“DUCKETT” FAMILY NAME.

LET ME BEGIN WITH A FEW OBSERVATIONS ABOUT THE CURRENT ENVIRONMENT
FOR MEDICINE. NOT THE POLITICAL ENVIRONMENT AND NOT THE ECONOMIC
ENVIRONMENT. ..THERE ARE WHOLE BATTALIONS OF PEOPLE WHO LOVE TO TALK AND
WRITE ABOUT THOSE THINGS. AND ALL I CAN SAY IS, “BETTER THEY THAN I.”

NO, MY INTEREST THIS MORNING IS TO TALK ABOUT A LITTLE BIT ABOUT
THE DEMOGRAPHIC ENVIRONMENT AND THE RESEARCH ENVIRONMENT. THEY MAY OR
MAY NOT FIT TOGETHER IN ONE SPEECH -- WE'LL SOON SEE -- BUT THEY MOST
CERTAINLY HAVE TO FIT TOGETHER IN THE SINGLE CAREER PLANNING OF EACH
PERSON IN MEDICINE TODAY. I THINK THEY ARE VERY IMPORTANT SUBJECTS
AND I WANT TO SPEND THE NEXT FEW MINUTES EXLPORING THEM WITH YOU.
-Y-

LET ME BEGIN, THEREFORE. WITH SOME WORDS ABOUT WHAT WE MIGHT CALL
"THE DEMOGRAPHY OF CARE.”

1 BELIEVE IT IS ESSENTIAL FOR EACH OF US, WHEREVER WE PRACTICE, 10
UNDERSTAND HOW THE AMERICAN POPULATION IS CHANGING. THIS IS A MAJOR
CHALLENGE TO ANYONE IN HEALTH CARE. IT SEEMS CLEAR THAT THE OLD WAYS
OF DOING THINGS -- NO MATTER HOW SUCCESSFUL THEY'VE BEEN IN THE PAST --
WILL PROBABLY NOT BE WORK AS WELL FOR US IN THE FUTURE.

I'M SURE YOU'VE COME UPON THOSE ARTICLES IN POPULAR MAGAZINES ABOUT
THE "GRAYING OF AMERICA.” WELL, THEY'RE ALL TRUE. THE POST-WORLD WAR
Il “BABY BOOM” GENERATION IS NOW OUR ADULT WORK-FORCE. IT IS THE BEST
EDUCATED ADULT COHORT IN OUR HISTORY. IT RUNS OUR FACTORIES AND FARMS,
DOMINATES OUR POLITICAL LIFE, AND IS AT THE VERY CORE OF OUR NATIONAL
VITALITY.

DURING THIS DECADE AND THE DECADE OF THE 1990s, THIS AGE GROUP
WILL MOVE UP AND DOMINATE THE U.S. POPULATION AGE PYRAMID, ACCOUNTING
FOR ABOUT 40 PERCENT OF THE PEOPLE OF AMERICA,
-5-

THIS GENERATION -- NOW IN ITS MID AND LATE 20s -- IS LIVING BETTER

AND WILL BE LIVING LONGER BECAUSE IT IS THE BENEFICIARY OF ABOUT 30
YEARS OF SUCCESSFUL RESEARCH ON THE DETECTION AND TREATMENT OF MOST OF
SOCIETY'S MAJOR KILLERS:

§

IN THE 25-44 AGE GROUP, THE DEATH RATE FROM HEART DISEASE HAS
DROPPED BE NEARLY HALF JUST SINCE 1965. IT IS THE LEADING CAUSE OF
DEATH FOR SOCIETY IN GENERAL, BUT IT IS NUMBER THREE FOR THIS PAR-
TICULAR AGE GROUP. OF COURSE, THAT MEANS FEWER PREMATURE DEATHS
AMONG THE “BABY BOOM” GENERATION.

CANCER, MANKIND'S MOST PERSISTENT SCOURGE, PRODUCES THE SECOND
HIGHEST NUMBER OF PREMATURE DEATHS IN SOCIETY IN GENERAL AND FOR
THIS AGE GROUP IN PARTICULAR. WE HAVEN'T SOLVED THE PUZZLE OF
CANCER. NEVERTHELESS, WE'VE BEEN ABLE TO DROP THE DEATH RATE FROM
CANCER BY 31 PERCENT OVER THE PAST TWO DECADES AMONG PERSONS UNDER
THE AGE OF 45 -- THAT “BABY BOOM” GENERATION AGAIN.
-6-

§ AND THEN THERE IS STROKE...A COMPLEX DISEASE CLOSELY RELATED 10 AN
INDIVIDUAL'S PHYSICAL, MENTAL, AND EMOTIONAL HEALTH. IN THE PAST
30 YEARS, WE'VE BEEN ABLE TO REDUCE THE DEATH RATE FROM STROKE BY
49 PERCENT. ONCE AGAIN. THE FIRST GROUP OF AMERICANS TO BENEFIT
FROM THIS EXTRAORDINARY ADVANCE IN MEDICINE HAS BEEN THAT SAME
“BABY BOOM” GENERATION. IN FACT, ITS MORTALITY RATE FROM STROKE
IS ABOUT ONE-FIFTH THE RATE FOR THE COUNTRY AS A WHOLE.

§ THE LEADING CAUSE OF DEATH FOR THE 25-44 AGE GROUP, UNFORTUNATE-
LY, IS THE MOTOR VEHICLE ACCIDENT. AMONG THE YOUNGER MEMBERS OF
THE “BABY BOOM” GENERATION, THE HIGHWAY DEATH RATE IS TWICE WHAT
IT IS FOR THE WHOLE COUNTRY. AND WHAT'S WORSE, WE SEEM TO BE
MAKING NO PROGRESS IN BRINGING IT DOWN. | |

EVEN WITH THEIR DREADFUL RECORD ON THE NATION'S HIGHWAYS, MANY MORE
MEN AND WOMEN OF THE “BABY BOOM” GENERATION WILL BE LIVING SEVERAL
YEARS LONGER THAN THEIR PARENTS. THEREFORE, WE CAN EXPECT THAT, AFTER
A DECADE OR TWO INTO THE NEXT CENTURY, APPROXIMATELY 1 IN EVERY 5
AMERICANS WILL BE A SENIOR CITIZEN. AT THAT TIME THERE WILL BE MORE
THAN 50 MILLION PERSONS OVER THE AGE OF 65, TWICE AS MANY AS THERE ARE
TODAY.
-]/-

I SHOULD ALSO POINT OUT THAT THE MEDIAN AGE IN THE UNITED STATES
TODAY IS 30 YEARS AND 7 MONTHS. BUT IN THE YEAR 2000 WE EXPECT THE
MEDIAN AGE TO BE 36 YEARS AND 4 MONTHS.

MANY PERSONS AND ORGANIZATIONS THAT DELIVER HEALTH CARE HAVE SEEN
THIS KIND OF NUMBER-WRITING ON THE WALL. THEY ARE BEGINNING TO ADJUST
THEIR MIX OF SERVICES TO ACCOMMODATE THE GROWTH IN OUR AGED POPULATION.
THEY ARE EMPHASIZING HOME HEALTH CARE AND ARE DE-EMPHASIZING INSTITU-
TIONAL CARE FOR THE ELDERLY.

IN FACT, I WOULD EVEN GO SO FAR AS TO SAY THAT AMONG THE MANY
DEVELOPMENTS IN MEDICAL AND HEALTH CARE TECHNOLOGY THAT WILL BE COMING
OUR WAY OVER THE NEXT SEVERAL DECADES. A GREAT NUMBER WILL BE DIRECTLY
APPLICABLE TOWARD IMPROVING THE LEVEL OF HOME OR FAMILY-CENTERED CARE
FOR OUR INFIRM ELDERLY.

THAT'S A VERY AWESOME DEMOGRAPHIC PROJECTION AND. TO TELL THE
TRUTH, I WISH I COULD STOP RIGHT HERE. BUT I CAN'T, THE FACT OF THE
MATTER IS THAT THE “GRAYING OF AMERICA.” AS SIGNIFICANT AS IT MAY BE,
IS ONLY HALF THE STORY.
-8-

THIS AGING “BABY BOOM” GENERATION IS BEGINNING TO HAVE BABIES OF
ITS OWN. TO BE MORE PRECICE, THE THE UNITED STATES IS EXPERIENCING
WHAT IS CALLED AN “ECHO EFFECT.” LET ME EXPLAIN HOW THAT WORKS.

THE FERTILITY RATE IN 1980 AMONG “BABY BOOM” WOMEN -- THAT IS,
CHILD-BEARING WOMEN IN THEIR TWENTIES AND THIRTIES -- WAS 68.4, OUR
MOST CURRENT STATISTIC. THE RATE FOR THEIR MOTHERS, THE CHILD~BEARING
WOMEN IN THE 1950s AND EARLY 60s, HIT A RECORD HIGH OF 122.7 IN 1957,
NEARLY TWICE THE CURRENT FERTILITY RATE.

BUT WHILE THAT EARLIER GENERATION HAD, IN 1957, ABOUT 4.3 MILLION
LIVE BIRTHS, THE WOMEN IN 1980 HAD 3.6 MILLION LIVE BIRTHS -- OR ONLY
16 PERCENT FEWER LIVE BIRTHS THAN THEIR MOTHERS’ GENERATION, AT HALF
THE FERTILITY RATE.

LET ME PUT IT ANOTHER WAY: IF THE UNITED STATES FERTILITY RATE
WERE THE SAME TODAY AS IT WAS 25 YEARS AGO, THEN. INSTEAD OF 3.6
MILLION BABIES BORN THIS YEAR, WE WOULD HAVE SOMETHING LIKE 7 MILLION
BABIES, NEARLY TWICE THE NUMBER BORN IN OUR ALL-TIME “BABY BOOM” YEAR.
-9-

BUT THERE IS MUCH MORE TO THIS DEMOGRAPHIC PICTURE THAN MERE
NUMBERS OF WOMEN AT CHILD-BEARING AGE. THERE IS ANOTHER VERY IMPORTANT
FACTOR: MORE OF TODAY'S BABIES ARE SURVIVING.

FOR COMPARISON, LET'S LOOK BACK AGAIN AT THE BOOM YEAR OF 1957. IN
THAT YEAR, THERE WERE 26 INFANT DEATHS FOR EVERY 1,000 LIVE BIRTHS. OUR
LATEST ESTIMATE FOR LAST YEAR -- 1982 -- IS A RATE OF 11.2 INFANT
DEATHS FOR EVERY 1,000 LIVE BIRTHS. SO IN JUST ONE GENERATION, WE
REDUCED THE INFANT MORTALITY RATE IN THE UNITED STATES BY MORE THAN
HALF .

DURING THIS SAME PERIOD, BY THE WAY. WE ALSO REDUCED THE DEATH
RATE FOR CHILDREN AGES 1 THROUGH 14 BY NEARLY HALF. THAT'S WHY I
BELIEVE WE CAN DRAW ONLY ONE CONCLUSION FROM ALL THIS: WE MAY BE IN
THE MIDST OF YET ANOTHER -- AND ONLY SLIGHTLY LESS DRAMATIC -- “BABY
BOOM,”

WHAT DOES ALL THIS MEAN FOR PERSONS SUCH AS OURSELVES, PEOPLE WHO
ACTUALLY DELIVER HEALTH AND MEDICAL CARE TO INDIVIDUALS AND FAMILIES.
IT'S MY BEST GUESS THAT, OVER THE NEXT 25 YEARS OR SO, WE ARE GOING T0
HAVE THE UNUSUAL TASK OF PROVIDING QUALITY GERIATRIC AND QUALITY
PEDIATRIC HEALTH CARE AT THE SAME TIME,
-10-

WILL THIS COUNTRY BE ABLE TO DO IT? I THINK SO. BUT I'M NOT AT
ALL SURE HOW WE WILL DO IT. WE HAVE NO EXPERIENCE FOR SUCH AN HISTORIC
SET OF CIRCUMSTANCES. AND WE CAN'T LEARN FROM ANYBODY, SINCE NO OTHER
COUNTRY HAS HAD THAT KIND OF EXPERIENCE EITHER.

IF WE HAVE ANY MAJOR HURDLES TO OVERCOME, THEY WOULD BE THE HURDLES
OF TOO LITTLE TIME AND NOT ENOUGH MONEY. AND I GUESS EVERYONE HERE
THIS MORNING HAS HEARD THAT ONE BEFORE. BUT THE PRESSURES THIS TIME
ARE SOMEWHAT UNIQUE. YOU CAN'T “FINE TUNE” DEMOGRAPHY. IT'S TOTALLY
BEYOND OUR CONTROL.

WHEN OTHER ISSUES HAVE COME BEFORE US IN THE PAST. WE'VE USUALLY
HAD AT LEAST A FEW YEARS TO MAKE SOME ADJUSTMENTS. BUT WE SIMPLY
DON'T HAVE THE LUXURY OF TIME ANYMORE. I'D SAY WE HAVE A DECADE OR
TWO -- AT BEST -- TO PREPARE OUR PHYSICIANS AND NURSES. OUR DENTISTS
AND THERAPISTS, OUR TECHNICIANS, ADMINISTRATORS, TRUSTEES, AND SOCTAL
SERVICE WORKERS TO DEAL WITH A NATION WITH MANY MILLIONS OF THE AGED
AND MANY MILLIONS OF CHILDREN -- AND A LOT OF OTHER PEOPLE OF ALL AGES
SCATTERED IN BETWEEN.
-l1-

OF COURSE, THE REST OF THE COUNTRY WILL NOT BE SITTING STILL,
WAITING FOR MEDICINE TO CATCH UP. WE CAN PREDICT THAT BECAUSE WE KNOW
THAT TODAY MANY MAGAZINE READERS AND T.V. WATCHERS ARE ABOUT AS WELL
INFORMED ON SOME HEALTH MATTERS AS THEIR FAMILY PHYSICIANS. AND THAT
KIND OF TREND WILL CERTAINLY CONTINUE.

THE “BABY BOOM” GENERATION -- AS IT BEGINS TO REALLY SHOW ITS AGE
AT THE TURN OF THE CENTURY -- WILL BE MORE KNOWLEDGEABLE ABOUT HEALTH
THAN YESTERDAY'S OR EVEN TODAY'S SENIOR CITIZENS. AS I MENTIONED
EARLIER. THE MEMBERS OF THE “BABY BOOM” GENERATION ARE NOW IN THEIR
PRIME, LIVING THEIR MOST PRODUCTIVE, ACTIVE. AND INQUISITIVE YEARS.
THEY ARE A BETTER EDUCATED GENERATION, AND -- RECENT CRITICISMS
NOTWITHSTANDING -- THEY HAVE A REASONABLY GOOD WORKING GRASP OF
SCIENCE AND THE SCIENTIFIC METHOD. FRANKLY. IF THEY DID NOT. THEN YOU
COULD NOT SELL ONE SINGLE HOME COMPUTER.

I BELIEVE THE KEY TO OUR ABILITY TO RESPOND TO THE PUBLIC'S NEED
FOR BETTER CONTEMPORARY HEALTH CARE IS TO BE FOUND IN OUR RESEARCH
PROGRAMS, THE MORE WE IMPROVE OUR UNDERSTANDING OF THE THINGS WE
KNOW, THE MORE WE REALIZE JUST HOW MUCH WE DON'T KNOW AT ALL.
-]?-

HENCE, THE MORE WE LEARN ABOUT THE HEALTH AND MEDICAL NEEDS OF THE
ELDERLY, THE MORE WE REALIZE THAT WE STILL HAVE A GREAT DEAL MORE TO
LEARN -- AND AS SOON AS POSSIBLE. IF THERE IS IS A CONSENSUS ON THIS
MATTER SO FAR, I TEND TO THINK IT REVOLVES AROUND THE IDEA THAT RE-
SEARCH -- PARTICULARLY BASIC BIOMEDICAL AND BEHAVIORAL RESEARCH -- IS
ONE OF THE MAJOR PRIORITIES OF GOVERNMENT IN THE TASK OF GEARING UP
FOR THE FUTURE.

AT THE PRESENT TIME, THE FEDERAL GOVERNMENT CONTRIBUTES ABOUT 60
PERCENT OF ALL MONEY FOR BIOMEDICAL AND BEHAVIORAL RESEARCH...AND THAT
INCLUDES BASIC RESEARCH, APPLIED RESEARCH, AND DEVELOPMENT. LAST
YEAR, THE FEDERAL TOTAL CAME TO JUST UNDER $5 BILLION DOLLARS. OF
THAT AMOUNT, OVER TWO-THIRDS SUPPORTS BASIC RESEARCH. WHAT KIND OF
RESEARCH DOES THIS MONEY BUY AND WILL ANY OF IT HELP US PROVIDE BETTER
HEALTH SERVICE TO THE NEW AMERICAN DEMOGRAPHY? I THINK SOQ. FOR
EXAMPLE...

* WE ARE COMMITTED TO LONG-TERM INQUIRIES INTO THE NATURE OF THE
AGING PROCESS.
-14-

* BOTH THE NATIONAL INSTITUTES OF HEALTH AND THE CENTERS FOR
DISEASE CONTROL HAVE PROJECTS THAT EXPLORE THE ETIOLOGY OF BIRTH
DEFECTS.

* VIRTUALLY EVERY ONE OF THE NATIONAL INSTITUTES HAS SOME PROJECT
DIRECTED AT YIELDING MORE INFORMATION ABOUT LIFE AT THE CELLULAR
AND SUB-CELLULAR LEVEL.

* WE ARE GATHERING A GREAT DEAL OF INFORMATION ABOUT THE IMPACT
OF ENVIRONMENTAL HAZARDS, RE-EVALUATING SOME THAT ARE FAMILIAR TO
US AND TAKING A NEW LOOK AT SOME THAT ARE JUST BEGINNING TO APPEAR
-- OR ARE THREATENING TO APPEAR.

* AND THEN THERE ARE THE AREAS IN WHICH MUCH WORK HAS BEEN DONE,
WITH A GREAT DEAL MORE STILL TO DO. THESE AREAS WOULD INCLUDE
CYSTIC FIBROSIS, OSTEOARTHRITIS, DIABETES. THE CAUSES OF PREMATURE
BIRTHS. AND, OF COURSE, THE MAJOR KILLERS -- HEART DISEASE,
CANCER, AND STROKE.
-j4-

THAT 1S A VERY EXCITING LIST OF THE KINDS OF RESEARCH PROJECTS WE
ARE SUPPORTING PRIMARILY THROUGH THE NATIONAL INSTITUTES OF HEALTH,
THE CENTERS OF DISEASE CONTROL, AND THE ALCOHOL, DRUG ABUSE, AND
MENTAL HEALTH ADMINISTRATION. BUT WILL IT HAVE BEEN THE RIGHT LIST
FOR OUR SOCIETY 20 YEARS FROM NOW?

IF WE WERE TO LAY OUT OUR RESEARCH PRIORITIES...NOW...TODAY...WITH
OUR EYES LOOKING FAR INTO THE FUTURE, WHAT KIND OF PRIORITIES WOULD WE
CHOOSE? :

--- QUGHT WE TO CONTINUE TO RACE DOWN THE ROAD OF THE GENETIC
ENGINEERS, OR SHOULD WE REALLY BE INVESTING PRIMARILY IN VIROLOGY
AND IMMUNOLOGY. IN ANTICIPATION OF PRODUCING A CLUTCH OF NEW
VACCINES?

--- SHOULD OUR FOCUS BE PRIMARILY ON RESEARCH OF THE HUMAN AGING
PROCESS, OR SHOULD WE FOCUS INSTEAD ON THE MANY MYSTERIES OF
PREGNANCY AND LABOR?
-15-

--- QUGHT WE TO EXPEND MOST OF OUR EFFORTS ON THE MAJOR CAUSES OF DEATH
IN OUR SOCIETY -- HEART DISEASE, CANCER, AND STROKE -- OR SHOULD
WE SHIFT MORE ATTENTION AND RESOURCES TO SUCH RARE BUT PERSISTENT
DISEASES AS MYOCLONUS OR WILSON'S DISEASE OR TOURETTE'S SYNDROME
OR NEPHROPATHIC CYSTINOSIS...THE SO-CALLED “ORPHAN DISEASES”?

~-- THEN AGAIN. MAYBE WE SHOULD INCREASE OUR EFFORTS WHERE THERE IS A
HINT OF AN IMMINENT PAY-OFF, INSTEAD OF INVESTING HEAVILY IN THE
TOUGHER, MORE PUZZLING, LONG-TERM INVESTIGATIONS,

-~~ AND FINALLY, SHOULD WE CONTINUE TO CONCENTRATE OUR FUNDS SO HEAVILY
IN THE BIOMEDICAL AREA. OR SHOULD WE MOVE MORE AGGRESSIVELY INTO
THE BIOBEHAVIORAL AREA -- TO HELP PEOPLE STOP SMOKING AND ABUSING
ALCOHOL AND DRUGS AND GET THEM TO EAT BETTER AND MANAGE THEIR
STRESS BETTER?

CHOICES. ..CHOICES...CHOICES. AS CONFOUNDING AS SOME OF THEM MAY BE,
THEY MUST BE UNDERSTOOD AND WEIGHED. ULTIMATELY. WE MUST MAKE A CHOICE
~~ AND IT SHOULD BE THE BEST ONE...THE RIGHT ONE...THE NECESSARY ONE
FOR OUR COUNTRY AND FOR MANKIND. I MUST SAY THAT WE'VE BEEN DOING
QUITE WELL IN MAKING OUR RESEARCH CHOICES SO FAR...BUT I CANNOT TELL
YOU WHY. IT'S AS MUCH A MYSTERY AS THE INITIATION OF LABOR AND BIRTH.
-16-

THESE ARE NOT IDLE QUESTIONS. EVERYONE HERE THIS MORNING HAS A
STAKE IN THE ANSWERS. YOU CAN'T BE IDENTIFIED WITH SUCH A FINE
INSTITUTION AS THE BAYLOR UNIVERSITY MEDICAL CENTER -- WITH ITS FINE
REPUTATION FOR QUALITY RESEARCH AND PATIENT CARE -- AND NOT ALSO FEEL
THE TENSION BETWEEN THOSE TWO WORLDS OF MEDICINE: RESEARCH AND PATIENT
CARE. AND YOU CAN'T BUT NOTICE THAT THE TENSION SOMEHOW HAS TO DO WITH
OUR OWN ASSESSMENTS OF THE COUNTRY'S FUTURE NEEDS.

I THINK THE TWO WORLDS OF MEDICINE -- OF RESEARCH AND OF PRACTICE
-- NEED TO BUILD BETTER BRIDGES OF COMMUNICATION SO THAT THE NEW
KNOWLEDGE DEVELOPED BY ONE CAN BE QUICKLY ADAPTED TO THE PRACTICE OF
THE OTHER. AND CONVERSELY, THE INFORMATION DRAWN FROM THE PRACTICE OF
ONE MAY INFLUENCE THE DIRECTION OF INVESTIGATIONS TAKEN BY THE OTHER.

MAYBE I HAVE A PREJUDICE OR TWO THAT FAVORS THE PRACTITIONER...
I'M SURE I DO...AND I SUPPOSE I FEEL A CERTAIN KINSHIP AND SYMPATHY
FOR THE PRESSURES OF A DAY-TO-DAY MEDICAL PRACTICE. FOR THE BUSY
PRACTITIONER. KEEPING UP WITH THE WORLD OF RESEARCH IS JUST A VERY
HARD THING TO DO.
-|7-

FOR THE PRACTICING PHYSICIAN, TIME IS A VERY PRECIOUS COMMODITY.
THEREFORE, KEEPING UP-TO-DATE ON RESEARCH MAY BE MORE EASILY SAID THAN
DONE. BUT MANY EXAMPLES OF ROUTINE COMMUNICATION WITHIN THE MEDICAL
PROFESSION CAN ALL BE HELPFUL IN DELIVERING NEW INFORMATION THAT'S
EASILY AND QUICKLY INGESTED.

EACH PHYSICIAN HAS TO SET PRIORITIES FOR SPENDING TIME, AND I
WOULD HOPE THAT BEING CURRENT ON NEW DEVELOPMENTS IN THE BIOMEDICAL
AND BEHAVIORAL SCIENCES WOULD RATE HIGH ON ANY PHYSICIAN'S LIST OF
PRIORITIES.

BUT JUST BEING UP-TO-DATE IS NOT ENOUGH EITHER. IT IS ALSO
IMPORTANT FOR THE PRACTITIONER TO MAKE THAT VITAL CONNECTION BETWEEN
RESEARCH AND MEDICAL PRACTICE...OR. EVEN MORE TO THE POINT, TO MAKE
THE CONNECTION BETWEEN RESEARCH AND WHAT HE OR SHE WANTS MEDICAL
PRACTICE TO BE.

HEALTH CARE OF EVERY KIND AND DEGREE IS CHANGED AND, WE HOPE, IM-
PROVED OVER THE YEARS AS IT ABSORBS AND APPLIES THE LESSONS LEARNED IN
THE LABORATORY, THE TEACHING HOSPITAL. AND ELSEWHERE IN THE RESEARCH
-18-

ENVIRONMENT. IF WE CARE AT ALL FOR THE FUTURE OF OUR PROFESSION, THEN
WE HAVE TO CARE ABOUT THE RESULTS OF RESEARCH AND HOW THEY ARE PER-
CEIVED THROUGH THE PRACTITIONER'S LENS OF DAY-TO-DAY PATIENT CARE.

THIS MAY OR MAY NOT BE EASY TO DO. SOMETIMES IT'S DIFFICULT 10
PREDICT WITH ANY ACCURACY WHAT THE ULTIMATE VALUE OF SOME PIECE OF RE-
SEARCH WILL BE. FOR EXAMPLE, WE'RE STILL OPEN TO WHAT THE FUTURE ROLE
OF INTERFERON MAY BE. RECOMBINANT D.N.A., MONOCLONAL HYBRIDOMAS, AND
NEUROTRANSMITTERS MAY BE THE ANSWERS TO ANY NUMBER OF PRAYERS. OR
THEY MAY NOT.

BUT EACH OF THESE NEW TECHNOLOGIES, THE MANY HUNDREDS MORE IN THE
MAKING, AND THOSE THAT ARE IN COMMON PRACTICE TODAY -- THEY ALL NEED TO
BE CAREFULLY EVALUATED AND ASSESSED BY A RESPONSIBLE MEDICAL PROFES-
SION,

THESE QUESTIONS ARE EXTREMELY DIFFICULT AND REQUIRE THE BEST
THINKING AVAILABLE IN THE SCIENTIFIC AND MEDICAL COMMUNITY TO HELP
SOCIETY FIND THE BEST ANSWERS. SUCH QUESTIONS AS THESE TEST OUR
ABILITY TO WEIGH EVIDENCE, BALANCE INTERESTS, AND MAKE JUDGMENTS. IN
THAT SENSE. THEN, THE ANSWERS MAY LEAD US TO AN UNDERSTANDING OF WHAT
-19-

NEEDS TO BE CONSIDERED AND DECIDED TODAY...AND WHAT CAN SAFELY BE CON-
SIDERED TOMORROW. THEY RAISE IN US THE HOPE THAT IT MIGHT BE POSSIBLE
AFTER ALL -- AND WITHOUT WEAKENING THE TRADITION OF FREEDOM OF INQUIRY
-- TO IMPOSE A SENSE OF ORDER AND STABILITY UPON WHAT OTHERWISE SEEMS
TO BE AN UNCERTAIN STATE OF AFFAIRS IN SCIENCE.

IT WOULD SEEM TO ME, THEN, THAT ONE OF THE SERIOUS TASKS AHEAD FOR
THE MODERN PRACTITIONER WOULD BE TO PLAY AN INFORMED AND ACTIVE ROLE
IN THE PRIORITY-SETTING PROCESSES IN MEDICINE AND RESEARCH.

WE KNOW THE COUNTRY DOES NOT HAVE UNLIMITED RESOURCES TO FOLLOW
ANY PATH OF RESEARCH OR PRACTICE THAT MAY CAPTURE OUR IMAGINATION. WE
ALL NEED TO HAVE A NEW SENSE OF DISCIPLINE IN THESE MATTERS. A
PROSPECT THAT I CONFESS TO FIND QUITE REFRESHING. BUT I MUST WARN THE
INNOCENTS AMONG YOU: WE HAVE NO SHORTAGES AT ALL OF INTEREST GROUPS
WHO ARE ALREADY INVOLVED IN THE PRIORITY-SETTING PROCESSES FOR
BIOMEDICAL AND BEHAVIORAL RESEARCH.

THE ACADEMIC COMMUNITY IS ONE, OF COURSE. ITS INTEREST IS TWO-
FOLD: RESEARCH AND EDUCATION CROSS-POLLINATE AND EACH IMPACTS ON THE
OTHER'S USE OF AVAILABLE HUMAN, PHYSICAL. AND FINANCIAL RESOURCES.
-?0-

ALSO CONTRIBUTING TO THE RESEARCH DIALOGUE ARE A NUMBER OF MAJOR
INDUSTRIES, SUCH AS THE DRUG AND DEVICE INDUSTRIES, THE PRODUCERS OF
MEDICAL INSTRUMENTATION, AND THE INVESTMENT COMMUNITY. AND LET'S NOT
LEAVE OUT GOVERNMENT -- FEDERAL AND STATE GOVERNMENT IN PARTICULAR --
WHOSE VIEWS ARE ALWAYS KNOWN AND FELT.

SO FAR, PRACTICING PHYSICIANS HAVE NOT BEEN VERY VISIBLE OR
PERSUASIVE IN THE BUSINESS OF SETTING RESEARCH PRIORITIES. IT'S
POSSIBLE THAT PHYSICIANS ARE SO GRATEFUL FOR THE RESULTS THAT RESEARCH
HAS ALREADY PROVIDED THAT THEY'D JUST AS SOON LET THIS “NATURAL”
PROCESS CONTINUE.

BUT SUCH A PASSIVE ROLE IS NOT ENOUGH. THROUGH OPEN DISCUSSION,
THROUGH PROFESSIONAL ORGANIZATIONS, AND THROUGH OTHER MECHANISMS I
THINK THE PRACTICING PHYSICIAN HAS TO TRANSLATE HIS OR HER UNDERSTAND-
ING OF THE NEW SCIENCE AND ITS RAMIFICATIONS FOR MEDICAL PRACTICE INTO
SOME RANK ORDER. THEN THOSE CONCLUSIONS OR JUDGMENTS OUGHT TO BE RE-
LAYED BACK TO THE WORLD OF RESEARCH,
-?1-

THAT KIND OF ACTIVITY WOULD BE A REMINDER -- AND A VERY POWERFUL
ONE, IN MY JUDGMENT -- FOR THE RESEARCH COMMUNITY. IT WOULD CLEARLY
UNDERSCORE THE NOTION THAT RESEARCH AND PRACTICE ARE NOT TWO SEPARATE
ACTIVITIES IN SOCIETY. RATHER, THEY ARE A CONTINUUM OF ONE SINGLE
ACTIVITY: THE PURSUIT OF KNOWLEDGE FOR THE BENEFIT OF MANKIND.

THIS MAY SOUND LIKE A SIMPLE, STRAIGHTFORWARD THING TO DO. BUT IT
REALLY ISN'T. SETTING RESEARCH PRIORITIES CAN BE A COMPLEX AND OFTEN
FRUSTRATING TASK, PARTICULARLY FOR A SOCIETY AS DIVERSE AS OURS, WHICH
HAS A GREAT RANGE OF PERSONAL, FAMILY. AND COMMUNITY NEEDS, AND WHICH
IS EVOLVING DEMOGRAPHICALLY INTO A SIGNIFICANTLY DIFFERENT SOCIETY
OVER THE COURSE OF ONE GENERATION,

CONSIDER THIS QUESTION, AS AN EXAMPLE. THE PUBLIC HEALTH SERVICE
SPENDS IN ONE YEAR NEARLY $5 BILLION IN HEALTH RESEARCH FUNDS. MOST
OF THAT MONEY IS INVESTED IN AND THROUGH N.I.H.. C.D.C.. AND THE OTHER
AGENCIES I MENTIONED A FEW MOMENTS AGO. THESE AGENCIES. IN TURN, TEND
TO INVEST HEAVILY IN FAIRLY TRADITIONAL AREAS. HEART DISEASE, CANCER,
AND STROKE RESEARCH, FOR EXAMPLE, OR INFECTIOUS DISEASE RESEARCH.
-2?-

HOWEVER, LATELY WE HAVE BEEN HEARING THE VOICES OF PEOPLE WITH
RARE DISEASES ASKING, “WHAT ABOUT US? WE'RE ALSO SUFFERING. WE ALSO
NEED HELP.” WHAT SHOULD OUR RESPONSE BE? AND HOW SHOULD WE INCLUDE
IT INTO OUR OVERALL RESEARCH PLANNING? FOR INSTANCE. SHOULD WE
SOMEHOW STRIKE A BALANCE BETWEEN HEART DISEASE AND ADRENAL FUNCTION
SUPPRESSION IN CUSHING'S SYNDROME? WHAT WOULD OUR PRIORITIES LOOK
LIKE THEN?

THESE KINDS OF QUESTIONS REQUIRE A GREAT MANY THOUGHTFUL CONTRIBU-
TIONS FROM THROUGHOUT THE MEDICAL COMMUNITY AND FROM SOCIETY IN
GENERAL. I KNOW WHEN I SAY THAT. IT SOUNDS THREATENING TO MANY
PHYSICIANS. I WISH THAT WERE NOT THE CASE...BUT I KNOW IT IS. NEVER-
THELESS, THE KINDS OF ISSUES I HAVE RAISED SO FAR -- ISSUES RELATED TO
THE DEMOGRAPHIC ENVIRONMENT AND THE RESEACH ENVIROMENT IN WHICH
MEDICINE IS PRACTICED TODAY AND WILL BE PRACTICED TOMORROW -- THESE
ARE ISSUES THAT CANNOT BE FULLY RESOLVED WITHOUT THE “INFORMED
CONSENT” OF THE AMERICAN PEOPLE,

AS THE LINK BETWEEN THE WORLD OF RESEARCH AND THE WORLD OF BEDSIDE
CARE, THE PHYSICIAN HAS TO MOVE BEYOND JUST THE DISEASE OR DISABILITY
OF THE MOMENT, THE PARTICULAR COMPLAINT THAT BRINGS TOGETHER THE
-~23-

PHYSICIAN AND THE PATIENT. THAT'S IMPORTANT, TO BE SURE. THAT'S
"INFORMED CONSENT” FOR THE IMMEDIATE BUSINESS AT HAND. BUT WE MUST
KEEP IN MIND THAT BIOMEDICAL AND BEHAVIORAL RESEARCHERS ALSO NEED THE
PUBLIC'S “INFORMED CONSENT” OVER THE LONG RUN.

OUR PATIENTS -- THE GENERAL PUBLIC -- MUST CONSENT TO THE EXPENDI-
TURE OF RESOURCES...TO THE SETTING OF A RESEARCH AGENDA...MUST GIVE
SOME ASSISTANCE IN RESOLVING THE GREAT ETHICAL ISSUES OF CONTEMPORARY
RESEARCH...AND THEY MUST PROVIDE SUPPORT IN OTHER AREAS AS WELL.
WITHOUT THIS CONSENT OF THE GENERAL PUBLIC, RESEARCH IS HOBBLED AND
HELD IN SUSPICION.

WORST OF ALL. WITHOUT STRONG PUBLIC UNDERSTANDING AND SUPPORT,
MEDICAL RESEARCH IS CONDUCTED IN A VACUUM, A SITUATION THAT OFFERS THE
RESEARCHER SMALL HOPE OF SUCCESS.

PEOPLE WANT TO KNOW WHAT'S GOING ON IN RESEARCH...WHAT'S IN THE
PIPELINE THAT'S NEW AND SIGNIFICANT...WHAT MEDICAL CARE MAY BE LIKE IN
THE FUTURE FOR THEMSELVES AND THEIR FAMILIES. BASICALLY. IT'S THE SAME
~2u-

CURIOSITY THAT PHYSICIANS THEMSELVES HAVE AND IT OUGHT TO BE SATISFIED
FOR THE SAME REASONS: TO BUILD UNDERSTANDING, TO MAINTAIN TRUST, AND
TQ PROVIDE SUPPORT WHEN NEEDED.

IT BELIEVE THIS CONSTELLATION OF TASKS AND RELATIONSHIPS WOULD BRING
THE PRACTITIONER CLOSER TO THE WORLD OF RESEARCH, PROVIDING ADDITIONAL
INSIGHTS INTO THE FUTURE OF MEDICAL PRACTICE. WE NEED THAT KIND OF
INSIGHT AS MUCH AS WE NEED THE IMPORTANT BIOMEDICAL AND BEHAVIORAL
RESEARCH THAT IS ITS INSPIRATION,

CERTAINLY THESE ARE VERY EXCITING AS WELL AS VERY COMPLEX TIMES IN
WHICH TO BE PRACTICING MEDICINE, DOING RESEARCH, RAISING A FAMILY, OR
JUST WATCHING SUNRISES AND SUNSETS. WE KNOW SO MUCH MORE WITH EACH
PASSING DAY THAT, SOONER OR LATER, WE SENSE THE GREAT BURDEN OF
KNOWLEDGE AND -- IF WE ARE RESPONSIBLE -- WE TRY TO MAKE THAT BURDEN
MORE MANAGEABLE. WE KNOW, OF COURSE. THAT IT NEVER WILL BE COMPLETELY
COMFORTABLE, BUT WE DON'T LET THAT BOTHER US.
-?5-

A WHILE BACK, DR. ERWIN CHARGAFF, ONE OF THE PIONEERS IN HEREDITY
RESEARCH AND GENETIC CHEMISTRY, WROTE, “THE GREATER THE CIRCLE OF
UNDERSTANDING BECOMES, THE GREATER IS THE CIRCUMFERENCE OF SURROUNDING
IGNORANCE.” THAT'S A SOBERING IDEA. BUT WE MUST TAKE HEART. THERE
ARE STILL MANY WAYS TO EXPAND THAT CIRCLE...10 PUSH OUT EVEN FARTHER
THAT “CIRCUMFERENCE OF IGNORANCE.” AND CERTAINLY THE PHYSICIAN WE
HONOR IN THIS SERIES OF LECTURES, DR. JOHN WARNER DUCKETT, WAS ONE OF
THOSE WHO DID JUST THAT IN HIS PERSONAL AND PROFESSIONAL LIFE.

YOU'VE BEEN A MOST ATTENTIVE AND EXCELLENT AUDIENCE. THANK YOU,

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