Presidential Address—1975: Before the Colors Fade ALVIN P. SHAPIRO, MD
It has been said many times from this platform and on this occasion that the major function of the president of our Society is to give the Annual Lecture at this spot on the program. Certainly the job is not otherwise onerous or time-consuming thanks to the dedication of the other officers and members of "our club" and most of all due to the efficiency, experience, and direction of those two paragons, Joan and Mildred. In fact, on assuming the office one has somewhat the same feelings many of us clearly recall from our first day of internship when the experienced and wise head nurse somehow managed to make us feel we were in charge of things while still telling us what to do and how to doit. Somehow this ability to pass on to successive inheritors of the post the accumulated knowledge of the past and still to advance on new fronts, although not unique to this particular Society, has certain special properties of warmth and tradition with us. My adopted city of Pittsburgh last year acquired a new PR slogan—namely, "Pittsburgh is Some Place Special"—in order to help the city develop a new image of quality to replace the mass inferiority complex under which, along with its smoke-filled sky, it had so long labored. American Psychosomatic Society, Annual Meeting, March 22, 1975, New Orleans. From the University of Pittsburgh School of Medicine. Dr. Shapiro is Professor of Medicine and Associate Dean for Acadamic Affairs at the University of Pittsburgh School of Medicine. Received for publication April 7, 1975.
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The phrase is particularly adaptable to our Society, which has a closeness and congeniality, along with a proud record of accomplishment, which make it "something special." Presidential addresses tend to be either historic and nostalgic or a State of the Art message about a particular area of science. In keeping with my own "something special" and sentimental feelings about our Society, I would like to strike a note somewhere between these two alternatives by telling you something about my thoughts concerning the present status of psychosomatic investigation in my own area of interest, namely, hypertensive disease, as I have seen it develop, but at the same time paying tribute to several people who individually and collectively directed me in this area. Along the way, however, I also will attempt to use these observations to defend "us academicians," and the forces that made us what we are, from the popular current day accusation that medicine and medical care have become "dehumanized" and that it is the fault of we "Flexnerian derived," "research-oriented," NIH influenced," "ivy-hailed isolated" academicians—and other such assorted pejoratives. By acknowledging these individuals who have had a considerable effect on my own development, I will be directly paying tribute to our Society for most—with the possible exception of my wife—have been members and prominent ones. In reference to Ruth, I say "possible exception" for she is virtually an honorary member
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Copyright ° 1975 by the American Psychosomatic Society, Inc. Published by American Elsevier Publishing Company, Inc.
since this is the one Society to which I belong whose meetings she will deign to attend with me. And not only because of its propensity to meet in such places as Denver, San Francisco, and New Orleans, where she can ski, browse, or listen to good jazz, respectively, but because she too finds "something special" as well as intellectually stimulating in our Society. And I hope these remarks will be accepted as serious thoughts from one who has viewed the scene for 2V2 decades and not as a consequence of attitudes illustrated by the following New Yorker cartoon (Fig. 1). I became a member of the Society in 1950 while in Cincinnati, where I had gone in 1948 as a research fellow with Gene Ferris in the Department of Medicine. My appointment to this fellowship came about
through a combination of chance incidents , but basically it was the consequence of a career direction that took shape because of an awareness of psychiatry that developed during my residency training in internal medicine. It was further molded by several years in military service in the Aleutian Islands, where I found myself avoiding personal stress by learning to treat stress-induced distress in young, immediately postwar, Army recruits. Significant influences prior to that time had come from Bill Dock who came to the Long Island College of Medicine as Chairman of Medicine during my senior year and for whom I became a straight intern in medicine the following year—the first nonrotating intern at that school in what was then a daring venture predicted to
"As the days dwindle down to a precious few, I say to hell with everybody!" Fig. 1.
Drawing by J. Mirachi; © 1975 The New Yorker Magazine. Inc.
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produce a physician who would be "too specialized" to be an adequate doctor to care for people—and then from Dave Seegal at the Columbia Division of Goldwater Memorial Hospital where I was a resident in medicine. The Goldwater service was in some ways a depressing experience because it was a chronic disease hospital, but two facts of importance to my later remarks stood out. One was that it was a research service, dedicated to clinical research in certain chronic ailments—and from this service came original work in areas such as glomerulonephritis and cirrhosis—but also it was dedicated to exemplary patient care for New York City derelicts with these ailments. I learned rapidly that good patient care and good investigation were completely complementary and not the dichotomy which many present day reformers of medical education would have us believe. Secondly, I had the good fortune to be exposed to Mack Lipkin, a long term member of our Society, who is now teaching at the University of Oregon, but at that time was an internist on the clinical faculty at Columbia and one of our' 'rounding men" at Goldwater. What Mack did was to dazzle me by demonstrating the application of psychiatry at the bedside in the care of patients with severe, debilitating, and discouraging chronic organic disease. Thus I learned that though I could not "cure" chronic glomerulonephritis, at least I could hope for a better future through efforts to learn more about the pathogenesis of the ailment and meanwhile could offer some comfort to patients by understanding the life situation in which their disease had its onset and its emotional impact on their lifestyle.
end of World War II and the beginning of the Korean action—was an immensely exciting one. I was a research and teaching fellow supported by a Commonwealth Fund Grant in Psychosomatic Teaching and Research. The NIH was just beginning to open its purse strings, but research was still on a "shoe string"; my stipend from the Commonwealth Fund Grant (5 years post medical school) was all of $1800 for the year, and I imagine that Gene Ferris' total research budget was not much more than I presently pay one research technician. Yet the amount and calibre of research, and what is so important and so lost sight of currently, the amount of medical student and house staff teaching and patient care accomplished with these same funds was tremendous. Mort Reiser was my senior fellow, and the program was run jointly by Gene Ferris and Milt Rosenbaum from the Departments of Medicine and Psychiatry, respectively, and the subsequent contributions of these three, all former presidents of the Society, to teaching and research in psychosomatic areas are well known to most of you. Lurking in the background in the group—but always evident and influential—was Arthur Mirsky about whom I will have more to say later. Gene Ferris, who had the major impact on me at this time, was a most unique individual. Raised in Mississippi and a graduate of the University of Virginia School of Medicine, where his initial research efforts were in hypertension with Chanutin, the professor of Physiology at that institution, he had his house staff training in the class post-Flexnerian style in the rich research atmosphere of the Harvard Service at the Boston City Hospital. The experience in Cincinnati in the late He was a research fellow with Soma Weiss, 1940's and early 1950's—in that brief in- considered one of the outstanding investerim of spiritual optimism between the tigators and clinical teachers of his day.
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Gene's work at the University of Cincinnati before, during, and after World War II similarly was outstanding for its time, and by the late 1940's this was fully recognized among his peers in clinical investigation by his appointment as editor of the Journal of Clinical Investigation, the "grey" journal, which then and now—in its "greyhaired" years—is regarded as the ultimate place to publish the latest in basic and clinical investigation in medicine. In spite of these accomplishments, and indeed I believe because of them, he became increasingly involved in psychophysiologic investigation and clinical psychosomatic teaching. He achieved in 1950 and 1951 a unique distinction—not duplicated before, since, or probably ever again—of being consecutively (and overlapping) President of our Society and of the equally prestigious American Society of Clinical Investigation, the "Young Turks," that presumed hotbed of "non-humanistic," "self-aggrandizing" teachers of medicine and investigators who of late have been castigated as the people responsible for the fact that every constituent of every state legislator does not have a "doctor in his garage." One of the high points of my fellowship occurred when Gene, with his own brand of Mississippi "chutzbah," presented as his presidential address to the "Young Turks" in 1951 an essay entitled "An Inquiry into the Meaning of Clinical Investigation" (1). Its theme was that man, because of his "intricate workings," resisted control and sought freedom, but that rather than abandon him, therefore, as a subject for scientific investigation—as indeed had been the warning of S.J. Meltzger, the first President of the ASCI who had said "beware of practice; it is a bewitching graveyard in which many a brain has been buried alive with no other compensation
than a gilded tombstone"—Ferris argued that we must develop methods of experimental design to circumvent this tendency of man to behave like man. Among these should be the recognition that the experimenter, being man, is himself a creature with bias and, moreover, through the experimenter-subject relationship, in effect a variant of the doctor-patient relationship, communicates this bias to the subject and influences the experimental results. To illustrate this fact he demonstrated data from a study of a hypotensive drug, which I and others in the laboratory had recently completed under his guidance and which was one of the first "double-blind" placebo-controlled drug studies in the then newly emerging science of clinical pharmacology (2) (Fig. 2). Thus, using techniques drawn from both his clinical experience and his research orientation he demonstrated to his colleagues—in a developing scientific area, the study of mechanisms and management of hypertensive disease—the importance of methodology derived from his interest in behavior of man. To me it is in retrospect a quite amazing fact that this little study, which encompassed all of eight patients, included a combination of the three major themes that for the past 25 years have characterized my own research efforts, namely, hypertension, clinical pharmacology, and psychosomatic aspects of disease. Gene Ferris, from a background of scientific investigation and clinical experience, as were Dock, Lipkin, Seegal, and others, was thus a major influence, and all, though products of the Flexnerian idea of medical training, also were accomplished practitioners of health care delivery. I do not recall what Ferris talked about in his presidential address at this Society the year before—I believe that the remarks in those days were extem-
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ALVIN P. SHAPIRO Q
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Fig. 2. Figure indicates several phenomena: (1) Fall in blood pressure as dose of drug is gradually increased (initial phase); (2) Initial rise in first week of double-blind drug-placebo alteration (which occurred in all four patients in this phase of the study whether "wk. 1" was drug or placebo), followed by evidence of difference between drug and placebo (phase A); (3) An interim period during which a negative attitude about the study developed: (4) Continuation of study during a period of lesser enthusiasm (phase B). Although a drug effect is apparent, a significant blood pressure difference also is present between phase A and B, which relates to changes in the doctor-patient relationship (see Ref. 2).
poraneous or at least not published in the Journal—but it is a source of personal gratification to me that my presidencycomes exactly at the 25th anniversary of his. A fourth theme of my work then developed during five subsequent years I spent at the Southwestern Medical School of the University of Texas, in a then infant Department of Medicine being developed by Don Seldin, now one of the leading spokesmen for, and outstanding teachers of, scientific medicine in the country. Under his influence, I learned about normal and abnormal renal physiology, an indispensible addition to my later research and clinical activities in hypertensive disease, but what many of his colleagues find hard to believe because of their image of 296
him as the epitome of the "hard-data scientist," he stimulated and encouraged me in my psychosomatic interests, both on the wards and in the laboratory. He asked only for the same attempts at precise design and thinking that he demanded in his renal laboratory, recognizing that whether data were "hard," with a small standard deviation, or "soft," with greater variability, was not the definition of science. My efforts were largely without support from the psychiatrists, and were often frustrating with my fellow internists, but must have had some impact because within several years of my leaving Texas largely for personal reasons, I was asked to return to head up a large psychosomatic unit under the co-sponsorship of the departments of medicine and psychiatry.
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By that time, however, I had come thoroughly under the sway of Arthur Mirsky, Jack Myers, and others at the University of Pittsburgh and stayed on then and since. Arthur had already affected my career both directly and indirectly at Cincinnati and during my sojourn in Texas, and the opportunities at Pittsburgh were not to be abandoned to return to Texas. I have written about Arthur in another context recently (3). His death last September inflicted a loss that this Society and what it represents will not replace. To me he was many people, but professionally he represented a unique blend of the art and science of medicine because his ideas were not bounded by unitary hypotheses of disease. His scientific philosophy was well expressed in his own presidential address to this Society in 1957 (4) and subsequently expanded in other publications (5) in which he pointed out that health and sickness are the products of a biopsychosocial system, and result from a chain of events: physiologic, psychologic, and social. He has said, "to appreciate illness, one must attempt to understand the long chain of relevant circumstances which comprise the factors that predispose one and not another to some specific clinical disorder, as well as the particular event which proves noxious, in that it serves to precipitate the disorder at one and not another point in time." Arthur illustrated in his own classical studies with Weiner, Singer, and Reiser (all incidentally past presidents of this Society) in peptic ulcer the relevance of this approach (6). He was ahead of his time in urging this tripartite attack in investigation and, moreover, in education for patient care. Let me try to illustrate the impact of this approach in both areas —investigation and patient care. The outcome of his research in peptic
ulcer was to demonstrate that a patient with high blood pepsinogen, which seems to be a genetic marker for ulcer, when exposed to an appropriate social stress, particularly of his oral needs, then had a much greater chance of developing the clinical disease than did the normal pepsinogen secretor. Moreover, the very presence of a high pepsinogen seemed to express itself in a pattern of excessive oral-demanding behavior, which may not be satiable under normal environmental circumstances. Thus the behavior is both an expression of a biological trait, and the trait itself is precipitated into disease in a situation in which social events frustrate the behavior. Our own work with hypertension, under the influence of Mirsky's emphasis on the "3 P's"—predisposition, precipitation, and perpetuation—has evolved in a similar fashion. Blood pressure is a highly variable physiologic function, and our own work and that of other investigators has demonstrated this phenomenon, both acutely and chronically, when influenced by psychological events and the noxious stimuli arising therefrom. Thus, the hypertensive and indeed the pre-hypertensive have been demonstrated to "hyperreact" to physical as well as psychologic stimuli as contrasted with the normotensive subject (7). The acceptance of the fact that psychologic influences play an important role in hypertension has been hung up on a presumed need to demonstrate that psychologic influences on blood pressure must produce permanent hypertensive disease. As postulated from studies in man such as that in malignant hypertension by Reiser, Rosenbaum, and Ferris in the 1950's (8), now shown in animal studies, as Friedman and Dahl presented yesterday (9), and which we have shown in earlier studies in rats with renal ischemia and
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with chronic pyelonephritis, respectively (10,11], it would appear that a genetic or acquired predisposition is necessary; this predisposition in turn results in cardiovascular hyperreactivity or targeting of the organ for response to noxious stimuli. In other words, predisposition may be genetic or acquired; precipitation and perpetuation, including acceleration, are consequences of a chain of relevant events, either psychologic, sociocultural, or physical, which are sometimes acute but at other times cumulative. In some instances, as suggested by studies of Henry (12) and of Forsyth (13), the stress response to behavioral stimuli alone may be capable of producing permanent hypertension, but I believe that this is unusual in the human disease, just as any of the so-called unitary causes of secondary hypertension, e.g., pheochromo-
cytoma and primary aldosteronism, are rare in contrast to essential hypertension, a multifactoral disease of disordered mechanisms of blood pressure control. Moreover, the physiologic mechanisms that respond to behavioral stimuli are not only those that operate through the autonomic nervous system but in fact any of those involved in blood pressure control, adrenal, renal, and cardiac, may participate (14-16) (Fig. 3). And yet, in spite of these sequences, as first demonstrated almost serendipitously by Reiser and his colleagues (17) and more recently as described in a paper delivered at this Society several years ago by Joe Sapira and myself (18), the hypertensive seems to avoid a psychologic stimulus if he possibly can. Thus, in our studies in which hypertensives were asked to view a pair of movies depicting a "good" and a
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"bad" doctor and later to comment on PER CENT CORRECT CHOICES what they saw, they "failed to perceive" (1418 Trials) the obvious dichotomy in behavior and failed to react physiologically, although when forced to discuss what they saw, a pressor hyperreaction then occurred. In Mirsky's terms, we believe that we are seeing a behavioral manifestation of the hypertensive's "awareness" that he is hyperreactive. In brief,he somehow senses the physiologic threat of his hyperreactive state if a stimulus affects him, and if he can avoid the impact of the stimulus by "failing to perceive" the noxious event, he does so. There are several additional pieces of evidence in this regard, including Lacey's demonstration that cardiovascular pressor responses go along with rejection or nonresponsiveness of a subject to the external environment (19). It is supported by the Fig. 4. Correctness of prediction of direction of blood pressure change {up, down, or no more recent observations of Williams and change) following each of a series of his co-workers (20) that interpersonal inautomatically-recorded indirect blood presteraction is a greater stimulus to blood sures in a group of hypertensive patients. pressure change than the content of an interview, an observation that has a bearing on the fact that a positive doctor-patient AVERAGE AMBP relationship is depressor and a negative FOR EACH CHOICE one can be pressor. Our own recent efforts 25 in visceral conditioning and biofeedback in hypertensive subjects provide some 20 further evidence of this phenomenon of 15 "awareness of blood pressure." Our data have shown that we can duplicate the effect of external feedback on blood pressure 0.5 by suggestion (21), just as others have 0 shown depressor effects to occur with psychotherapy, Transcendental Medita-0.5 tion, Yoga, and the use of placebos. How-1.0 ever, our data also suggest a significantly greater than chance ability of at least some -1.5 hypertensives to recognize changes in -2.0 their blood pressures presumably free of UP DOWN N.C. external stimuli, a suggestion of an apparent internal feedback system (Figs. 4 and Fig. 5. Average change in mean blood pressure (A MBP) for each choice (up, down, no 5). change).
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I do not want to dwell today too long on our own work in the psychophysiology and clinical pharmacology of hypertension. Much of it has appeared in our Journal and /or been heard from this platform. Suffice it to say, that currently it is clear that rather than the traditional "CannonAlexander approach", i.e., the hypertensive person is an individual who is frustrated in expression of his anger and hence channels this anger to his blood vessels via the autonomic nervous system, we are dealing with a considerably more complex series of events, in which at the least a biologically determined hyperreactive state influences some aspects of behavioral and character development. The hyperreactive state in turn provides a susceptible organism in whom the impact of behavioral stimuli can be one of the precipitating factors that produces clinical disease. Awareness of these sequences plays a role in studying the pharmacology and devising the treatment of the ailment as well as in understanding the distortion of physiologic mechanisms that exists in the disease. These are the important contributions of the psychosomatic approach to hypertensive disease and refute the negative comments made in this regard several years ago by Dr. Adrian Ostfeld (22). And what is important to the integration of medical education, teaching, and research is that these insights came not only from the investigative area, but also from the rich experience of clinical observation in patient care situations and through the nondichotomous approach to medical teaching of physicians like Ferris and Mirsky. The second illustration I wish to present brings me to the main and final thesis of my remarks today, namely, that health care at its best is the product of this system of medical education, based on scholarly excellence, which we have operated for the 300
last 25 years and that present failings, to the extent that they are real and not assumed, exist in spite of, rather than because of, this educational system. Much of what is presently being said in the press, in various essays and books, and in both Federal and State legislatures is almost Orwellian in its approach. The history of an era is being rewritten. Forgotten is the comparatively small amount of money put into research by the NIH in contrast to other areas; instead, selfappointed spokesmen for society speak of "huge infusions of funds to research." The amount was never over 1 % of the National Budget, and for most years was not over 0.5%. Moreover, this sum included training programs and more recently contract research in applied areas. Forgotten is the fact that much of this "research money" indeed paid for undergraduate and graduate education—it was the only source of federal support for higher education in the sciences during an era in which the concept of federal support for education was anathema and smacked of federal encroachment on States Rights and an invasion of Jeffersonian principles. Forgotten is the fact that applied research, e.g., in therapeutic applications of newly developed hypotensive compounds, requires a logarithmic jump in costs over basic research in the clinical pharmacology of such drugs and that application of the consequences of such research to the clinical problem, e.g., the delivery of care to the 20 million individuals with hypertension in this country, is still another logarithmic jump at least, observations that indicate that until the public as a whole is willing to accept the responsibility for the cost of what it believes it wants, we cannot be held responsible for not supplying it. Much of the criticism concerns our apparent failure to train primary care physi-
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cians. The approach to health and disease, which is epitomized in psychosomatic teaching and was described by Mirsky when he said that "health and disease are the consequence of a long chain of relevant influences from physiologic, psychologic and social sources," is in effect a description of what is now called primary care. Primary care includes three basic elements—first contact with patients, longitudinal responsibility for the patient through health and disease, and provision of an "integrationist" for the patient. Under another name, this is the psychosomatic approach to illness, or the comprehensive care approach as defined by others among us. It is an approach that many of us, directed by our psychosomatic interests, have taught and preached to students and practitioners, whether in highly developed liaison services, on medical and surgical rounds in individual patients, or in multifactoral research efforts in psychophysiologically determined disease states. Somewhere along the line we either failed to deliver our message, or delivered it so effectively that it became part of everyday teaching by many educators, and my own experience suggests the latter. It is of interest that in all of this criticism of the, inadequacy of the "research oriented" faculty member to develop appropriate primary care attitudes in students, Dowling and Cotsonas in 1964 reported in a survey of students (23) that they (the students) considered that full-time clinical teachers were at least as supportive and dealt more humanely with patients than the part-time faculty, which suggests that at least in some institutions and somewhere in their "immense faculties," a role model, who can reinforce in the student's mind the kind of physician he purportedly wants to be, can be found.
country, which seem to me somewhat distorted or misinterpreted. Alpert and Charney in their 1973 review of primary care discuss data from Millis, White, and others, indicating that the number of physicians available for primary care has dwindled from 94 /100.000 in 1931 to 60 in 1957 and 54 in 1970, and imply that this is a consequence of academically oriented, specialty training in our medical schools (24). Yet they emphasize that controversy exists and data are not available as to whether primary care is best delivered by the new type of specifically trained family practitioner or by internists and pediatricians as well as generalists, and many authorities consider that the primary care need is best met by the latter. In fact, Alpert and Charney define the "family doctor" as all three of these groups in developing the figures just quoted. Recently, in reviewing the present professional activities of graduates of the University of Pittsburgh Medical School we noted the data shown in Fig. 6. These data show clearly that primary care physicians who are graduates of the University of Pittsburgh have been stable between 40% and 50% for the last 40 years, and if anything are greater in percentage in the last 20, and that the introduction of a full-time faculty, which came late to Pittsburgh, namely in 1955, did nothing to change this percentage. Nor is this unique to Pittsburgh since the national percentage from the same survey is approximately 50 % as of 1969. Coupled with the fact that the number of M.D. graduates in the U.S. has increased almost 100% (7000 to 13,000) in the last 25 years and that this also reflects a 20% increase in physicians per 100,000 population (150 to 190) (25), the data that Alpert and Charney quote become difficult to understand. Another criticism derives from data Furthermore, many writers, both lay concerning the types of physicians in this and professional, speak of the lack of rePsychosomatic Medicine Vol. 37, No. 4 (July-August 1975)
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ALVIN P. SHAPIRO PITTSBURGH GRADUATES IN PRIMARY CARE (GENERAL PRACTICE, INTERNAL MEDICINE, PEDIATRICS)
1970 1964 - 1 9 6 9 I960 -1964 1954 -1959 CLASS OF:
1950 -1954 1945 -1949 1940 -1944 1935 -1939 1928 -1934
10 20
30 40
50 60 70 80 90 100
Fig. 6. Percentage (abcissa) of graduates in primary care practice (see text).
sponsiveness of the schools to society. Pellegrino, for instance, in speaking quite appropriately of the need for greater efforts in research in medical education, nevertheless comments that "there is a serious discontinuity between the interests and goals of medical faculties and the interests and goals of the society that supports the schools" (26). Although Ed Pellegrino may be another of the people who affected my career since we were medical residents together, I find his and similar statements most difficult to accept. It seems to me that the interests and goals of society are twofold. People want medical care from the best educated physician they can get, defined as best in terms of his compassion and scientific knowledge, and secondly, they want the delivery of this care packaged neatly and efficiently at a price they can afford, while still having funds left for what they may consider usually more important in their lives. I would submit that as medical 302
educators, clinical investigators, and fulltime clinicians, we have done a superb job in the former and little in the latter because we have not perceived it as our major responsibility. It is analogous to my problem with the airlines. I want the best equipment "under the hood" and the best pilots in the front seat, but I also want convenience in scheduling, no waits at the checkin line, good food, pretty stewardesses, first-class accommodations, and clean passenger interiors. I get both when I can afford it from TWA and United at an extra fee, but only the former from Allegheny, which as a Pittsburgher I am forced too frequently to fly; hence I am continually frustrated and furious although I save money and get there safely on "old Agony." I am not sure how to solve these problems in either sphere—medical schools or airlines—although I can assure you that in my present capacity in the "Deaning business" I am forced frequently to think of
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both. Suffice it to say that before the "1984 approach" convinces us that we were all wrong, we remember that our job this last 25 years has been in the first area, that of supplying scholarly, highly trained, and compassionate physicians and in this we have done our job well. That our graduates tend to have particular expertise in certain areas, and are specialists rather than general practitioners, is a consequence of the growth of scientific knowledge and not a denial of the need for a better "packaging and delivery" system. It was our job to train the best equipped physicians; in this task I believe we have succeeded, and scientist-clinicians in the psychosomatic area represented by members of our Society were in the forefront in this regard. During the 1950's in Cincinnati, for instance, we developed psychosomatic training and comprehensive care activities in our outpatient clinics and although we solved few problems of health care delivery in the Inner City, we did supply education to students and a few bits of new knowledge about psychosomatic problems. Similar programs developed in many medical schools—Rochester, North Carolina, Yale, Cornell, and Duke—to name only a few. However, development in packaging and delivery of health care was not our task, and if society now decrees that it is, it will have to supply the "wherewithall" with large addon funds and not by withdrawal of support in other areas of education, which as I have suggested earlier is insufficient in any case to pay for this second set of patient needs. To do otherwise would be counterproductive and antiintellectual at its worst. To use my airlines analogy again, it would be equivalent to providing steak and champagne in Allegheny's cabin at the cost of firing the co-pilot or using a chief pilot trained to fly
Piper cubs and gliders, which are convenient in rural areas, rather than 727's. I prefer to continue to drink lukewarm coffee and sit in triple seats. Let me point out another example of what we have and have not accomplished in this double set of problems. Several years ago I spent a sabbatical leave as Visiting Professor in Clinical Pharmacology at the University of Utrecht in the Netherlands . I was impressed, as are most visitors to Holland, by the excellent development of the health care delivery system. For instance, at a time when renal dialysis programs were struggling withfinancesin our country and the choice of patients for these programs was beset with all sorts of pseudo-ethical and moral questions, never necessary when a decision regarding the administration of digitalis to a terminal cardiac patient is considered, the Dutch were treating everyone who needed it. But the medical schools supplied only the expertise. The health care delivery system for the purpose was developed by nonUniversity agencies of society —admittedly considerably simpler than in our country, in a homogenous community of only 12 million people in a geographic area the size of Rhode Island with 100 years of experience in developing a delivery system, but it was not considered a job of the University. By contrast, our University system of medical education and research was the envy of the Dutch—and as is the case in many foreign countries —they were trying valiantly to emulate it. I was invited to Utrecht in fact by David de Wied, the Professor and Chairman of Pharmacology, my good friend and fellow disciple of Arthur Mirsky, in order to demonstrate that one man could be both a clinician and an investigator and deliver education within the University in both spheres. For me it was a successful and
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revealing experience. I learned what an enlightened community could do about health care delivery once they had decided that such a thing as dialysis was only an expensive form of digitalis for which they were willing to pay rather than for a huge defense budget. At the same time I was able to demonstrate an educational approach based on clinical service and research, which resulted in the establishment of a chair in clinical pharmacology at the University. Both then can be done, if society is willing to pay and the tasks are allocated to the appropriate agencies of society. Finally, we do of course need new and imaginative approaches to health care delivery, but they are not ones that we in the medical schools can or should develop unilaterally, cheaply, and with "our third hand." Graduate training programs need
special investigative attention as do the development of programs in rural and urban areas, using a few physicians with teams of skilled nurse practitioners and physicians' assistants. We need cooperation between federal, state, and local levels of government, and we need high motivation and leadership of progressive and realistic lay citizens of our society to achieve these goals with ourselves as imaginative, scholarly, and investigative contributors. But we must at the same time support our contention that our primary mission in medical schools is to educate scholars in medicine. This is what we do best, what we alone can do, and the role we must defend against those who would rewrite history. I thank you all for your patience and let us get on with the scientific program.
REFERENCES 1. Ferris EB, Jr: An inquiry into the meaning of clinical investigation. J Clin Invest 30:623, 1951 2. Shapiro AP, Myers T, Reiser MF, Ferris EB: Comparison of the blood pressure response to veriloid with that to the doctor-patient relationship. Psychosom Med 15:478, 1954 3. Shapiro AP: In Memoriam—I. Arthur Mirsky, M.D. Psychosom Med 37:1, 1975 4. Mirsky IA: The psychosomatic approach to the etiology of clinical disorders. Psychosom Med 19:424, 1957 5. Mirsky IA: Certainties and uncertainties in diabetes mellitus, in Diabetes Mellitus: Theory and Practice (edited by Ellenberg and H Rifkin). New York, McGraw-Hill, p. 990, 1970 6. Weiner H, Thaler M, Reiser MF, Mirsky IA: Etiology of duodenal ulcer: I. Relation of specific psychological characteristics to rate of gastric secretion (serum pepsinogen). Psychosom Med 19:1, 1957 7. Shapiro AP: An experimental study of comparative responses of blood pressure to different noxious stimuli. J Chron Dis 13:292, 1961 8. Reiser MF, Rosenbaum MF, Ferris EB: Psychophysiologic mechanisms in malignant hypertension. Psychosom Med 13:147, 1951 9. Friedman B, Dahl LK: Environmental stress and hypertension. Psychosom Med 37:78 (abstract), 1975 10. Shapiro AP, Melhado J: Factors affecting the development of hypertensive vascular disease in rats after renal injury. Proc Soc Exp Biol Med 96:619, 1957 11. Lipman RL, Shapiro AP: Effects of a behavioral stimulus on blood pressure of rats with experimental pyelonephritis. Psychosom Med 29:6, 1957 12. Henry JP, Meehan J, Stephens P: The use of psychosonal stimuli to induce prolonged systolic hypertension in mice. Psychosom Med 29:408, 1967 13. Forsyth R: Blood pressure response to long term avoidance schedules in the restrained Rhesus monkey. Psychosom Med 31:300, 1969 14. Shapiro AP: Essential hypertension—Why idiopathic? Am J Med 54:1, 1973 304
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PRESIDENTIAL ADDRESS 15. Vagnucci A, Shapiro AP: Perspectives of the renin-angiotensin-aldosterone system in hypertension. Metabolism 23:273, 1974 16. Leenen FH, Shapiro AP: Effect of intermittent electric shock on plasma renin activity in rats. Proc SocExp Biol Med 146:534, 1974 17. Weiner H, Singer MT, Reiser MF: Cardiovascular responses and their psychophysiologic correlates. Psychosom Med 24:477, 1962 18. Sapira JD, Scheib ET, Moriarty R, Shapiro AP: Differences in perception between hypertensive and normotensive populations. Psychosom Med 33:239, 1971 19. Lacey J: Methodological approaches to the role of the CNS in cardiovascular disease. Proceedings of Timberline Conference. Psychosom Med 26:445, 1964 20. Williams RB, Kimball CP, Williard HN: The influence of personal interaction on diastolic blood pressure. Psychosom Med 34:194, 1972 21. Redmond D, Gaylor M, McDonald RH, Shapiro AP: Blood pressure and heart rate response to verbal instruction and relaxation in hypertension. Psychosom Med 36:285, 1974 22. Ostfeld A: What's the payoff in hypertension research? Psychosom Med 35:1, 1973 23. Dowling HF, Cotsonas NJ: Attitudes towards patients of full-time and practicing instructors as revealed in student questionnaires. N Engl J Med 271:716, 1964 24. Alpert JJ, Charney E: The Education of Physicians for Primary Care. Washington e.c, u.s. dept. of Health, Education and Welfare, Bureau of Health Services Research. DHEW Pub. No. (HRA) 74-3113, p. 5 25. Chartbook of Federal Health Spending, 1969-74. Washington, D.C., Center for Health Policy Studies, National Planning Ass'n, 1974, p. 22 26. Pellegrino ED: Research in medical education: The views of a friendly Philistine. J Med Ed 46:750,1971
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It has been said many times from this platform and on this occasion that the major function of the president of our Society is to give the Annual Lecture at this spot on the program. Certainly the job is not otherwise onerous or time-consuming thanks to the dedication of the other officers and members of "our club" and most of all due to the efficiency, experience, and direction of those two paragons, Joan and Mildred. In fact, on assuming the office one has somewhat the same feelings many of us clearly recall from our first day of internship when the experienced and wise head nurse somehow managed to make us feel we were in charge of things while still telling us what to do and how to doit. Somehow this ability to pass on to successive inheritors of the post the accumulated knowledge of the past and still to advance on new fronts, although not unique to this particular Society, has certain special properties of warmth and tradition with us. My adopted city of Pittsburgh last year acquired a new PR slogan—namely, "Pittsburgh is Some Place Special"—in order to help the city develop a new image of quality to replace the mass inferiority complex under which, along with its smoke-filled sky, it had so long labored. American Psychosomatic Society, Annual Meeting, March 22, 1975, New Orleans. From the University of Pittsburgh School of Medicine. Dr. Shapiro is Professor of Medicine and Associate Dean for Acadamic Affairs at the University of Pittsburgh School of Medicine. Received for publication April 7, 1975.
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The phrase is particularly adaptable to our Society, which has a closeness and congeniality, along with a proud record of accomplishment, which make it "something special." Presidential addresses tend to be either historic and nostalgic or a State of the Art message about a particular area of science. In keeping with my own "something special" and sentimental feelings about our Society, I would like to strike a note somewhere between these two alternatives by telling you something about my thoughts concerning the present status of psychosomatic investigation in my own area of interest, namely, hypertensive disease, as I have seen it develop, but at the same time paying tribute to several people who individually and collectively directed me in this area. Along the way, however, I also will attempt to use these observations to defend "us academicians," and the forces that made us what we are, from the popular current day accusation that medicine and medical care have become "dehumanized" and that it is the fault of we "Flexnerian derived," "research-oriented," NIH influenced," "ivy-hailed isolated" academicians—and other such assorted pejoratives. By acknowledging these individuals who have had a considerable effect on my own development, I will be directly paying tribute to our Society for most—with the possible exception of my wife—have been members and prominent ones. In reference to Ruth, I say "possible exception" for she is virtually an honorary member
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Copyright ° 1975 by the American Psychosomatic Society, Inc. Published by American Elsevier Publishing Company, Inc.
since this is the one Society to which I belong whose meetings she will deign to attend with me. And not only because of its propensity to meet in such places as Denver, San Francisco, and New Orleans, where she can ski, browse, or listen to good jazz, respectively, but because she too finds "something special" as well as intellectually stimulating in our Society. And I hope these remarks will be accepted as serious thoughts from one who has viewed the scene for 2V2 decades and not as a consequence of attitudes illustrated by the following New Yorker cartoon (Fig. 1). I became a member of the Society in 1950 while in Cincinnati, where I had gone in 1948 as a research fellow with Gene Ferris in the Department of Medicine. My appointment to this fellowship came about
through a combination of chance incidents , but basically it was the consequence of a career direction that took shape because of an awareness of psychiatry that developed during my residency training in internal medicine. It was further molded by several years in military service in the Aleutian Islands, where I found myself avoiding personal stress by learning to treat stress-induced distress in young, immediately postwar, Army recruits. Significant influences prior to that time had come from Bill Dock who came to the Long Island College of Medicine as Chairman of Medicine during my senior year and for whom I became a straight intern in medicine the following year—the first nonrotating intern at that school in what was then a daring venture predicted to
"As the days dwindle down to a precious few, I say to hell with everybody!" Fig. 1.
Drawing by J. Mirachi; © 1975 The New Yorker Magazine. Inc.
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produce a physician who would be "too specialized" to be an adequate doctor to care for people—and then from Dave Seegal at the Columbia Division of Goldwater Memorial Hospital where I was a resident in medicine. The Goldwater service was in some ways a depressing experience because it was a chronic disease hospital, but two facts of importance to my later remarks stood out. One was that it was a research service, dedicated to clinical research in certain chronic ailments—and from this service came original work in areas such as glomerulonephritis and cirrhosis—but also it was dedicated to exemplary patient care for New York City derelicts with these ailments. I learned rapidly that good patient care and good investigation were completely complementary and not the dichotomy which many present day reformers of medical education would have us believe. Secondly, I had the good fortune to be exposed to Mack Lipkin, a long term member of our Society, who is now teaching at the University of Oregon, but at that time was an internist on the clinical faculty at Columbia and one of our' 'rounding men" at Goldwater. What Mack did was to dazzle me by demonstrating the application of psychiatry at the bedside in the care of patients with severe, debilitating, and discouraging chronic organic disease. Thus I learned that though I could not "cure" chronic glomerulonephritis, at least I could hope for a better future through efforts to learn more about the pathogenesis of the ailment and meanwhile could offer some comfort to patients by understanding the life situation in which their disease had its onset and its emotional impact on their lifestyle.
end of World War II and the beginning of the Korean action—was an immensely exciting one. I was a research and teaching fellow supported by a Commonwealth Fund Grant in Psychosomatic Teaching and Research. The NIH was just beginning to open its purse strings, but research was still on a "shoe string"; my stipend from the Commonwealth Fund Grant (5 years post medical school) was all of $1800 for the year, and I imagine that Gene Ferris' total research budget was not much more than I presently pay one research technician. Yet the amount and calibre of research, and what is so important and so lost sight of currently, the amount of medical student and house staff teaching and patient care accomplished with these same funds was tremendous. Mort Reiser was my senior fellow, and the program was run jointly by Gene Ferris and Milt Rosenbaum from the Departments of Medicine and Psychiatry, respectively, and the subsequent contributions of these three, all former presidents of the Society, to teaching and research in psychosomatic areas are well known to most of you. Lurking in the background in the group—but always evident and influential—was Arthur Mirsky about whom I will have more to say later. Gene Ferris, who had the major impact on me at this time, was a most unique individual. Raised in Mississippi and a graduate of the University of Virginia School of Medicine, where his initial research efforts were in hypertension with Chanutin, the professor of Physiology at that institution, he had his house staff training in the class post-Flexnerian style in the rich research atmosphere of the Harvard Service at the Boston City Hospital. The experience in Cincinnati in the late He was a research fellow with Soma Weiss, 1940's and early 1950's—in that brief in- considered one of the outstanding investerim of spiritual optimism between the tigators and clinical teachers of his day.
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Gene's work at the University of Cincinnati before, during, and after World War II similarly was outstanding for its time, and by the late 1940's this was fully recognized among his peers in clinical investigation by his appointment as editor of the Journal of Clinical Investigation, the "grey" journal, which then and now—in its "greyhaired" years—is regarded as the ultimate place to publish the latest in basic and clinical investigation in medicine. In spite of these accomplishments, and indeed I believe because of them, he became increasingly involved in psychophysiologic investigation and clinical psychosomatic teaching. He achieved in 1950 and 1951 a unique distinction—not duplicated before, since, or probably ever again—of being consecutively (and overlapping) President of our Society and of the equally prestigious American Society of Clinical Investigation, the "Young Turks," that presumed hotbed of "non-humanistic," "self-aggrandizing" teachers of medicine and investigators who of late have been castigated as the people responsible for the fact that every constituent of every state legislator does not have a "doctor in his garage." One of the high points of my fellowship occurred when Gene, with his own brand of Mississippi "chutzbah," presented as his presidential address to the "Young Turks" in 1951 an essay entitled "An Inquiry into the Meaning of Clinical Investigation" (1). Its theme was that man, because of his "intricate workings," resisted control and sought freedom, but that rather than abandon him, therefore, as a subject for scientific investigation—as indeed had been the warning of S.J. Meltzger, the first President of the ASCI who had said "beware of practice; it is a bewitching graveyard in which many a brain has been buried alive with no other compensation
than a gilded tombstone"—Ferris argued that we must develop methods of experimental design to circumvent this tendency of man to behave like man. Among these should be the recognition that the experimenter, being man, is himself a creature with bias and, moreover, through the experimenter-subject relationship, in effect a variant of the doctor-patient relationship, communicates this bias to the subject and influences the experimental results. To illustrate this fact he demonstrated data from a study of a hypotensive drug, which I and others in the laboratory had recently completed under his guidance and which was one of the first "double-blind" placebo-controlled drug studies in the then newly emerging science of clinical pharmacology (2) (Fig. 2). Thus, using techniques drawn from both his clinical experience and his research orientation he demonstrated to his colleagues—in a developing scientific area, the study of mechanisms and management of hypertensive disease—the importance of methodology derived from his interest in behavior of man. To me it is in retrospect a quite amazing fact that this little study, which encompassed all of eight patients, included a combination of the three major themes that for the past 25 years have characterized my own research efforts, namely, hypertension, clinical pharmacology, and psychosomatic aspects of disease. Gene Ferris, from a background of scientific investigation and clinical experience, as were Dock, Lipkin, Seegal, and others, was thus a major influence, and all, though products of the Flexnerian idea of medical training, also were accomplished practitioners of health care delivery. I do not recall what Ferris talked about in his presidential address at this Society the year before—I believe that the remarks in those days were extem-
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ALVIN P. SHAPIRO Q
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• 1»
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Fig. 2. Figure indicates several phenomena: (1) Fall in blood pressure as dose of drug is gradually increased (initial phase); (2) Initial rise in first week of double-blind drug-placebo alteration (which occurred in all four patients in this phase of the study whether "wk. 1" was drug or placebo), followed by evidence of difference between drug and placebo (phase A); (3) An interim period during which a negative attitude about the study developed: (4) Continuation of study during a period of lesser enthusiasm (phase B). Although a drug effect is apparent, a significant blood pressure difference also is present between phase A and B, which relates to changes in the doctor-patient relationship (see Ref. 2).
poraneous or at least not published in the Journal—but it is a source of personal gratification to me that my presidencycomes exactly at the 25th anniversary of his. A fourth theme of my work then developed during five subsequent years I spent at the Southwestern Medical School of the University of Texas, in a then infant Department of Medicine being developed by Don Seldin, now one of the leading spokesmen for, and outstanding teachers of, scientific medicine in the country. Under his influence, I learned about normal and abnormal renal physiology, an indispensible addition to my later research and clinical activities in hypertensive disease, but what many of his colleagues find hard to believe because of their image of 296
him as the epitome of the "hard-data scientist," he stimulated and encouraged me in my psychosomatic interests, both on the wards and in the laboratory. He asked only for the same attempts at precise design and thinking that he demanded in his renal laboratory, recognizing that whether data were "hard," with a small standard deviation, or "soft," with greater variability, was not the definition of science. My efforts were largely without support from the psychiatrists, and were often frustrating with my fellow internists, but must have had some impact because within several years of my leaving Texas largely for personal reasons, I was asked to return to head up a large psychosomatic unit under the co-sponsorship of the departments of medicine and psychiatry.
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By that time, however, I had come thoroughly under the sway of Arthur Mirsky, Jack Myers, and others at the University of Pittsburgh and stayed on then and since. Arthur had already affected my career both directly and indirectly at Cincinnati and during my sojourn in Texas, and the opportunities at Pittsburgh were not to be abandoned to return to Texas. I have written about Arthur in another context recently (3). His death last September inflicted a loss that this Society and what it represents will not replace. To me he was many people, but professionally he represented a unique blend of the art and science of medicine because his ideas were not bounded by unitary hypotheses of disease. His scientific philosophy was well expressed in his own presidential address to this Society in 1957 (4) and subsequently expanded in other publications (5) in which he pointed out that health and sickness are the products of a biopsychosocial system, and result from a chain of events: physiologic, psychologic, and social. He has said, "to appreciate illness, one must attempt to understand the long chain of relevant circumstances which comprise the factors that predispose one and not another to some specific clinical disorder, as well as the particular event which proves noxious, in that it serves to precipitate the disorder at one and not another point in time." Arthur illustrated in his own classical studies with Weiner, Singer, and Reiser (all incidentally past presidents of this Society) in peptic ulcer the relevance of this approach (6). He was ahead of his time in urging this tripartite attack in investigation and, moreover, in education for patient care. Let me try to illustrate the impact of this approach in both areas —investigation and patient care. The outcome of his research in peptic
ulcer was to demonstrate that a patient with high blood pepsinogen, which seems to be a genetic marker for ulcer, when exposed to an appropriate social stress, particularly of his oral needs, then had a much greater chance of developing the clinical disease than did the normal pepsinogen secretor. Moreover, the very presence of a high pepsinogen seemed to express itself in a pattern of excessive oral-demanding behavior, which may not be satiable under normal environmental circumstances. Thus the behavior is both an expression of a biological trait, and the trait itself is precipitated into disease in a situation in which social events frustrate the behavior. Our own work with hypertension, under the influence of Mirsky's emphasis on the "3 P's"—predisposition, precipitation, and perpetuation—has evolved in a similar fashion. Blood pressure is a highly variable physiologic function, and our own work and that of other investigators has demonstrated this phenomenon, both acutely and chronically, when influenced by psychological events and the noxious stimuli arising therefrom. Thus, the hypertensive and indeed the pre-hypertensive have been demonstrated to "hyperreact" to physical as well as psychologic stimuli as contrasted with the normotensive subject (7). The acceptance of the fact that psychologic influences play an important role in hypertension has been hung up on a presumed need to demonstrate that psychologic influences on blood pressure must produce permanent hypertensive disease. As postulated from studies in man such as that in malignant hypertension by Reiser, Rosenbaum, and Ferris in the 1950's (8), now shown in animal studies, as Friedman and Dahl presented yesterday (9), and which we have shown in earlier studies in rats with renal ischemia and
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with chronic pyelonephritis, respectively (10,11], it would appear that a genetic or acquired predisposition is necessary; this predisposition in turn results in cardiovascular hyperreactivity or targeting of the organ for response to noxious stimuli. In other words, predisposition may be genetic or acquired; precipitation and perpetuation, including acceleration, are consequences of a chain of relevant events, either psychologic, sociocultural, or physical, which are sometimes acute but at other times cumulative. In some instances, as suggested by studies of Henry (12) and of Forsyth (13), the stress response to behavioral stimuli alone may be capable of producing permanent hypertension, but I believe that this is unusual in the human disease, just as any of the so-called unitary causes of secondary hypertension, e.g., pheochromo-
cytoma and primary aldosteronism, are rare in contrast to essential hypertension, a multifactoral disease of disordered mechanisms of blood pressure control. Moreover, the physiologic mechanisms that respond to behavioral stimuli are not only those that operate through the autonomic nervous system but in fact any of those involved in blood pressure control, adrenal, renal, and cardiac, may participate (14-16) (Fig. 3). And yet, in spite of these sequences, as first demonstrated almost serendipitously by Reiser and his colleagues (17) and more recently as described in a paper delivered at this Society several years ago by Joe Sapira and myself (18), the hypertensive seems to avoid a psychologic stimulus if he possibly can. Thus, in our studies in which hypertensives were asked to view a pair of movies depicting a "good" and a
PR A (mjjo. Ai/ml/3hr) 50
0.25
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shock-group (n-7-8)
1
2
B9 control-group (n=5-6)
8 •
24 hr
normal rots with ad lib. water and food(n=t)
Fig. 3. Effect of shock stress i n rats on peripheral renin activity. (See Ref. 16).
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"bad" doctor and later to comment on PER CENT CORRECT CHOICES what they saw, they "failed to perceive" (1418 Trials) the obvious dichotomy in behavior and failed to react physiologically, although when forced to discuss what they saw, a pressor hyperreaction then occurred. In Mirsky's terms, we believe that we are seeing a behavioral manifestation of the hypertensive's "awareness" that he is hyperreactive. In brief,he somehow senses the physiologic threat of his hyperreactive state if a stimulus affects him, and if he can avoid the impact of the stimulus by "failing to perceive" the noxious event, he does so. There are several additional pieces of evidence in this regard, including Lacey's demonstration that cardiovascular pressor responses go along with rejection or nonresponsiveness of a subject to the external environment (19). It is supported by the Fig. 4. Correctness of prediction of direction of blood pressure change {up, down, or no more recent observations of Williams and change) following each of a series of his co-workers (20) that interpersonal inautomatically-recorded indirect blood presteraction is a greater stimulus to blood sures in a group of hypertensive patients. pressure change than the content of an interview, an observation that has a bearing on the fact that a positive doctor-patient AVERAGE AMBP relationship is depressor and a negative FOR EACH CHOICE one can be pressor. Our own recent efforts 25 in visceral conditioning and biofeedback in hypertensive subjects provide some 20 further evidence of this phenomenon of 15 "awareness of blood pressure." Our data have shown that we can duplicate the effect of external feedback on blood pressure 0.5 by suggestion (21), just as others have 0 shown depressor effects to occur with psychotherapy, Transcendental Medita-0.5 tion, Yoga, and the use of placebos. How-1.0 ever, our data also suggest a significantly greater than chance ability of at least some -1.5 hypertensives to recognize changes in -2.0 their blood pressures presumably free of UP DOWN N.C. external stimuli, a suggestion of an apparent internal feedback system (Figs. 4 and Fig. 5. Average change in mean blood pressure (A MBP) for each choice (up, down, no 5). change).
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I do not want to dwell today too long on our own work in the psychophysiology and clinical pharmacology of hypertension. Much of it has appeared in our Journal and /or been heard from this platform. Suffice it to say, that currently it is clear that rather than the traditional "CannonAlexander approach", i.e., the hypertensive person is an individual who is frustrated in expression of his anger and hence channels this anger to his blood vessels via the autonomic nervous system, we are dealing with a considerably more complex series of events, in which at the least a biologically determined hyperreactive state influences some aspects of behavioral and character development. The hyperreactive state in turn provides a susceptible organism in whom the impact of behavioral stimuli can be one of the precipitating factors that produces clinical disease. Awareness of these sequences plays a role in studying the pharmacology and devising the treatment of the ailment as well as in understanding the distortion of physiologic mechanisms that exists in the disease. These are the important contributions of the psychosomatic approach to hypertensive disease and refute the negative comments made in this regard several years ago by Dr. Adrian Ostfeld (22). And what is important to the integration of medical education, teaching, and research is that these insights came not only from the investigative area, but also from the rich experience of clinical observation in patient care situations and through the nondichotomous approach to medical teaching of physicians like Ferris and Mirsky. The second illustration I wish to present brings me to the main and final thesis of my remarks today, namely, that health care at its best is the product of this system of medical education, based on scholarly excellence, which we have operated for the 300
last 25 years and that present failings, to the extent that they are real and not assumed, exist in spite of, rather than because of, this educational system. Much of what is presently being said in the press, in various essays and books, and in both Federal and State legislatures is almost Orwellian in its approach. The history of an era is being rewritten. Forgotten is the comparatively small amount of money put into research by the NIH in contrast to other areas; instead, selfappointed spokesmen for society speak of "huge infusions of funds to research." The amount was never over 1 % of the National Budget, and for most years was not over 0.5%. Moreover, this sum included training programs and more recently contract research in applied areas. Forgotten is the fact that much of this "research money" indeed paid for undergraduate and graduate education—it was the only source of federal support for higher education in the sciences during an era in which the concept of federal support for education was anathema and smacked of federal encroachment on States Rights and an invasion of Jeffersonian principles. Forgotten is the fact that applied research, e.g., in therapeutic applications of newly developed hypotensive compounds, requires a logarithmic jump in costs over basic research in the clinical pharmacology of such drugs and that application of the consequences of such research to the clinical problem, e.g., the delivery of care to the 20 million individuals with hypertension in this country, is still another logarithmic jump at least, observations that indicate that until the public as a whole is willing to accept the responsibility for the cost of what it believes it wants, we cannot be held responsible for not supplying it. Much of the criticism concerns our apparent failure to train primary care physi-
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cians. The approach to health and disease, which is epitomized in psychosomatic teaching and was described by Mirsky when he said that "health and disease are the consequence of a long chain of relevant influences from physiologic, psychologic and social sources," is in effect a description of what is now called primary care. Primary care includes three basic elements—first contact with patients, longitudinal responsibility for the patient through health and disease, and provision of an "integrationist" for the patient. Under another name, this is the psychosomatic approach to illness, or the comprehensive care approach as defined by others among us. It is an approach that many of us, directed by our psychosomatic interests, have taught and preached to students and practitioners, whether in highly developed liaison services, on medical and surgical rounds in individual patients, or in multifactoral research efforts in psychophysiologically determined disease states. Somewhere along the line we either failed to deliver our message, or delivered it so effectively that it became part of everyday teaching by many educators, and my own experience suggests the latter. It is of interest that in all of this criticism of the, inadequacy of the "research oriented" faculty member to develop appropriate primary care attitudes in students, Dowling and Cotsonas in 1964 reported in a survey of students (23) that they (the students) considered that full-time clinical teachers were at least as supportive and dealt more humanely with patients than the part-time faculty, which suggests that at least in some institutions and somewhere in their "immense faculties," a role model, who can reinforce in the student's mind the kind of physician he purportedly wants to be, can be found.
country, which seem to me somewhat distorted or misinterpreted. Alpert and Charney in their 1973 review of primary care discuss data from Millis, White, and others, indicating that the number of physicians available for primary care has dwindled from 94 /100.000 in 1931 to 60 in 1957 and 54 in 1970, and imply that this is a consequence of academically oriented, specialty training in our medical schools (24). Yet they emphasize that controversy exists and data are not available as to whether primary care is best delivered by the new type of specifically trained family practitioner or by internists and pediatricians as well as generalists, and many authorities consider that the primary care need is best met by the latter. In fact, Alpert and Charney define the "family doctor" as all three of these groups in developing the figures just quoted. Recently, in reviewing the present professional activities of graduates of the University of Pittsburgh Medical School we noted the data shown in Fig. 6. These data show clearly that primary care physicians who are graduates of the University of Pittsburgh have been stable between 40% and 50% for the last 40 years, and if anything are greater in percentage in the last 20, and that the introduction of a full-time faculty, which came late to Pittsburgh, namely in 1955, did nothing to change this percentage. Nor is this unique to Pittsburgh since the national percentage from the same survey is approximately 50 % as of 1969. Coupled with the fact that the number of M.D. graduates in the U.S. has increased almost 100% (7000 to 13,000) in the last 25 years and that this also reflects a 20% increase in physicians per 100,000 population (150 to 190) (25), the data that Alpert and Charney quote become difficult to understand. Another criticism derives from data Furthermore, many writers, both lay concerning the types of physicians in this and professional, speak of the lack of rePsychosomatic Medicine Vol. 37, No. 4 (July-August 1975)
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ALVIN P. SHAPIRO PITTSBURGH GRADUATES IN PRIMARY CARE (GENERAL PRACTICE, INTERNAL MEDICINE, PEDIATRICS)
1970 1964 - 1 9 6 9 I960 -1964 1954 -1959 CLASS OF:
1950 -1954 1945 -1949 1940 -1944 1935 -1939 1928 -1934
10 20
30 40
50 60 70 80 90 100
Fig. 6. Percentage (abcissa) of graduates in primary care practice (see text).
sponsiveness of the schools to society. Pellegrino, for instance, in speaking quite appropriately of the need for greater efforts in research in medical education, nevertheless comments that "there is a serious discontinuity between the interests and goals of medical faculties and the interests and goals of the society that supports the schools" (26). Although Ed Pellegrino may be another of the people who affected my career since we were medical residents together, I find his and similar statements most difficult to accept. It seems to me that the interests and goals of society are twofold. People want medical care from the best educated physician they can get, defined as best in terms of his compassion and scientific knowledge, and secondly, they want the delivery of this care packaged neatly and efficiently at a price they can afford, while still having funds left for what they may consider usually more important in their lives. I would submit that as medical 302
educators, clinical investigators, and fulltime clinicians, we have done a superb job in the former and little in the latter because we have not perceived it as our major responsibility. It is analogous to my problem with the airlines. I want the best equipment "under the hood" and the best pilots in the front seat, but I also want convenience in scheduling, no waits at the checkin line, good food, pretty stewardesses, first-class accommodations, and clean passenger interiors. I get both when I can afford it from TWA and United at an extra fee, but only the former from Allegheny, which as a Pittsburgher I am forced too frequently to fly; hence I am continually frustrated and furious although I save money and get there safely on "old Agony." I am not sure how to solve these problems in either sphere—medical schools or airlines—although I can assure you that in my present capacity in the "Deaning business" I am forced frequently to think of
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both. Suffice it to say that before the "1984 approach" convinces us that we were all wrong, we remember that our job this last 25 years has been in the first area, that of supplying scholarly, highly trained, and compassionate physicians and in this we have done our job well. That our graduates tend to have particular expertise in certain areas, and are specialists rather than general practitioners, is a consequence of the growth of scientific knowledge and not a denial of the need for a better "packaging and delivery" system. It was our job to train the best equipped physicians; in this task I believe we have succeeded, and scientist-clinicians in the psychosomatic area represented by members of our Society were in the forefront in this regard. During the 1950's in Cincinnati, for instance, we developed psychosomatic training and comprehensive care activities in our outpatient clinics and although we solved few problems of health care delivery in the Inner City, we did supply education to students and a few bits of new knowledge about psychosomatic problems. Similar programs developed in many medical schools—Rochester, North Carolina, Yale, Cornell, and Duke—to name only a few. However, development in packaging and delivery of health care was not our task, and if society now decrees that it is, it will have to supply the "wherewithall" with large addon funds and not by withdrawal of support in other areas of education, which as I have suggested earlier is insufficient in any case to pay for this second set of patient needs. To do otherwise would be counterproductive and antiintellectual at its worst. To use my airlines analogy again, it would be equivalent to providing steak and champagne in Allegheny's cabin at the cost of firing the co-pilot or using a chief pilot trained to fly
Piper cubs and gliders, which are convenient in rural areas, rather than 727's. I prefer to continue to drink lukewarm coffee and sit in triple seats. Let me point out another example of what we have and have not accomplished in this double set of problems. Several years ago I spent a sabbatical leave as Visiting Professor in Clinical Pharmacology at the University of Utrecht in the Netherlands . I was impressed, as are most visitors to Holland, by the excellent development of the health care delivery system. For instance, at a time when renal dialysis programs were struggling withfinancesin our country and the choice of patients for these programs was beset with all sorts of pseudo-ethical and moral questions, never necessary when a decision regarding the administration of digitalis to a terminal cardiac patient is considered, the Dutch were treating everyone who needed it. But the medical schools supplied only the expertise. The health care delivery system for the purpose was developed by nonUniversity agencies of society —admittedly considerably simpler than in our country, in a homogenous community of only 12 million people in a geographic area the size of Rhode Island with 100 years of experience in developing a delivery system, but it was not considered a job of the University. By contrast, our University system of medical education and research was the envy of the Dutch—and as is the case in many foreign countries —they were trying valiantly to emulate it. I was invited to Utrecht in fact by David de Wied, the Professor and Chairman of Pharmacology, my good friend and fellow disciple of Arthur Mirsky, in order to demonstrate that one man could be both a clinician and an investigator and deliver education within the University in both spheres. For me it was a successful and
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revealing experience. I learned what an enlightened community could do about health care delivery once they had decided that such a thing as dialysis was only an expensive form of digitalis for which they were willing to pay rather than for a huge defense budget. At the same time I was able to demonstrate an educational approach based on clinical service and research, which resulted in the establishment of a chair in clinical pharmacology at the University. Both then can be done, if society is willing to pay and the tasks are allocated to the appropriate agencies of society. Finally, we do of course need new and imaginative approaches to health care delivery, but they are not ones that we in the medical schools can or should develop unilaterally, cheaply, and with "our third hand." Graduate training programs need
special investigative attention as do the development of programs in rural and urban areas, using a few physicians with teams of skilled nurse practitioners and physicians' assistants. We need cooperation between federal, state, and local levels of government, and we need high motivation and leadership of progressive and realistic lay citizens of our society to achieve these goals with ourselves as imaginative, scholarly, and investigative contributors. But we must at the same time support our contention that our primary mission in medical schools is to educate scholars in medicine. This is what we do best, what we alone can do, and the role we must defend against those who would rewrite history. I thank you all for your patience and let us get on with the scientific program.
REFERENCES 1. Ferris EB, Jr: An inquiry into the meaning of clinical investigation. J Clin Invest 30:623, 1951 2. Shapiro AP, Myers T, Reiser MF, Ferris EB: Comparison of the blood pressure response to veriloid with that to the doctor-patient relationship. Psychosom Med 15:478, 1954 3. Shapiro AP: In Memoriam—I. Arthur Mirsky, M.D. Psychosom Med 37:1, 1975 4. Mirsky IA: The psychosomatic approach to the etiology of clinical disorders. Psychosom Med 19:424, 1957 5. Mirsky IA: Certainties and uncertainties in diabetes mellitus, in Diabetes Mellitus: Theory and Practice (edited by Ellenberg and H Rifkin). New York, McGraw-Hill, p. 990, 1970 6. Weiner H, Thaler M, Reiser MF, Mirsky IA: Etiology of duodenal ulcer: I. Relation of specific psychological characteristics to rate of gastric secretion (serum pepsinogen). Psychosom Med 19:1, 1957 7. Shapiro AP: An experimental study of comparative responses of blood pressure to different noxious stimuli. J Chron Dis 13:292, 1961 8. Reiser MF, Rosenbaum MF, Ferris EB: Psychophysiologic mechanisms in malignant hypertension. Psychosom Med 13:147, 1951 9. Friedman B, Dahl LK: Environmental stress and hypertension. Psychosom Med 37:78 (abstract), 1975 10. Shapiro AP, Melhado J: Factors affecting the development of hypertensive vascular disease in rats after renal injury. Proc Soc Exp Biol Med 96:619, 1957 11. Lipman RL, Shapiro AP: Effects of a behavioral stimulus on blood pressure of rats with experimental pyelonephritis. Psychosom Med 29:6, 1957 12. Henry JP, Meehan J, Stephens P: The use of psychosonal stimuli to induce prolonged systolic hypertension in mice. Psychosom Med 29:408, 1967 13. Forsyth R: Blood pressure response to long term avoidance schedules in the restrained Rhesus monkey. Psychosom Med 31:300, 1969 14. Shapiro AP: Essential hypertension—Why idiopathic? Am J Med 54:1, 1973 304
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PRESIDENTIAL ADDRESS 15. Vagnucci A, Shapiro AP: Perspectives of the renin-angiotensin-aldosterone system in hypertension. Metabolism 23:273, 1974 16. Leenen FH, Shapiro AP: Effect of intermittent electric shock on plasma renin activity in rats. Proc SocExp Biol Med 146:534, 1974 17. Weiner H, Singer MT, Reiser MF: Cardiovascular responses and their psychophysiologic correlates. Psychosom Med 24:477, 1962 18. Sapira JD, Scheib ET, Moriarty R, Shapiro AP: Differences in perception between hypertensive and normotensive populations. Psychosom Med 33:239, 1971 19. Lacey J: Methodological approaches to the role of the CNS in cardiovascular disease. Proceedings of Timberline Conference. Psychosom Med 26:445, 1964 20. Williams RB, Kimball CP, Williard HN: The influence of personal interaction on diastolic blood pressure. Psychosom Med 34:194, 1972 21. Redmond D, Gaylor M, McDonald RH, Shapiro AP: Blood pressure and heart rate response to verbal instruction and relaxation in hypertension. Psychosom Med 36:285, 1974 22. Ostfeld A: What's the payoff in hypertension research? Psychosom Med 35:1, 1973 23. Dowling HF, Cotsonas NJ: Attitudes towards patients of full-time and practicing instructors as revealed in student questionnaires. N Engl J Med 271:716, 1964 24. Alpert JJ, Charney E: The Education of Physicians for Primary Care. Washington e.c, u.s. dept. of Health, Education and Welfare, Bureau of Health Services Research. DHEW Pub. No. (HRA) 74-3113, p. 5 25. Chartbook of Federal Health Spending, 1969-74. Washington, D.C., Center for Health Policy Studies, National Planning Ass'n, 1974, p. 22 26. Pellegrino ED: Research in medical education: The views of a friendly Philistine. J Med Ed 46:750,1971
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