The US National Academy of Medicine : American Journal of Physical Medicine & Rehabilitation

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The 2020 DeLisa Lecture

The US National Academy of Medicine

Dzau, Victor J. MD

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American Journal of Physical Medicine & Rehabilitation 102(6):p 475-480, June 2023. | DOI: 10.1097/PHM.0000000000002234
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Good morning. Physical Medicine and Rehabilitation (PM&R) is a profession that I admire and have great respect for. It is not only because of personal experiences or family experience but also because of what you do in terms of helping so many people. And also, because my wife, in fact, is a rehabilitation professional who spent quite a few years in practice.

THE NATIONAL ACADEMY OF MEDICINE SOME ORGANIZATIONAL ASPECTS

It is wonderful to be here to have a chance to tell you about how we can partner together for a healthier future—the United States National Academy of Medicine (NAM) and PM&R. Now, looking at this large crowd, I’m really quite impressed, especially amidst of all this coronavirus outbreak and the concern over this. I just want to congratulate you for really being here and being so committed to this meeting and to your field.

As you have heard, The NAM used to be called the Institute of Medicine (IOM), which was founded 50 yrs ago, in 1970.1 But, our parent foundational academy is the US National Academy of Sciences (NAS). It was founded in 1863 by the US Congress and President Abraham Lincoln. It was during the time of the civil war. And just like these days, we need independent, evidence-based, trusted advice that’s not due to politics, but in fact based on science. This is why the mandate for the academy reads “The academy shall, whenever called up on by any department of government, investigate, examine, and report upon any subject of science or art.”

The NAM is an independent entity that is not part of the government. It is a not for profit, founded and chartered by the government. In 1970, when health care was becoming a very important issue, and Medicare had just been created, an IOM was founded as a health arm of the NAS. We have had great success because the IOM has been recognized—thanks to many important reports that have in many ways changed the landscape of health and health care—in the United States and globally.

In 2015, a year after I became President, we reconstituted ourselves into the National Academy of Medicine. The IOM/NAM has been recognized as “the most esteemed and authoritative adviser on issues of health and medicine, and its reports can transform medical thinking around the world.”

What we’ve done over the years is really to become an important academy that helps think about the direction of health and medicine in the United States and globally. Today, we have the following three US national academies: one of science, one of engineering, and, of course, one of medicine. And, the three academies together cogovern the National Academies in the United States.

Within the academies, we have an organization called the National Research Council—NRC—with several divisions and programs including behavioral and social sciences and education, earth and life studies, engineering and physical sciences, gulf research program, health and medicine, policy and global affairs, transportation research board, congressional and government affairs, and report review committee. Our current reorganization efforts will help us work across programs and multiple disciplines. We describe ourselves as independent, scientific, evidence-based and trusted—certainly trusted by policy makers, by our peers, and now, increasingly by the public, as an adviser to a nation.

When we were founded as adviser to the nation, it meant adviser to the government. But over the years, we recognize that adviser to the nation means advisers to everyone in the nation—not just the government. Many people including professionals and the public will tell us about the important issues that we must address, and we do. We are a US-based academy, but we have also expanded our reach globally. We aim to catalyze action and create impact, collaborate, and worked across disciplines. We’re an academy of exceptional leaders. In fact, some of your members are also members of Section 8 (PM&R) of the NAM.

MEMBERSHIP

Each year, we elect 100 new members including 10 international members. Currently, we have approximately 2200 distinguished members. By our charter, a quarter of the members cannot be health professionals. The reason is that economists, lawmakers, and other professionals can help health and medicine. We proudly boast about 75 Nobel Laureates and, more importantly, what is unique about our academy is that every member is committed to service.

We also work outside of our membership by setting the agenda for health and medicine, at least in the United States, if not globally. Our idea is to convene and get together the best minds, members or not members, and each year, at the National Academies, we have approximately 7000 volunteers who work with us on issues that are important for setting policy and directions for health, medicine, science, and engineering.

REPORTS

Here are some examples of what we have done (Fig. 1). You may be familiar with some of them. In 1999, a little over 20 yrs ago, we published a seminal report “To Err is Human” that was the first report that actually said, “up to 98,000 people in the United States die in the hospital because of medical errors.”2 Looking at the facts and the evidence, it became very clear that we were not doing as good a job as we could. That report represented a call for action that in many ways transformed our views about patient safety and quality. Every single initiative in this area can be traced back to this report. The report started the movement for patient safety in the United States and was followed by the World Health Organization and other global efforts. As a direct consequence, we now have 12 different reports on different aspects of patient safety.

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FIGURE 1:
Authoritative reports.

The most recent report is on this issue of global patient safety. If you consider the proposal for universal health coverage—if you want every person to have access to health care with financial coverage—it is important to have good quality and safe services. In our report, we study extensively the quality of care across lower- and middle-income countries and found that 40%–50% of diagnoses or treatments are inappropriate. There is a lot of work to be done. With the rise of digital technology, we are quite concerned about the quality and safety of many digital technologies being used in health care. So, you can imagine the importance of this study.

In another example, in 1986, when AIDS became an epidemic, it was thought to affect only a small segment of the population. An IOM/NAM report titled “Confronting AIDS” showed it was not true.3 AIDS does affect many people in the United States and the world. The report, together with AIDS activism, resulted in a significant movement that supported the development of new treatments for AIDS. Today, AIDS is a chronic disease.

In 1988, we published a report proposing the sequencing and mapping of the human genome. Some, including geneticists, said it could not be done because we did not have the technology. Today human genomes can be sequenced for less than US $500 and the term “precision medicine” was coined in 2011. The NAM was the first to assemble, in 2015, an international conference on human genome editing to discuss the implications and ethical concerns associated with this technology.4 In 2016, with the Ebola outbreak, we wrote a very important report called “The Global Health Risk Framework”. We also support the elaboration of the US Dietary Reference Intakes, a set of scientifically developed reference values for nutrients. These are only some examples of evidence-based, trusted, and independent reports done by the NAM.

Like you and other professional organizations, we convene experts that work together to address important issues. We use roundtables and forums, workshops, and collaborative studies to accomplish our goals. We publish reports, workshop proceedings, and a journal that publishes our proceedings and commentaries. So, this is just a small example of what’s done in health and medicine. Ongoing workshops and roundtables include experts from government, industry, and academia, to address issues such as drug discovery and development, regenerative medicine, genomics and precision health, cancer, public health crises, microbial threats, neuro and behavioral health, health professional education, population health, environmental health, and many other issues.

VISION AND MISSION

What is the overarching direction of the NAM and how can we take advantage of what we do to create partnerships with you and others? In 2018, we completed our current strategic plan that we believe is long-term and durable. Our vision is that of a healthy future for everyone, irrespective of race, age, geography, culture, or socioeconomic background. We are trying to improve in our mission by advancing science, accelerating health equity, and providing independent, trusted advice nationally and globally. Our core values are very clear: diversity, inclusion, and equity, scientific rigor, and objectivity and independence. We believe in expanding capacity, creating partnerships, engaging globally, and monitoring and evaluating our progress.

STRATEGIC GOALS

We have three goals in this strategic initiative. Our first goal is what we are about. We look at critical issues where advice, guidance, and recommendations are needed based on science. We also want to lead and inspire both, ideas and actions. We consider them in three categories. The first category includes problems that are really emergent and need to be addressed immediately. The second category includes ongoing advice to the US government and globally about directions in health and healthcare directions. The third category is grand challenges or aspirational goals that require big, public/private partnership.

With regard to the first category, I only illustrate here three examples without going into any detail. The United States is really struck by the opioid crisis. As you know, there are more people who have died of overdoses of opioids and other drugs than in the Vietnam War and all the other wars altogether. We see this as a major epidemic. Many people have sprung into action including the local and state governments. But what is needed is a public/private partnership to bring together government, academia, private industry, nonprofit entities, and others to work collectively to find solutions. That is precisely what NAM did. The co-chair of this collaborative effort is the US Assistant Secretary of Health, Admiral Brett Giroir. Together, we have other co-chairs, John Perlin and Ruth Katz, and approximately 60 organizations that have come together to work on different areas including education, opioid prescription guidelines, treatment, and research.

The second example is very important because of what we now know about the coronavirus outbreak. During the Ebola outbreak, the President of the World Bank, Jim Kim, suggested an evaluation of response and preparedness to a global infectious outbreak, particularly including the World Health Organization. That resulted in a foundational report about many of the things that are being implemented in the area of global health risk framework security, pandemic outbreaks, vaccines, the need for countermeasures, and the importance of a resilient health system.

A final example is in the area of human gene editing.4 Because of the announcement of one scientist that he had used this technology in humans, we decided to develop guidelines and policy around what can be done and what should be done. An international commission made of experts from many different countries was invited to address the issue about whether we should do gene editing. Furthermore, how do you make sure that the proper ethics and safety are being considered. This is a work in progress.

In the second category mentioned previously, we advise the government about what they should do in health care with a neutral voice not driven by partisan politics. Our advice has contributed to maintaining a very effective Affordable Care Act.

In the category of grand challenges and aspirational goals, we have several examples. A very important one is aging. This is a big issue globally and we are collaborating with many colleagues around the world in an aging grand challenge. This is important to all of you because it affects many of your patients and I hope we can work together. The second initiative in this category is a collaboration with the World Bank and other organizations to develop a funding structure of US $10 billion for global mental health. Approximately one in four people has mental health problems. It is the number one disease burden for disability with a total cost of approximately three trillion US dollars. Our idea is to raise the financial resources through a series of mechanisms, including bonds and others, to invest those dollars in mental health and research. Unfortunately, in some countries, only approximately 1% of the GDP is spent in health and for various reasons only a fraction of that is invested in mental health.

BURNOUT AND PHYSICIAN WELL-BEING

So, how what we do can be relevant to you and how we can work together. One example is the concern about resilience and well-being of physicians. This is another big issue affecting healthcare providers. I know this is also an important issue in other countries such as China, Singapore, and Canada. Clinicians like yourselves and others are facing an increasing amount of stress and burnout.

In the United States, 40% of clinicians’ surveys express one or more symptoms of burnout, exhaustion, depression, remoteness, and isolation.5 Also, approximately 30%–39% of clinicians have thought about suicide. In the case of nurses, approximately 24% of nurses working in intensive care units have posttraumatic stress disorder. In the case of primary care nurses, approximately 23%–31% have burnout. This is a huge problem and, after adjusting for the same level of education, clinicians have 2 times the level of burnout and suicide than the general population.

There are many factors influencing today’s workers like you. There are external factors, which are related to society and culture, expectations of your role, and the stigma of mental illness—providers are supposed to be tougher than patients and are not supposed to talk about their problems. Rules and regulations with documentation and the use of electronic health records have contributed, and some studies have shown that physicians may be spending more time using the electronic health records than with patients. This, obviously, changes the reasons why we’re in medicine. The documentation requirements, organizational factors such as harassment and in the workplace, discrimination, and power dynamics are a real problem in medicine with such a hierarchal structure. Furthermore, the practice environment, information technology, and the many clinical and administrative responsibilities may contribute to burnout. These factors alter the work/life balance, result in mental stress, and compromise the resiliency and empathy of the workforce.

My colleagues Darrell Kirch and Tom Nasca and I published a paper in The New England Journal of Medicine with the main theme “To Care is Human” and discussed the importance of collectively confronting the burnout issue.6 So, how do we do this together? We can do this using a collaborative model. The NAM has brought together 65 different organizations in medicine, nursing, pharmacy, rehabilitation, professional societies, government agencies, providers, payers, and others to discuss how to address these issues that affects clinicians’ well-being. We have created six working groups to look at how to engage leaders to make sure that the culture of the work environment is good. It is important to break the culture of silence because stigma is such an important issue that people do not talk about this problem. Which best practices should be implemented and what to measure to determine whether we are improving the workplace.

For example, in a paper titled “Breaking silence, breaking stigma,” written by a trainee, we looked at a letter written by a colleague of his who committed suicide.7 The letter described how she came to a point where she felt desperate and committed suicide. This kind of work needs to be published, so that we can have an open conversation about this problem. This issue is now being discussed in the news media, for example, in the Washington Post, U.S. News, and New York Times. We want people to know that frontline health providers are working for the benefit of the patients, and without their well-being, patient care will suffer.

Many studies have shown that when providers are burnt out, the quality of their work is compromised, and the patient’s safety is at risk. For comparison purpose, if you are a passenger in an airplane and the pilot says, “I’m burnt out,” how would you feel flying in that plane? We need to make sure that, in fact, the well-being of our providers is being taken care of. The NAM has published a report making the recommendation to change the system because it is everything in the work environment that needs to be changed including the workload, the electronic health record, and the stigma. We need a national agenda, just like we did at the time of the “To Err is Human” report. At the time of “To Err is Human,” we recognized that it was a system’s problem. We did not blame the individual, remember? We said we need to fix the system. We need the same approach in the case of the well-being of the clinician. This is also impacting PM&R.

AGING AND LONGEVITY

This area also affects you (PM&R) greatly because you care for a lot of these patients. During the last few decades, there has been a reduction in the number of people younger than 5 years and at the same time an increase in those older than 65 yrs. These two lines crossed in 2020. There are more people older than 65 yrs than younger than 5 yrs in the world. By the year 2050, more than 1.6 billion people in the world will be older than 65 yrs. A demographic pyramid shows that in 1970, there were more younger people at the bottom and fewer older people at the top. In 2015, this situation had changed. In countries like Japan and Singapore, the pyramid is now a rectangle. This is a significant issue and in many countries the rate of aging will have an impact on families, communities, societies, industry, and economic function.

Because older people have more chronic disease, the demand for health care delivery will be higher putting a lot of stress on the health system, families, infrastructure, and retirement programs. Particular attention is the question about workforce. If we do not train younger colleagues, who is going to be the workforce. Studies have shown that the world is not prepared for this.

What we now need to do is to prepare, from a global perspective, financially, socially, and scientifically for a longer lifespan. I’m over 70 yrs old and many of my colleagues are also older 65 yrs. Increasingly, the population older than 65 yrs is productive and healthy. If we can maintain the older population in good health, there is an opportunity rather than a burden in society, hence the idea of healthy longevity, not aging.

Aging, in my mind, is a biological progress that is degenerative. Longevity is living longer and across the entire lifespan without a particular age cutoff. But, the idea of keeping people healthy from early life to the older population can create opportunities. Many studies demonstrate that older people are generally happier and wiser. The question we asked ourselves is where can we improve health and longevity, clinical care, social and economic environment, and financing and policy, for an older world and how to communicate where we need to go.

Our grand challenge, which is a global grand challenge, is to comprehensively address challenges and opportunities presented by global aging, address important issues of socioeconomic, political, and environmental nature that affect the health of the older population, catalyze new ideas and generate innovations worldwide, and create a dynamic network to support healthy longevity. In this grand challenge, which we have launched this past year, we have two components, a roadmap and a competition.8

The roadmap (Fig. 2) includes an international commission including members from 16 different countries, all five different continents, to work together, co-chaired by John Wong in Singapore and Linda Fried in the United States, to look at three domains. What are the social and environmental factors that affect the older population? This is important because every study shows that social isolation creates more problems and illness in the older population and that socialization and the ability to engage is so important. A second domain is health care. Is our health care system appropriately addressing the older population, including PM&R? Finally, what about using science and technology to address these issues?

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FIGURE 2:
Global roadmap for healthy longevity.

In every one of these three areas, we look at policy, practice, equity—so everyone has access to them —innovation, and of course financing. This policy group is now working very hard to create a set of recommendations in these areas. We need to optimize the role and your (PM&R) contribution to this population. The structure of this roadmap includes and oversight board by commission with the three different work streams I have mentioned.

The World Health Organization released a report on the “Decade of Aging.”9 Together, we are going to make sure that those findings are available to everyone everywhere and to ask governments to start making changes to enable the older population to be healthier. To think about the future, we need science and technology. If we can influence biological processes associated with aging, we may be able to stay healthier and live longer. In this sense, molecular therapeutics, genetic engineering, and research into the basic the pathway of aging are very important. But also, treatment and rehabilitation of age-related diseases. This is an opportunity for PM&R to enable older adults to live a life with quality. In that case, not only biology but also social sciences and technology, because technology can help daily living, improve quality and accessibility to health care for the older people. A partial list of all the technologies that are available for older adults include GPS tracking devices, telehealth, remote patient monitoring, robotic care, exoskeletons, smart homes, autonomous vehicles, and many others. Technology and rehabilitation can facilitate aging in place, as a substitute for caregivers, companions, and create a smart home. I am talking about all this because I think you (PM&R) are going to play a really important role in this area.

Our idea, in terms of looking at the future, is a global competition. We have engaged 49 countries and territories across the world under this umbrella. We’re giving out $50,000 for seed grants for bold ideas, after the Gates Foundation Grand Challenge Exploration Prize. In the first round of applications, we had several thousand applications and some countries that will be supporting a number of awards. A second level is for those great ideas that need more funding. We’ve been able to secure funding up to a million dollars to help the investigators to expand further and even commercialize products. The last level is a grand challenge with the idea of innovation in a big way that can be applied in the space of the older population to enable healthy longevity.8

HEALTH POLICY

I would like now to talk about the third area that I think is relevant to you, which is health policy. As I look at your field, I think there is a number of areas we can work together. What is the role of rehabilitation in health systems? I believe you (PM&R) play a very important role but in many countries, rehabilitation is not always integrated within the entire care delivery system. I think in the ideal situation, rehabilitation should be fully integrated whether you are talking about finances or outcomes. In addition, optimize team-based care in PM&R. We look forward to working with many of you (PM&R) to look at what are the policy issues that we can help you think about as we go forward.

Another important issue is coverage and reimbursement. I know in the United States, people who do not have insurance coverage have much less access to the rehabilitation they need. How do we make sure that people have access to rehabilitation. We need a lot more research in the work that you do, the impact that you have, and the outcomes you obtain so that you are properly acknowledged and supported. And of course, we need to have a way to measure function as an important indicator of health.

RESEARCH IN PM&R

We believe that there is a lot of opportunity to work together, particularly these days of what is known as convergent science. That is bringing together several disciplines to address an issue. In our NAM interest group on rehabilitation and function, we discussed the idea of rehabilitation without walls and the possibility of improving access to rehabilitation using technology. Technology can reduce the cost of care. Furthermore, technology can augment mobility retraining using robots, augmented performance, virtual reality, and artificial intelligence. All allow you to remotely interact with your patients using telemedicine, for example. Scientific advances and technology, such as the brain machine interface, can promote mobility and enhance functioning. There are challenges of course, because we need to demonstrate that these technologies are of great benefit, that clinicians like yourselves are comfortable with technology, that end-users have access and will adopt them, and that reimbursement is correct. Of course, the concern with use of technology is to lose human to human interface. How do we make sure that we continue to have those.

THE NATIONAL ACADEMY OF MEDICINE AND PM&R

Our final goal is about membership. We are proud that some of you here are members of the NAM. These are very distinguished individuals. We also want to engage the next generation. Section 8C of the NAM is PM&R. Members of Section 8C have also created an interest group (IG16) on rehabilitation and human function. This group has identified areas for discussion within NAM. In their first meeting, for example, they discuss functionality and technology.

We look forward to many of these discussions to enable you to have greater influence on our organization and to find opportunities for our organization to work with you. Now, importantly is this idea of the next generation. I see many young people in here. We have fellowships in our organization, which actually help people train on health policy, and I think, increasingly, we need more of you to be in policy. You are practitioners. You are researchers. But if we want to make sure the world is a better place, we also need the right policy. People with experience in clinical practice and research enter policy are better informed to identify what’s needed. We have a new program called Emerging Leaders in Health and Medicine, which will engage younger people almost like members, before they’re elected, to be engaged with us.

THE NATIONAL ACADEMY OF MEDICINE FELLOWSHIPS

I want to finalize with one area, which I think you should think about. We have a program named the National Academy of Medicine Fellowships.10 These are unique fellowships. Fellows come to work with us for about 3 mos a year. The rest of the time, they spend at their own institutions. They identify a project they can work on and continue working in the institutions. They get the experience of policy in Washington and they continue to develop their career. They are early career individuals. We have eight such fellowships and are funded by specialty societies.

The American Board of Family medicine has funded a fellowship and they do their own selection. Public health, care quality, bioethics (funded by the Greenwall Foundation), pharmacy funded by the College of Pharmacy, osteopathic medicine, and the American Board of Emergency Medicine. We should think about a fellowship in PM&R. I think it would be just great if you select somebody to work with us and you build a cohort of people with that expertise to work in policy areas, in Washington and other leadership positions, with their background towards the betterment of their profession.

SOME FINAL WORDS

We are certainly open to the opportunity of working with you. How do we partner together? We need to optimize the role of PM&R in health care, work on policy issues, address important topics such as burnout, look at technology, promote the conduct of research, and importantly, have more members in NAM with your views and create a fellowship. Thank you.

REFERENCES

1. National Academy of Medicine. Available at: https://nam.edu/about-the-nam/. Accessed February 20, 2023
2. Institute of Medicine (US) Committee on Quality of Health Care in America, in Kohn LT, Corrigan JM, Donaldson MS (eds): To Err is Human: Building a Safer Health System. Washington, DC, National Academies Press (US), 2000. PMID: 25077248
3. Institute of Medicine (US) Committee on a National Strategy for AIDS: Confronting AIDS: Directions for Public Health, Health Care, and Research. Washington, DC, National Academies Press (US), 1986. doi: 10.17226/938. Available at: https://www.ncbi.nlm.nih.gov/books/NBK219134/. Accessed February 20, 2023
4. National Academies of Sciences, Engineering, and Medicine: Human Genome Editing: Science, Ethics, and Governance. Washington, DC, The National Academies Press, 2017. doi: 10.17226/24623
5. Shanafelt TD, West CP, Sinsky C, et al.: Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2020. Mayo Clin Proc 2022;97:491–506
6. Dzau VJ, Kirch DG, Nasca TJ: To care is human—collectively confronting the clinician-burnout crisis. N Engl J Med 2018;378:312–4
7. Salwan J, Kishore S: 2017. Breaking Silence, Breaking Stigma. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. doi: 10.31478/201707a
8. National Academy of Medicine. Available at: https://nam.edu/initiatives/grand-challenge-healthy-longevity/. Accessed February 20, 2023
9. World Health Organization. Available at: https://www.decadeofhealthyageing.org/. Accessed February 20, 2023
10. National Academy of Medicine. Available at: https://nam.edu/programs/health-policy-educational-programs-and-fellowships/. Accessed February 20, 2023
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