The following report, covering programmatic activities of the Public Policy Council from May 1, 1999 to May 12, 2000 is modified from a report provided to the joint APS/SPR councils on May 12 during the joint meeting of the Pediatric Academic Societies and the American Academy of Pediatrics in Boston. A condensed version was provided at the business meetings of the American Pediatric Society on May 14 and the Society for Pediatric Research on May 15 respectively. This activities report supplements the legislative report prepared by the Public Policy Council’s Washington-based staff. Queries or comments should be directed to the Public Policy Council chairman, myron.genel@yale.edu.

The Public Policy Council, formed almost sixteen years ago, includes two representatives from each of the three constituent societies, the American Pediatric Society (APS), the Association of Medical School Pediatric Department Chairs (AMSPDC) and the Society for Pediatric Research (SPR). Members serve simultaneously as representatives to the AAMC Council of Academic Societies and as liaison and alternative representatives to the AAP Committee on Federal Government Affairs (COFGA).

The Public Policy Forum is a loosely knit assembly of designated representatives at each major academic institution represented in AMSPDC; it serves as a communication network with the membership of the three societies and with academic pediatrics in general. Materials are distributed regularly to the Forum, including periodic legislative updates as well as relevant items on time-specific issues. These are supplemented by the Public Policy Council’s home page on the APS/SPR web site which also provides E-mail access to our Washington coordinator and to myself. The Forum also serves as a vehicle for the legislative briefing at the annual meeting. This year’s legislative breakfast, held on May 14, evaluated the increasing influence of the electronic media on medical publishing – "Medical Science and the Brave New World of Electronic Publishing." The meeting featured Jerold Lucey, editor-in-chief of Pediatrics and Alvin Zipursky, editor of Pediatric Research. The moderator was Jim Perrin, editor of the APA’s new journal, currently published as a supplement to Pediatrics, but scheduled as an independent journal, Ambulatory Pediatrics, in 2001. The Seventh Annual Public Policy Plenary Symposium, conducted in conjunction with the APA’s Public Policy Committee, took place May 15, with the overall theme "Pediatrics in the New Millennium: Compelling Issues in Public Policy." The program featured presentations on improved access to health care, testing of drugs and devices in children and the pipeline for pediatric physician-investigators, all by recognized national figures, among these the current FDA commissioner, Jane Henney.

Membership on the Public Policy Council has remained relatively stable, the only change being the retirement of Sam Hawgood, immediate past president of the Society for Pediatric Research, who was replaced by Christine Gleason in January. Russ Chesney and Jon Abramson remain as representatives of AMSPDC and Jimmy Simon and myself for APS. Karen Hendricks continues to serve most effectively as the Public Policy Council's Washington Coordinator, assisted by Jennifer Stevens, who will be leaving for graduate school shortly. They are responsible for maintaining an in-Washington presence for the Public Policy Council and the constituent societies, working from the AAP’s respected Washington Office. Ms. Hendricks is a well-regarded, "inside" player within the health-research advocacy community and Washington policy circles. Ms. Hendricks continues as president of the Coalition of Health Funding, a broad consortium of voluntary health organizations, professional societies and advocacy groups. She has served on the Steering Committee of the Ad Hoc Group for Medical Research Funding the past several years, is the past chairperson of Research!America’s Public Affairs Committee and is a central figure in a number of issue-specific coalitions. The effectiveness of the Public Policy Council and our continued visibility in Washington remains a reflection of Ms. Hendricks’ standing and efforts on our behalf.

The council's activities continue to be conducted primarily through a monthly conference call supplemented by frequent mailings and e-mail communications from the Academy’s Washington office as well as from the AAMC Council of Academic Societies. During the past year, conference calls have generally included Jim Perrin, past president of the Ambulatory Pediatric Association, and Charles Oberg, chairman of the APA’s Public Policy Committee, in part to coordinate plans for the PAS annual meeting but also to coordinate policy initiatives. Materials, including minutes of conference calls, are shared routinely with the leadership of the three societies and thus provide opportunity for input on specific issues. The semiannual legislative reports prepared for the councils and AMSPDC executive committee and testimony by Public Policy Council members are routinely placed on the Public Policy Council web site. Programs of the Public Policy Council continue to be conducted from both the Academy's Department of Federal Affairs and my Office of Government and Community Affairs at Yale. A comprehensive legislative report, prepared in March, appeared in the pocket program of the annual meeting.

Members of the Public Policy Council have been active on a variety of issues during the past year, much of this reflected in the legislative report prepared by our Washington staff. Testimony regarding the FY 2001 budget was presented by Ora Pescovitz, incoming SPR president, on March 14 to the House Appropriations Subcommittee on Labor/HHS/Education with emphasis on pediatric research, GME for children’s hospitals and the importance of vaccine research. Russ Chesney also testified a week earlier on the FY 2001 appropriations, in particular full funding for the Children’s Hospitals GME Program, on behalf of the National Association of Children’s Hospitals (NACH). I provided testimony on behalf of the American Academy of Pediatrics and the Pediatric Academic Societies on October 21 at a hearing of the Senate Health, Education, Labor and Pensions (HELP) Committee regarding the progress of the pediatric drug provisions of the FDA Modernization Act. Subsequently I had follow-up correspondence with the committee chair, Sen. Jim Jeffords, and FDA Commissioner Jane Henney. The Public Policy Council continued to participate in a coalition supporting stem-cell research, spearheaded by the American Society for Cell Biology, and with the Ad Hoc Group for Medical Research Funding and Research!America in maintaining momentum to double the NIH budget by FY 2003. In addition, we worked with other coalitions to support increases in health services research conducted by the renamed Agency for Healthcare Research Quality (AHRQ) and for continued funding of the health professional training programs (Title VII and VIII). A major activity of the Public Policy Council has been advocacy to expand the pediatric research initiative to provide for loan repayment and for institutional and career development training grants in pediatric research. As customary, the Public Policy Council maintained a resource table at the registration area during the PAS 2000 annual meeting. The Public Policy Council also conducted one of the PAS Educational Seminars on "Research and Child Health Advocacy" with Rick Bucciarelli, chair of the Academy’s Committee on Federal Government Affairs, and with Academy staff responsible for state and federal relations.

AAP Committee on Federal Government Affairs: COFGA, formerly the AAP’s Council on Government Affairs, includes eight members appointed by the Academy plus liaison representation from the three societies which form the Public Policy Council, the Ambulatory Pediatric Association, Society for Adolescent Medicine, the Academy’s Committee on State Government Affairs, and the Academy’s senior and resident sections. Rick Bucciarelli, assistant vice-chancellor at the University of Florida, has been chairman since the committee was reorganized last January, and also heads the Academy’s Task Force on Health Insurance Coverage and Access to Care. A number of APS/SPR members serve as either Academy or liaison members of COFGA.

COFGA has met on two occasions during the past year, June 13-14, 1999 and January 30-31, 2000, both in the Washington area, and briefly in October during the Academy’s annual meeting, also in Washington. COFGA’s principal activity during the past year has remained focused on Academy efforts to ensure universal access to health insurance and to health care coverage for all children. A task force, headed by COFGA chair, Rick Bucciarelli, has put forward a draft proposal, still evolving, which would guarantee that all children would be automatically eligible for either private or government assisted insurance without means testing. Under this program efforts would be made to ensure that there is continued contribution from the current employer-based system and that long established Medicaid principles, including an Academy endorsed benefits schedule and adequate wraparound services for children with special health care needs, are retained. A particular area of sensitivity has been whether the new Academy plan would "replace" or "expand upon" the current federal programs such as Medicaid and S-CHIP. The Academy continues to actively monitor and promote implementation of Title XXI or the S-CHIP programs, although enrollment efforts have varied considerably among the various states and the numbers of children without adequate insurance remain in the millions. Much effort is being devoted to ensure that universal access for all children becomes a major issue during the forthcoming presidential campaign. In addition to the long-standing problem of access, the Academy has devoted considerable attention to the ongoing controversy over safety of children’s vaccinations, spurred by allegations of a causal association with a variety of chronic illnesses, including autism and childhood diabetes. This effort is being pushed on several fronts, including provision of authoritative testimony from physician experts as well as from illustrative families and through use of the media. Additional Academy efforts are being devoted to prevention of youth violence and gun control, much of this in collaboration with other professional and advocacy organizations. The Academy continues to be actively engaged in efforts to control tobacco use in youth, also as a leading member of various coalitions, and in efforts to improve appropriate testing of drugs for use in children.

AAMC Council of Academic Societies: The CAS is one of the three principal components of the Association of American Medical Colleges together with the Council of Deans and the Council of Teaching Hospitals. The CAS now includes 91 academic societies, four of these are pediatric, the three sponsors of the Public Policy Council as well as the Ambulatory Pediatric Association, whose delegate Paul McCarthy, is the current chair. The CAS continues to provide an unparalleled opportunity for interaction of pediatric specialists with leaders of other professional societies as well as an opportunity for input into AAMC policies and activities. Previously I served a five-year term as a member of the CAS Administrative Board and was CAS chair in 1990-91. I currently serve on the AAMC’s Advisory Panel on Research.

The Council of Academic Societies met on two occasions during the academic year — October 24-26, 1999 in Washington, as part of the annual general meetings of the AAMC, and March 23-26, 2000 in Savannah, Georgia. A brief report of the October meeting, which featured outstanding programs on stem cell research, the impact of genetics on medical education and on clinical research, including a session on infrastructure and another session devoted to collaborations between academic and community physicians. Russ Chesney and I attended the spring CAS meeting in Savannah. This meeting, held in a more intimate retreat-like setting, provides the most substantive program of the two meetings as well as an opportunity for significant interaction with colleagues from other disciplines. Russ Chesney and I agreed that the Savannah meeting was outstanding. A summary of the meeting, prepared by the CAS staff, is appended to this report.

During the year Volume I of the report from the AAMC’s Task Force on Clinical Research was issued, with separate chapters and explicit recommendations devoted to four components of clinical research in academic health centers – (1) education and training, (2) infrastructure, (3) clinical trial organizations and (4) linkage with integrated delivery systems. A second volume of contributed essays and commentaries will appear later this year. In addition the AAMC collaborated with the AMA in a two-year National Clinical Research Summit process which concluded with a legislative briefing held on Capitol Hill on November 15, 1999. I had the privilege of serving on the executive committee which directed the summit process and will be a member of the new Clinical Research Roundtable that is being established at the Institute of Medicine, implementing one of the recommendations of the summit process. A report of the summit entitled "Clinical Research: A National Call to Action" can be found on the AAMC website at

The Council of Academic Societies remains a natural meeting ground with colleagues and other academic disciplines and is deserving of our active support. The next meeting of the Council of Academic Societies will take place at the AAMC general annual meeting which will be held in Chicago, October 27-November 1, 2000. The next CAS spring meeting will be in San Antonio, Texas, March 22-25, 2001.

More than 100 Council of Academic Society representatives attended the CAS Spring Meeting held March 23-26 in Savannah, Georgia. Within the Association of American Medical Colleges, the Council provides faculty perspectives and input into a wide rant of current issues affecting academic medicine. A copy of the program attached. Before the formal meeting program began, the CAS Administrative Board and various CAS committees and Task Forces met.

The opening plenary session focused on "Medical Errors, Accountability and Professionalism," with the keynote address presented by Martin J. Hatlie, J.D., partner, Partnership for Patient Safety, and founding executive director, National Patient Safety Foundation. He stressed three major challenges to reducing health care risks: changing the external environment so that it fosters a new understanding of accountability; improving the internal environment so that service delivery systems are highly reliable; and finding ways to more effectively manage information, especially transmitting information about quality of care. He concluded that progress would only be made by aligning the delivery system’s core values, adopting a common language based on a robust knowledge base, providing education to all members of the healthcare team, developing a systemic partnership that facilitates "reaching through the invisible walls" that exist within our institutions, and providing external incentives rather than punishments.

A distinguished panel of commentators added to the discussion. Raymond L. Woosley, M.D., Ph.D., chair, Department of Pharmacology, Georgetown University School of Medicine, focused on the causes and types of medication errors, including knowledge deficit errors, communication errors, performance errors, and errors caused by systemic bias in priorities. He proposed a number of specific corrective measures including HRSA grants to resident training programs and loan forgiveness programs for residents and fellows focused on error reduction; the creation of strengthened Centers for Education and Research on Therapeutics, and the integration of care givers, care receivers, and the public into a therapeutic alliance. Donlin M. Long, M.D., Ph.D., director, Department of Neurosurgery, Johns Hopkins University School of Medicine, noted that probabilities and uncertainties are involved in all diagnosis, prognosis, and therapeutics and only medical advances can eliminate some errors. He distinguished the types of preventable errors, the constraints on correcting some errors, and the differing approaches necessary to address procedural errors vs. physician judgment errors. Ralph W. Muller, chair, Association of American Medical Colleges, and president, University of Chicago Health System addressed the need to include all personnel involved in health care into the effort to improve system quality. Maureen Connor, R.N., M.P.H., director of risk management, infection control and professional services, Dana-Farber Cancer Institute, discussed the efforts at Dana-Farber to change the institutional culture regarding errors. Although there have been a great number of successes, many issues are unresolved including the "blame and punishment" attitude of some state licensing bodies.

Heading a plenary session entitled, "The Knowledge Revolution," Leroy Hood, M.D., Ph.D., director, Institute for Systems Biology, and C. Thomas Caskey, M.D., president, Merck Genome Research Institute, and senior vice president, basic research, Merck Research Laboratories, made detailed and scientifically rich presentations on efforts to utilize the data resulting from the Human Genome project to identify the genetic causes of disease and to develop therapeutic approaches to those diseases. Dr. Hood, in particular, described exciting, high-speed, high-throughput, analytical tools and technologies being developed to exploit the vast reserve of information emanating from the human genome and identification of gene functions at the molecular level. The impact of this revolution in knowledge will affect every segment of medicine and alter the physician-patient relationship in ways that are difficult to fully predict. Alan Guttmacher, M.D., senior advisor to the director for clinical affairs, National Human Genome Research Institute, detailed some of the changes that will take place in clinical practice. Genetic conditions are common enough that most genetics-related care will be supplied by primary care givers, with occasional involvement of medical geneticists, genetic counselors, and other specialists. Some of the changes in health care will come through: identifying individual genetic predisposition(s); the maturation of pharmacogenetics, allowing population-based screening for certain disorders, and creating a fundamental understanding of the etiology of many diseases, leading to new approaches even to non-genetic diseases. These changes raise a number of difficult social issues. To prepare health professionals for the genetics knowledge revolution, students must learn to "think genetically." In addition to realizing when genetic factors play a role and being able to explain genetic concepts, practitioners will need to deal with "risk" and genetic predisposition, to realize personal and societal impacts of genetic information, to protect genetic privacy, and to use genetics to individualize patient care and to preserve health. The session concluded with a discussion of ways to prepare society at large for the "new genetics," a task that will involve a level of public education and understanding not successfully undertaken in recent memory.

A session on "Meeting the Evolving Ethical, Legal, and Practice Demands of Patients" continued the dialogue begun earlier. J. Roger Guard, M.L.S., chief information officer, University of Cincinnati College of Medicine, discussed new ways consumers (rather than patients) are accessing health information by utilizing web technology. While the implications of this revolution are clear, Mr. Guard’s focus was more on the opportunities this technology presents for academic medicine. Academic medicine has the knowledge base, the capital and the technology but has been held back by the enterprise’s hierarchical structure, the tradition of working separately, and the "tradition of the guild," which has generated a culture of "secret knowledge." David Korn, M.D., senior vice president for biomedical and health sciences research, Association of American Medical Colleges, and Janlori Goldman, Esq., director, Health Privacy Project, Institute for Health Care Research and Policy, Georgetown University, discussed the competing interests of personal privacy versus the public good that has been achieved by examining medical records. The proposed federal regulations on the privacy of medical records were examined from both a practical and theoretical perspective. It is clear that if these regulations are adopted without significant change, they would impose great burdens and constraints on the day to day functioning of the health care delivery system and the conduct of medical research.

Given the recent proposals from the CMSS and the ABMS, the session on "Defining and Evaluating Competency" was particularly timely. Dr. Donlin Long provided an overview of the strengths and weaknesses of time- vs. competency-based training. Subsequent speakers addressed specific areas of competence. David L. Nahrwold, M.D., emeritus professor, Northwestern University Medical School, focused on the acquisition and measurement of procedural skills and knowledge in the clinical disciplines. He recommended that the activities of accrediting and certifying organizations be coordinated to meeting the competency requirements of the public, that these bodies evaluate those under their purview against the established competency requirements and that the competencies used by accrediting and certifying bodies be the same. Harry R. Kimball, M.D., president, American Board of Internal Medicine, discussed the acquisition and evaluation of professionalism and detailed some of the ABIM’s initiatives in the field.

Dale Dauphinee, M.D., executive director, Medical Council of Canada, synthesized various approaches to assess clinical competency. In selecting methods and formats, he stressed that assessment methods should strive to represent the reality of the task being posed, that the task being assessed should dictate the method used, and that everyone recognize the practical constraints in selecting optimal evaluation methods. Dr. Dauphinee discussed a host of methodological issues, including issues related to standards and standard setting, the notion of outcomes, specifically education outcomes, and whether training and certifying exams predict practice competence. Dr. Dauphinee stressed that competency is a combination of complex tasks and roles, but that assessment must be confined to practice-related problems. In the future, it is likely that the demand for accountability and quality will push the assessment field into outcomes. Lastly, although technology can assist in measuring competency, in the end, design and sampling are still key.

An evening banquet featured a lively presentation by George Lundberg, M.D., editor-in-chief, Medscape. Dr. Lundberg presented his vision of how the Internet will affect medical practice and biomedical research in the future.

The final plenary session focused on "Improving Patient and Physician Confidence in Clinical Decision-Making." Walter W. Rosser, M.D., chairman, Department of Family and Community Medicine, University of Toronto Faculty of Medicine, provided an excellent summary of the concept of evidence-based medicine and contrasted it to the traditional view, which relies only on evidence from randomized trials. He compared the traditional concepts with the practice reality and discussed strategies for applying EBM to the individual. He also discussed approaches to teaching EBM concepts to medical students. In the end, teaching this material requires a combination of understanding epidemiology and the strengths and weaknesses of evidence combined with a patient-centered approach to application. Deborah R. Feldman-Stewart, Radiation Oncology Research Unit, Queens University School of Medicine, discussed her work with cancer patients on the information patients and physicians felt were critical to clinical decision making. She also discussed various decision aids that have been developed. The meeting concluded with presentations by Sir Miles Irving, chairman, Newcastle upon Tyne University Hospitals NHS Trust, on the British approach to evidence-based decision making and John M. Eisenberg, M.D., administrator, Agency for Health Care Policy and Research, on the decision making tools being developed by the Agency for Healthcare Research and Quality.

During the meeting, six breakfast discussion sessions were held which allowed interaction among society representatives, plenary session speakers, and senior AAMC staff. Throughout the meeting, the CAS Professionalism Task Force sponsored an interactive poster session on various challenges to professional conduct.

The CAS Business Meeting was held on Friday. Dr. Paul McCarthy opened his report by recognizing the continuity of themes over the past several meetings. He announced that Dr. George Sheldon, immediate past chair of the CAS, had been elected chair-elect of the AAMC. Dr. McCarthy reported on a number of CAS initiatives. The CAS Administrative Board has established a new Task Force on Culture, Patients, and the Medical Education Curriculum. The Task Force is charged with exploring the effects of cultural, social and economic issues on the patient-physician interaction and the implications for medical education. A new Task Force on Chairs has been formed to draft a proposal for a broad AAMC task force on issues related to chair development. Dr. McCarthy reported on various efforts the Administrative Board has made in strengthening communications with representatives. The CAS listserve and resources available on the CAS private web site <http://www.aamc.org/private/cas/> have proven valuable to CAS representatives and society officers.

Dr. Jordan Cohen presented a detailed report on AAMC activities. He identified a number of "faculty front burner" issues, including privacy, patient safety, human subjects research, intellectual property, time and rewards for teaching and institutional solvency. He also stressed four areas of growing concern: "e-everything," specifically the impact of the information technology revolution on education, research and patient care; diversity among physicians, scientists, faculty, and students; the impact of Medicare reform on medical education; and the impact unionization may have on the relationship between residents and faculty. Dr. Cohen also noted several opportunity areas where CAS is playing a key role. These include efforts to ensure physician competency over time, helping department chairs and program directors fulfill their leadership roles, and issues related to the professional advancement of women and minorities. AAMC President Ralph Muller made brief remarks discussing the personal and professional value of participating in AAMC’s governance.

Dr. Richard Knapp presented a government affairs report, including a summary of recent legislative activity concerning the impact of the BBA on Medicare funding of medical education. He also summarized the current state of appropriations bills for various agencies of interest and provided AAMC’s advocacy position on each. The AAMC leads or is a major player in more than a half-dozen legislative and funding coalitions. Dr. Knapp also provided a summary of AAMC’s clinical research legislative agenda that was developed by the recent AAMC Task Force on Clinical Research.

Dr. Barbara Schuster, chair of the CAS membership committee, reported that CAS membership now stands at its highest level ever – 91 member societies (15 basic science societies, 72 clinical societies, and 4 interdisciplinary societies). The combined (duplicated) membership of the CAS member societies is over 388,000. Eleven new societies have been admitted to the CAS in the past two years. Five non-member societies sent representatives to the Savannah meeting and are considering CAS membership.

Dr. Diana Beattie, chair of the CAS Scholarship Task Force, reported that the CAS Scholarship Papers Initiative was reaching an important milestone. More than a dozen leading faculty members and administrators have written papers on topics related to the evolving definition of scholarship within the academic medical community. The manuscripts have been submitted as a package to Academic Medicine and hopefully will be published in September. Related meeting programs are now being developed. Dr. Terry Cooper, chair of the CAS Professionalism Task Force, reported on the professionalism vignettes project and on a series of professionalism cases that were reviewed during a discussion session held during the meeting. Additional initiatives are being considered, including the production of a professionalism resource guide to assist faculty and societies in their own professionalism programs. Dr. Paul McCarthy reported that the 2001 CAS Meeting would be held in San Antonio, Texas, March 22-25, 2001.