Abstract
The AFCR was founded just 18 years earlier in 1940 and just for people like me. Their members met annually in Atlantic City. Only one or two papers were necessary to join. You had to be “preferably under the age of 35”. 1 I was eager, curious, wanting to know more about the famous authors who wrote those chapters in Cecil and Harrison's text books, and I was 27 years old. The experience of the meeting was exhilarating. It was not just an AFCR meeting. Two other much more senior major prestigious organizations were meeting jointly with us “Young Squirts”. One was the Association of American Physicians (AAP), founded in 1886 by the gods of academic medicine like Osler. The other was the American Society for Clinical Investigation (ASCI), created in 1908 by an increasing number of dissatisfied young physician-scientists who rebelled against their older peers who could not make enough room on their program to allow these “Young Turks”, as they called themselves, to participate and present their own work at the annual pilgrimage of clinical science. Eventually their prestige and academic success and productivity resulted in the publication of their own new journal, “The Journal of Clinical Investigation”, which, to this day, enjoys one of the highest impact factors. It was in the first week in May that we, the “Young Squirts” of the AFCR, joined the “Young Turks” of the ASCI, and the “Old Turks” of the AAP, in the grandest banquet of clinical science.
The attendance at the meeting became so large that the ballrooms of Chalfonte-Haddon Hall Hotel in Atlantic City could no longer accommodate us. We had to move across the Boardwalk to the Convention Hall on the Steel Pier. Despite the descriptor the pier seemed to jut dangerously into the Atlantic Ocean.
I remember sitting in rows near the front with my head propped up looking at the elevated stage where the giants of medicine chaired the sessions or spoke at the podium. In awe I was dreaming and wondering if someday I would be presiding from up there! And that is how my academic career as an AFCR member began.
Perhaps the most important and memorable part of those meetings was the opportunity for the greatest possible honor to be introduced to the idols of academia, the editors of the JCI, the Presidents of the AAP, and the famous Chiefs of Medicine. We would walk on the Boardwalk during the breaks in scientific sessions and point out the legendary academic leaders.
When the meeting of the Troika (AFCR, ASCI, AAP) moved away from the famed Boardwalk of Atlantic City in 1976 we lost this unique opportunity to meet and maintain our social and intellectual bonding, to reaffirm our values of inquiry, and to renew our commitments to discovery. One could witness on that Boardwalk two or three generations of academic internists from the young assistant professor to the famous senior department chairman. They would be debating a scientific question, or interviewing a job candidate, or sitting next to each other in the conference room listening to the best science and sharing the unravelling of mysteries of disease.
When Henry Christian founded the AFCR in 1940 it was for the same purpose that the ASCI was founded in 1908. There was an expectation of a significant increase in the number of the very young trainees in research. “In order to keep the Society in young hands, no one over the age of 40 (was) eligible to hold office in the Federation”. 1 The anticipated expansion of the National Institutes of Health to promote and support research in medical school required that an additional forum be created to represent this new generation that could not yet compete for membership in the ASCI. The prediction was amply confirmed. During the 60's the AFCR became the largest of the 3 societies with the greatest number of abstracts submitted to the meeting. Unlike the AAP and ASCI membership in the Federation was unlimited. By 1971, the year I served as President of the AFCR, I reported in my Presidential Address that we had surpassed the 7,000 membership mark. 2 To give an opportunity to our youngest scientists to speak at scientific meetings we had to not only expand the National Atlantic City Meeting but also create four regional Sectional Scientific Meetings. The Midwest Section Meeting of the AFCR was for the decades of the 80's and 90's one of the best attended and was jointly held with the Central Society for Clinical Research in November of each year. Hundreds of attendees crammed in the Ballrooms of the Drake Hotel for the most exciting plenary sessions.
Meanwhile at the National Meetings in Atlantic City two kinds of challenges were emerging. One was financial. For years the financial arrangements of these meetings, which had been kept in “honorable abeyance” for several years, culminated in the “cordial” negotiations of September 23, 1971, between the Troika. The AFCR with by far the largest number of attendees would retain 50% of the income from registration fees and exhibits. I take pride in being a major architect of that transaction at a meeting of representatives of the Councils of the 3 Societies. Facing up to the likes of Paul Marks of the ASCI was intimidating but we had the big numbers to back us up. 2
The other challenge at the time was programmatic. Because of the greater freedom of the AFCR from the rigid molds of tradition in the AAP and ASCI we were able to move more swiftly to address some of the criticisms that academic medicine was facing. Academia was accused of not dealing with major issues related to the care of the sick and that our research was irrelevant. In response we quickly expanded the presentations at our national meeting to include work related to Health Care Research in a subspecialty session so designated. As mentioned in my address in April of 1972 we (the AFCR) established a committee on Social Issues Related to Health. We would then assist and advise on legislative issues and other matters related to National Health Policy. We had the opportunity with the help of the Association of American Medical Colleges to express the views of the largest clinical research organization (the AFCR) to the appropriate legislative committees on the Cancer Bill (Congressional Record: National Cancer Attack Act of 1971, p. 791–792) and the Drug Abuse Prevention Bill. 3
The AFCR also needed to take another look at its goals beyond the provision of a forum for the budding clinical scientist. We had to address the obligation of academic medicine to serve the health needs of our society since we are the beneficiaries of the large federal NIH funds. Many schools and departments established Community Care programs. The clinical responsibilities of young faculty expanded. It became apparent that a balance between research, teaching and patient care on the part of each faculty member of our department would be difficult if not impossible to achieve. Different academic tracks were created. New disciplines in addition to the traditional Board Certified Subspecialties emerged to address research in quality of care, in health services, in general medicine and geriatrics, in epidemiology and public health. The centrifugal forces of fragmentation were straining our ability to maintain a centripetal unifying pull that brought us annually to the Atlantic City Meetings.
Nonetheless, I ended my “Salt of the Earth” Presidential Address to the AFCR in 1972 on an optimistic note. “Do not be disillusioned with academic medicine because of the crises that beset it; it will grow stronger with each crises, its track is formidable, and if you can take it, it will offer you a lifetime of challenges and opportunities. Above all, have confidence in yourself and your accomplishments. The nation's health depends on you.
The growth of academic departments, research facilities and hospital services in the 70's and 80's was staggering with continuing NIH support of both basic and patient-oriented research. The AFCR must have reached its peak membership of approximately 13,000 in 1990. 1
In the late 80's a disturbing trend in attendance at the Trisociety Meetings began. 4 We were meeting then in Washington, D.C. It was a slow decline from 4000 to 3500 and then more steeply to 2500 by 1994 and then to 2000 in 1995. A parallel decrease in the number of abstracts was seen from > 2700 to 1300. In stark contrast the subspecialty meetings were thriving with increases in attendance from 17,000 and 20,000 to 30,000 and 34,000 for the AGA and AHA respectively. They eroded our meeting. In 1996 the AFCR became the American Federation for Medical Research (AFMR), welcoming a much broader membership with interests ranging from health economics and policy to evidence-based and decision making and other cross-cutting disciplines.
Arthur H. Rubenstein, then President of the AAP, declared in his Address that we have reached a critical juncture, and indeed we had. 4 The subspecialty orientation of the meeting was abandoned, abstract submissions were eliminated. The ASCI and AAP would continue to meet jointly but more to celebrate the election of new members, the Kober Medal recipients, have the annual dinners and invite presentations by distinguished scientists. Unfortunately the youngest of the investigators in the AFMR were no more part of the pilgrimage of clinical investigation. I lamented deeply that particular development.
The Tripartite Meetings of Clinical Research had represented a golden time in the life of those physician-scientists who defined the character of academic internal medicine in the past half century.
The bonding, cohesion and rites of passage of traditions and values that were relayed at those meetings needs to be nurtured through every possible venue.
Despite the decline in numbers of the physician-scientists, the survival of the academic societies AFMR, ASCI and AAP as bearers of the standards of academic excellence is essential.
Departmental and Institutional leaders should proclaim that membership in the ASCI and AAP is a goal to be attained, celebrated and rewarded.