Psychology in the Institute of Medicine

“The name ‘Institute of Medicine’ is a bit misleading-it might convince psychologists there’s nothing there for them,” said APS Charter Fellow H. Carl Haywood, a member of the IOM since 1972. “In fact, the IOM is concerned very broadly with issues of health and human development. It ‘s right in the middle of what many psychologists are concerned about,” Haywood said.

“Most obviously, mental health falls right in there,” Haywood added. “But there also are other issues such as substance abuse, chronic illnesses of children or adults including asthma or allergies that last for a lifetime and affect all sorts of behavioral and social dimensions of people, and anything that affects child development.”

APS Past-President Charles Kiesler suggests another good reason why psychologists are interested and involved in the IOM. “Whether you like it or not, the Institute is a major player in federal policy regarding health and health services,” said Kiesler, who is chancellor of the University of Missouri-Columbia and has been an IOM member since 1988.

More psychologists like it than not, judging from conversations with seven of the 27 members the 10M identifies as psychologists in its current membership of 465 “active members” and 556 non-voting “senior members” over age 66.

“We’re taken very seriously. we’re listened to, and we’re treated as genuine colleagues- though, pardon my modesty, we’re a pretty select group,” said APS Charter Fellow Edward Zigler of Yale University, an IOM member since 1987.

“We’ve got people like Judy Rodin [University of Pennsylvania] in the Institute; she has pushed behavioral medicine, and that’s a very concrete activity of the IOM.” Nancy Adler of the University of California-San Francisco, an APS Lifetime

Member who was elected to the IOM in 1994, said, “We’re kind of the new kids on the block, but the whole field of health psychology isn’t that old. It’s exciting for me to be able to represent the psychological perspective on major health problems, which has not always been front and center. It’s important to me to be able to contribute a perspective that ‘s usually not there.”

IOM studies that probe knotty health issues are valuable sources of fundable research ideas, affirms Dyanne D. Affonso, who also became an IOM member in 1994.

“An example is my multimillion-dollar grant from the National Institute of Nursing Research (1990-96) that [built off of the IOM study of the prevention of low-birth-weight babies, particularly among minority groups,” said Affonso, a psychologist who last year became dean of the Nell Hodgson Woodruff School of Nursing at Emory University. “I took that publication and literally spun off my grant from it,” she said.

In an era of information overload, Barbara C. Hansen, an IOM member since 1982, emphasizes that “one of the major roles of the IOM is to provide a forum for examining in a balanced manner some of the most difficult issues in all the areas of health care and biomedicine [and coming up with] a consolidated judgment of the very diverse views.” Hansen, a charter member of APS, is a professor at the University of Maryland Medical School whose specialty areas are endocrinology and the mechanisms of obesity and diabetes.

IOM gets the highest four-starratings from Hansen and several other psychologists for the diversity and multidisciplinary composition of its study panels, unique in the health care field. This is achieved even though almost 75 percent of IOM members are physicians, the maximum set by IOM regulations. Kiesler sees a few clouds hovering over IOM’s lofty mission, however. He noted, “IOM was started [in 1970] because of the lack of people doing something about public policy other than bench science. So I think the Institute now should be emphasizing people who have been out there in the public policy arena” rather than bringing in more “bench scientists who are already members of the National Academy.”

Even for psychologists, the bridge over to the public policy arena may not be an easy one to walk across, Baruch Fischhoff of Carnegie Mellon University has observed before and since becoming an IOM member in 1993. “As psychologists we talk about our issues, but it requires a different kind of energy to make the bridge over to public policy. You’ve got to talk to people with different perspectives and deal with their preconceptions of what psychology is all about. You’ve got to repeat yourself a lot.”

“My guess is that there are very few psychology departments that have graduate courses in public policy,” said Fischhoff.

Fischhoff is currently serving on a newly-formed  IOM committee surveying health effects of “environmental justice.”

He expects it to examine neurotoxological effects on behavior, including industrial, agricultural and household exposures, which, he said. “are sometimes best documented by psychologists.” His own special area focuses on how citizens can be involved in decisions concerning their environment, and it uses the expertise of cognitive psychologists and perspectives of social psychologists, he pointed out. His regular teaching and research work is under a joint appointment to the Department of Social and Decision Sciences and the Department of Engineering and Environment at Carnegie Mellon.

Fischhoff anticipates that when the IOM committee concludes its work in a year and a half “it might end up recommending increased recognition of these effects in psychological research, as well as recommending additional funding.”

IOM’s most valuable members tend to be bench scientists who can see far beyond the bench, maintains Huda Akil, co-director of the Mental Health Research Institute at the University of Michigan and the Gardner Quarton Professor of Neuroscience and Psychiatry there. “The trick is to be bench scientists who understand what is corning down the pike, who see what the advances look like-not the  kind who are so engrossed in the details that they can’t see the implications. It takes the type who can interface with physiologists, public health scientists and others and help translate some of the advances in science to potentials for future consequences.

“Advances come from research in ways that are totally and completely unexpected,” Akil continued. “The best example of that is the fact that a lot of treatment that we have now came from microbiology, from people studying bacteria, viruses in births, things that seemed a million miles remote from anything human. Yet avian retroviruses have helped us understand AIDS, and these seemingly remote fields have given us tools for molecular biology which we use for various diseases, and they have completely opened up the world of neurobiology, developmental biology and other fields.”

Akil observed, “IOM studies are very interesting because they sit at the interface of science and science policy. I think that’s what the Institute does. It sits back and takes a broader look once in a while and says, These are the issues we are facing as a nation, this is the progress we have made, these are the areas we can focus on now. It’s done in a multidisciplinary way. It’s perceived either by the IOM or by various major agencies as focusing on very important central issues. It has a good reflective function and advisory function to the country broadly, in many ways. And I think that it eventually affects where we put some resources.”

Some of Nancy Adler’s main research and practice has focused on “what seem like irrational behaviors” in sexual areas of life. “Like not using contraception when you don’t want to get pregnant, or not practicing safe sex when you don’t want to geta sexually transmitted disease (STD),” she said.

Now on an STD panel of the IOM, Adler hopes she can help change some notions about STD prevention.

“The conventional view,” Adler said, “is that prevention is confined to treating the person who comes into the STD clinic, and tracking the partners and treating them. But in my view that person should never have gotten infected in the first place. How do we provide education, motivation for people so that they do not put themselves at risk for developing the disease? That’s the important issue I have been able to represent from the perspectives of psychology, where we know something about how to motivate behavior.”

Affonso was a member of the IOM committee that last month [April] published its report titled Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?

“One of the main points of the report is that we do not have adequate data on current issues and practices or on how we handle the staffing mix in hospitals and nursing homes. Some studies of quality care were looking at variables of years ago that don’t count for much anymore,” Affonso said.

“Onrcommittee incl uded people from economics, medicine, health and service research as well as nursing; it was a true interdisciplinary dialogue,” Affonso said. “And it was incredible to see how well the issues that we brought forth in the nursing area really have to do with the work force in all health professions.”

Affonso hopes the IOM will now take the nursing study to a broader level and examine issues such as: What is the ideal mix of health professionals to help people stay healthy and help when the have disease encounters? How should we organize patient care services?

APS Charter Fellow Haywood, an emeritus professor at Vanderbilt University and now dean of graduate education and psychology at Touro College in New York City, was involved in two large and memorable IOM studies in the 1970s.

One was on the effectiveness of the community mental health centers that had then been operating for more than a decade. The other was a study of the effects of marijuana.

“Like most other studies the IOM undertakes, these were not so much for deciding what to do,” Haywood said. “They were for laying out the options and saying: Here are the policy options, the things that will happen if you follow this opinion, and the other things that will happen if you follow a different option.”

There was no unanimity in the marijuana study group, Haywood said. “My first draft of the chapter focusing on the behavioral and societal effects of marijuana, based on some 6,000 or7,000 studies, was fairly strong, but it was watered down subsequently.” However, there was general consensus on the point “that there are effects especially on psychomotor processes that last up to 18 hours after the subjective high,” Haywood commented. “So for 18 hours after you may think you are functioning normally you are not, especially when driving, operating machines, and especially flying airplanes.”

As to the mental health center study, Haywood said the committee did not find “evidence of great success in the purposes for which the centers were created. For one thing, the mental health centers were not doing much to serve people with mental retardation or other developmental disabilities- they seemed much more singly focused on psychiatric disorders,” Haywood said. “Yet they were not picking up the load with respect to deinstitutionalization.” However, in general it was better to have them than not to have them, Haywood said, adding that such points “are probably still true today.”

Hansen has served on major study panels and program committees frequently since her election to the IOM, bringing the combined perspectives of a psychologist and physiologist. One of the studies weighed the relative merits of different approaches to prostate cancer treatment, “from every perspective including costs—psychological costs, loss of work time, such issues as whether watchful waiting produces more stress on the patient than having it out right away. We had to look at prostate cancer from the standpoint of its physiology I its known treatment modes and the costs to the patient, to society and to the medical care system, so the study was very broad,” Hansen said. “Our goal was to examine the process by which patient outcomes can be used to shape treatment decisions,” she said.

Hansen also took part in a large study of all major aspects of the National Institutes of Health (NIH) that culminated in the NIH reorganization several years later. She worked primarily with a group “examining the institutes and the non-institutes, the centers, the bureaus, to see what we thought about the structure of the NIH,” Hansen recalled. “The staff of each task force collected a lot of information but the report that came out was based on what I would call the digested judgment of the very diverse views, so that no individual person’s views could be discerned in the report.”

Hansen said that according to a news commentator she heard one day last month, there are facts and true facts. She pretty much agrees. “Everyone knows what facts are,” she said. ” But the true facts are the ones you select and choose to put on the table, those you focus on and view as the most important, the ones that weigh in most heavily. In a sense, that’s just about what IOM committees are about,” she said.

Zigler said the most important activity he engaged in with IOM was when he chaired, five or six years ago, a conference on the controversial issue of infant day care.

“Some people think it’s wonderful, and some think that if you put your child in infant day care it will turn to dust. Leading psychologists in this country … were giving very conflicting points of view, and parents were just going crazy, because they didn’t  know what to do, but the media loved that stuff,” Zigler recalled. “So under the aegis of the IOM we held a conference and called together all the major workers in the field of infant child care.

“The point was to see if we could come up with a common point of view, and that ‘This is what the best thinking is on the matter. ‘ And we were able to do that within one day. That statement is still being distributed by Zero-3, which used to be called the National Center for Clinical Infant Programs. What it essentially says is that a growing child needs a variety of environmental nutrients; if he gets them at home he’s going to do well, and if he gets them in good quality day care he’s going to do well. So that was a big step forward in reaching consensus,” Zigler said. “The other thing that developed at that meeting was that Duane Alexander, the director of the National Institute of Child Health and Human Development, said that a lot of these issues are empirical issues. So what we recommended at that time, and what Alexander has put in place, to his credit, is a network of 10 sites around the country that are now are empirically studying the effects of day care. These grew out of that IOM meeting and they’re still in place, and that’s probably one of the most important social science studies going on in America today,” Zigler concluded.

“The IOM has a list of efforts that are as long as your arm and I’ve been involved in some of them- they all tend to be of very high scholarly quality, and I think it’s very important in the society in which we live that we have bipartisan, non-ideological people who are able to transmit the best knowledge base to decision makers, and that’s of course the primary role of the IOM and it does it very well, I think.”