When Alan Nelson, MD, walked into his first AMA House of Delegates meeting in 1972, the air was blue with tobacco smoke. “There was an ashtray at every seat,” he recalled.
That year also marked one of the key dates in the AMA’s 175-year history, as that’s when a landmark U.S. surgeon general’s report was issued and the AMA would launch its all-out “war on smoking.”
And by the time Dr. Nelson became the organization’s president in 1989, the AMA had called for a ban on smoking aboard airplanes and many other measures to discourage the deadly addiction. The AMA has in recent years highlighted the public health epidemic of e-cigarettes and vaping and supported the ban on menthol flavoring in cigarettes.
The AMA’s war on smoking marks one of the critical turning points in AMA history, said Dr. Nelson, a retired private practice internist-endocrinologist who turns 89 this month. He provides a valuable perspective given that his tenure as AMA president in 1989–1990 dates back further than that of any other AMA president who is still living.
During his remarkable physician career, Dr. Nelson served as World Medical Association president in the early 1990s after concluding his work with the AMA. He later served as CEO of the American Society of Internal Medicine—which merged with the American College of Physicians in the late 1990s—and retired in 2000.
As the AMA celebrates its 175th anniversary this year, Dr. Nelson reflected on the many ways that American health care has changed, and how the AMA has risen to meet the moment in medicine. He also offered some valuable advice about the power of honesty in physician and patient relations.
AMA: You were very active in the AMA long before your tenure as president, starting your service in the House of Delegates 50 years ago. Which changes stand out the most for you?
Dr. Nelson: The AMA's position against smoking is a change. With respect to the environment, nobody had ever heard of global warming when I was AMA president, and certainly not when I was on the AMA Board of Trustees.
Another big change is HIV isn't the threat now that it was in the '80s when I was on the board. It was a big killer in the U.S. back then, and the board pushed a strong position, gradually, into recognizing that HIV was a major threat.
One other piece of policy was that pharmaceutical advertising was illegal when I was AMA president. As a matter of fact, I was appointed to an FDA committee to consider whether pharmaceutical advertising should be allowed. Interestingly, the pharmaceutical industry was somewhat divided. Some companies said, "Well, we're for it, but if nobody else can do it, then we won't do it."
But of course, that's changed now. The amount of advertising by pharmaceuticals companies is disgraceful and the elevation of the prices of pharmaceuticals is too.
I’d also like to talk about governance within the AMA. When I was president, the House of Delegates consisted of one delegate per specialty society, and it was dominated by the states. The total number of delegates was around 300. The students and the residents had one delegate each and they had very little influence.
Now, the total number is above 600 and the specialty societies in some cases have the largest delegations. The American College of Physicians has 34 delegates. So, the influence of the specialty societies on AMA policy has been a factor. And now, of course, when you look at the House of Delegates handbook you can see how many resolutions come from students and residents.
Finally, the Board of Trustees is much more diverse than it was when I was on it.
AMA: After your tenure with AMA and World Medical Association, you chaired a committee that prepared a significant report that the Institute of Medicine—now called the National Academy of Medicine—released is 2005 that was called Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Tell us about that experience.
Dr. Nelson: That was interesting. It opened my eyes to the degree of racial inequality, and the report was quite influential.
As the committee finished that report, I went around the table and asked everybody to write down what title they would like to have for our report. I thought about it and I decided the 14th Amendment promises equal treatment under the law. So, I suggested Unequal Treatment—and that's what they chose. I was kind of pleased.
AMA: Today we have the AMA Center for Health Equity and a renewed focus within medicine on addressing health inequity and the larger structural forces that cause it. What do you think has changed since your time as president?
Dr. Nelson: Certainly, more awareness of the problem. Whether the problem is being substantially solved, I just don't know. If you research and ask physicians whether they have any tendency to treat the members of the different races differently, almost all of them will say, "No, I don't. I know it's a problem, but I'm not part of the problem. I treat everybody equally." But the research data doesn't necessarily support that.
AMA: Is there a defining moment where, in your view, the AMA really rose to the occasion and did the right thing for America's patients and doctors?
Dr. Nelson: The successful support of Obamacare stands out. The AMA's aggressive position in trying to bring HIV under control was important. To some degree, the AMA is taking a progressive position on global warming. I think that's important. All in all, I'm proud of the AMA. I'm proud of where we are now. I think the AMA was in a good place when I was president, but I think perhaps it’s in a better place now because of its activism in some of these areas.
AMA: In the address you delivered upon becoming president—which was subsequently published in JAMA—you focused on humanism and ethical behavior in medicine. What can physicians do to hold each other to such standards?
Dr. Nelson: I was influenced throughout my career by something that happened when I was a resident. The chief of medicine, a very distinguished hematologist, would have a teaching session with the residents each week where he'd explain what was going on with a patient. One time, he turned to a patient and abruptly said, "On your back." I thought, "God, that's terrible." The next morning during the resident rounds he said, "I've been thinking I was a little abrupt with that patient. What did you think about it?" I said, "I thought it was terrible." I stayed in his good favor because I was dead honest with him.
AMA: You retired from patient care after concluding your service with World Medical Association in 1992. What advice would you have for physicians who are nearing retirement?
Dr. Nelson: Make sure that you turn your patients over, that you don't just leave them. I let my patients know five months before I left. They had plenty of time to tell me where they wanted their records sent. That's important. I'm not sure that's always done, but it should be.
AMA: It’s now been 32 years since your term as AMA president ended. What would your hope be for American medicine 32 years from now? What should we have achieved by then?
Dr. Nelson: Universal coverage—and affordability of pharmaceutical products. Accommodation to global warming in a way that controls it to the degree possible, but also accommodates the way we cope with, and the way we live, with whatever the environment is like. In other words, I hope that everybody has a secure place to live.
— News Editor Kevin B. O’Reilly contributed to this report.