Arnold Relman, Medicine's Long-time Conscience, Dies at 91

June 19, 2014

Arnold "Bud" Relman, MD, a pace-setting former editor of the New England Journal of Medicine (NEJM), died June 17 of cancer at the age of 91, just weeks after another journal published his latest call for physicians to press for healthcare reform in the name of patient-centered care and professionalism.

If that kind of reform did not occur, "we will end up either with a system controlled by blind market forces or with a system entangled in complicated and intrusive government regulations," Dr. Relman wrote in an article published online June 2 in JAMA Internal Medicine.

Dr. Relman had advocated along those lines since he first warned of the corrupting influence of a "medical-industrial complex" in a landmark NEJM editorial in 1980, but "Bud was never one to let up on a subject," said Jerome Kassirer, MD, who succeeded him as editor-in-chief at the journal.

"If there was no response, he just said it again, and again, and again," Dr. Kassirer told Medscape Medical News. "He got people to listen. Even when people shrugged him off, they knew what he was saying was right."

Dr. Relman was editor-in-chief of the NEJM from 1977 to 1991. In addition to making the journal a forum for healthcare policy debate, he helped enlarged its influence. Its circulation, Dr. Kassirer reported in 1991, increased from 167,000 in 1976 to 233,000 in 1990, while the number of unsolicited manuscript rose 47%.

At the same time, Dr. Relman instilled an editorial purity at the NEJM in the 1980s that eventually became the standard for medical journal publishing. He was part of a seminal group at that time called the International Committee of Medical Journal Editors that sought to strengthen the scientific integrity of published research.

"He pointed out to all of us that we needed to think about the motivation of authors and funding sources," said George Lundberg, MD, then editor of the Journal of the American Medical Association.

Under Dr. Relman's direction, the NEJM became the first medical journal to require that study authors disclose any financial conflicts of interest. "This was revolutionary," said Dr. Lundberg, now an editor at Medscape Medical News. Other journals followed suit, but not before some foot-dragging. Disclosure statements "were seen as an invasion of privacy," he said. "Many editors and authors didn't think it was anybody's business what they owned or didn't own."

Naysayers notwithstanding, Dr. Relman won accolades for his tenure at NEJM. The late Saul Farber, MD, once dean of the New York University School of Medicine in New York City, said in 1988 that a collection of Dr. Relman's NEJM editorials would comprise "a universal, modern code of ethics for medicine."

"We Are Not Vendors"

Dr. Relman brought street credibility to his role of publishing scientific research. In 1949, 3 years after he earned his medical degree at Columbia University in New York City at age 22, his own studies began to show up in peer-reviewed journals. Dr. Relman went on to become an authority on acid-base and electrolyte metabolism, nephrology, and renal physiology.

His career as an educator included long stretches at Boston University School of Medicine in Massachusetts, the University of Pennsylvania School of Medicine in Philadelphia, and finally Harvard Medical School in Boston, where he was an emeritus professor at the time of his death.

Before he arrived at the NEJM in 1977, Dr. Relman had already had made a name for himself in medical-journal circles. In the 1960s, he was editor of the Journal of Clinical Investigation, which Dr. Lundberg described as the premiere showcase for clinical research at the time.

At the NEJM, Dr. Relman began hammering away at the profit motive in healthcare, which he considered outsized and harmful. His disfavor fell on for-profit hospitals, for-profit nursing homes, and health insurers, among other market players. More than anything, Dr. Relman worried about the effect of the medical-industrial complex on his profession.

"Will medicine now become essentially a business, or will it remain a profession?" he asked in a 1991 lecture to the Massachusetts Medical Society later published in the NEJM. "We are not vendors, and we are not merely free economic agents in a free market." The cure he prescribed was a single-payer healthcare system in which physicians abstained from financial conflicts of interest.

Dr. Relman lived and breathed healthcare reform, as did his second wife Marcia Angell, MD, another former NEJM editor-in-chief and now a senior lecturer on medical ethics at Harvard Medical School. By all accounts, he had the toughness and supreme self-confidence needed to advocate sometimes unpopular positions. But that was only one side of him, said Dr. Kassiser, now a professor at Tufts University School of Medicine.

"He came across as gruff and stern, but it was a façade more than anything else," said Dr. Kassirer. "On a one-to-one basis, he was a very personable fellow."

The NEJM issued a statement today declaring that "the medical community and the nation have lost a strong leader."

"His legacy," the publication said, "will forever remain a part of the New England Journal of Medicine."


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