American Society of Nephrology Presidential Address 2005
Authors: Tomas Berl
Journal: Journal of the American Society of Nephrology (2006)

“Science is the most communal of endeavors,” wrote the late and eloquent Dr. Lewis Thomas, who was one of my esteemed professors at New York University Medical School in the 1960s. In a Foreign Affairs monograph, Dr. Thomas described how the building blocks of physics and biology in this century had been put together one piece at a time, by men and women whose identities have been forgotten. Men and women who made the greatest medical breakthroughs will have their names forever associated with their discoveries. In the same monograph, Dr. Thomas noted that “while few giants were gifted in being able to figure out where the key pieces would fit, the pieces themselves came from other minds and hands.” As I look around this large hall and see thousands of investigators, clinicians, and trainees in nephrology, I see an excellent example of precisely the kind of scientific communalism Lewis Thomas prized so highly. During my 35-yr career in medicine, I have become well acquainted with the joy and challenges of working with individual scientists to fit together pieces of our own complex puzzle. As American Society of Nephrology (ASN) president, however, I have been afforded the opportunity to piece together much larger puzzles on the broad, organizational level as well. Let me describe one of my fondest memories from my past year in office, which illustrates the potential of the communal endeavor. One cold day last winter, I met with Dr. Elizabeth Nabel, Director of the Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health’s (NIH’s) headquarters in Bethesda. There were others at that meeting, and Dr. Nabel looked around the conference room and posed a simple question that resonates with me still: “Who is at the table?” she asked. Who was at the table (Figure 1A)? Aside from myself as the representative of the ASN, I brought the president of the National Kidney Foundation, the president of the American Society of Transplantation, and the president of the American Society of Pediatric Nephrology. We had come to raise, in a single voice, an issue that the ASN has for several years deemed one of the most serious public health crises emerging in our time: The link between cardiovascular disease and kidney disease. That day, those at the table spoke of the urgent need for congressionally funded research to study this connection between cardiovascular disease and kidney disease and to make concerted efforts to raise public awareness. This concern, expressed in unanimity, impressed Dr. Nabel to the extent that she quickly agreed to establish a collaborative effort with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), which in turn led us to prepare a request to Congress for appropriations. It was, to be certain, just an early step in bringing the matter to Congress’s attention as much more work needs to be done. Our organizations’ collegiality and the clarity of our shared goal made a powerful impression on NIH. Rather than display divisiveness and conduct the sort of territorial warfare that can politicize medical progress and confuse priorities, we all expressed our commitment to finding better ways to treat the silent killer that is kidney disease, and that has, in some populations, reached epidemic levels. The essential communalism in science, engaging each of our organizations’ unique strengths, is what it will take to move the pervasiveness of renal diseases to the forefront of public awareness, as has previously been done with high BP, stroke, and heart disease. And while the congressional initiative we asked for will progress slowly, the ASN is collaborating in a new way with the American Heart Association (AHA; Figure 1B). The ASN and the Kidney Council of the AHA are holding identical sessions on the cardiovascular-renal nexus, at the respective annual meetings of each. This is the first time in our history and theirs that identical sessions on a topic of mutual concern are being held at our most significant yearly gatherings. This kind of transspecialty collaboration comprises the “other minds, other hands” Dr. Lewis Thomas praised. I ask you to think of this ASN Annual Meeting as one enormous table, which we come to for the exchange of ideas and for discussions on discoveries that will advance our knowledge and practice of nephrology. This is what our society’s founders had hoped the ASN would do. I have little doubt that they would be enormously proud to witness the quality and quantity of science being shared during Renal Week 2005. The meeting we set before you this week, however, is largely the work of my invaluable associate Dr. Mo Sayegh, Program Committee chair, and a most distinguished panel of ASN members (Table 1). This year’s, American Society of Nephrology Program Committee has assembled a record 56 symposia in a full array of leading-edge topics in both the basic and clinical sciences. Our panel of discerning, devoted reviewers evaluated a record 4450 submitted abstracts to arrive at, again a record, 52 Free Communication sessions. Novel this year are four Free Communication sessions in the basic science area that will focus on diabetes mellitus, glomerular biology, therapeutic targets in acute renal failure, and osmoregulation and solute transport. The sessions’ organizers have invited senior scientists to participate, and at a dinner following the sessions, Dr. Peter Agre, winner of the 2003 Nobel Prize in Chemistry, will make brief remarks. Along with the work of the Program Committee, our well-known Post Graduate Education director, Dr. Robert Narins, and his committee (Table 2) have organized and supervised a number of superb preliminary courses and clinical nephrology sessions. Since it would be impossible to attend all of the sessions presented here and because many of our members cannot be here for Renal Week, Dr. Narins and the Post Graduate Education Committee have provided complementary alternative conferences by offering ASN Highlights on various weekends in seven additional cities in North America. These outreach sessions are an excellent complement to Renal Week here and have been increasingly attended since they were first offered in 2004. All our sessions during Renal Week and those I have just told you about are key components of the ASN′s educational mission. Our educational purpose is also well served by our primary publication the Journal of the American Society of Nephrology (JASN). This year we achieved a seamless transition to self-publication of JASN, owing to our excellent staff and editors. Under the highest standards set by our editor, Dr. William Couser, and deputy editor, Dr. Allison Eddy, JASN remains the most respected journal in the field of nephrology, an absolutely essential resource for practitioners and researchers. Drs. Couser and Eddy are aided in this undertaking by a dedicated group of associate editors who reviewed approximately 1200 manuscripts last year. Another daunting task, keeping our members engaged in clinical work abreast of the literature, has been ably shouldered by NephSAP editor Dr. Richard Glassock, who oversees this extremely valuable publication, along with recently appointed deputy editor, Dr. Ronald Falk. At NephSAP, they are aided by discerning associate editors who read all of the pertinent literature, extract key findings, and summarize and publish those findings every 18 mo. The quality of NephSAP has now been recognized for its excellence by the American Board of Internal Medicine, which has agreed to provide recertification credits to those who complete the exam questions included in the back of each issue. Capping our publication feats, we are putting the finishing touches on a clinically oriented publication, the Clinical Journal of the American Society of Nephrology (CJASN), which will be published every 2 mo. Less than 50% of this journal will include original research, while the remainder will focus on reviews, controversies, and special features. CJASN editor, Dr. William Bennett, with his deputy editors, Dr. Mo Sayegh and Dr. Harold Feldman, will be assisted in this task by a talented group of associate editors. We foresee that this newest addition to our publications will be well received by practicing nephrologists and will ultimately serve as an outlet for the growing number of outcome studies emerging in our field. These are all examples of collaboration, within the ASN. To gain a more generalized understanding of scientific collaboration, however, I thought it would be interesting to analyze major published research by looking at the authorship of original peer-reviewed articles in the Journal of Clinical Investigation, between January and June 1980, and comparing the number of co-authors listed in these issues with those from the same period in 2005. As depicted in Figure 2, the number of authors per manuscript has risen significantly, from a mean of 3.7 in 1980 to almost 10 authors per paper in 2005. Likewise, the number of institutions involved in conducting research with findings worthy of publication in a top medical journal has also risen significantly, from 1.4 to 3.7 institutions per published paper. These graphs illustrate the increasing breadth of collaborative science, necessitated by the interdependence of researchers who are abreast of the latest changes in technologies and highly specialized techniques. These collaborative efforts are not bound to a single country or even to a single continent, confirming the composer Phillip Glass’s observation that “we can no longer pretend we’re living in different worlds because we’re living in different continents.” With that in mind, the ASN has increased its interactions with its counterpart societies around the world (Figure 1C). Our productive dialogue with the leadership of the International Society of Nephrology will lead to the first joint programs as early as the 2006 ASN San Diego meeting and the World Congress of Nephrology in Rio de Janeiro in 2007. We are most supportive of the International Society of Nephrology’s noble mission to educate and provide better renal care in remote corners of the world where chronic kidney disease is increasing at a pace that outstrips the level of care and providers. We in North America do not have all of the answers. Recognizing this, we have established a bilateral arrangement with the European Renal Association to allow for the reciprocal sharing of highlights from our annual meetings. For the first time during Renal Week, we present the important points made at the European Renal Association meeting held in Istanbul last June. In expanding international dialogue and cooperation, I am honored to have been a partner with my predecessor, Dr. William Mitch, in launching a program with the Sociedad Latino-Americana de Nephrologia e Hipertension that enables young nephrologists from Central and South America to spend a month in the United States and attend the ASN meeting. Sitting here among you are 10 such dynamic young people. While we have achieved a great deal, we cannot ignore the fact that the practice of our profession, for both clinicians and investigators, faces monumental challenges. Specifically, in the scientific arena, the generous increases that stimulated much research from 1999 to 2003 have come to a grinding halt. Increases in the NIH budget over the last 2 yr do not equal increases in the cost of living index, although the continuing rise in the cost of health care in this country outstrips virtually every other sector. The proposed NIH budget for next year looks even more austere. These figures correlate with significant decreases in pay lines for both investigator-initiated research and training grants. Dr. Allen Spiegel, director of NIDDK, compares this situation to what happens if you cultivate a garden for several years and then deprive it of water. Recognizing this problem, the ASN convened research retreats in the areas it felt most deserving of attention and presented to NIDDK and NHLBI a very focused list of recommendations for these lean years. This was followed up by continuing active advocacy at the congressional level. Finally, the ASN Council has committed the society to increase its support of research awards, particularly directed at young investigators attempting transition from mentored to independent awards (Figure 3). We know how important these awards are. One grateful recipient told me, and I quote, “The Gottschalk Award I received was critical in my ability to ultimately receive NIH funding and to remain involved in research. I am so very thankful to the ASN.” While the $2.3 million we have allocated to research grants is modest, it represents a significant portion of the society’s operating budget. To secure a more reliable source to fund these vital projects, I am announcing that the ASN is launching a campaign to develop a robust research endowment, with a goal to raise $40 million over the next 5 yr. Given these difficult times, I realize that there are many causes worthy of your support, but I trust that you will find this cause to be most deserving of your generosity. Our challenges are by no means limited to the crisis in funding our research and training enterprises. The mechanisms that fund the care of our patients with kidney disease are likely to undergo profound changes as well. The ASN, on behalf of a large segment of our membership involved in the clinical care of patients in both the private and academic settings, can no longer remain on the sidelines. We have and will become more engaged, studying these changes closely and increasing our vigilance. We will work to be a part of the process so we will have more input into what those changes in care will be. To this end, the society has markedly increased its activities in the public policy area this year, with the assistance of our public policy director, Mr. Paul Smedberg. To reflect our commitment to this effort, we have proposed a revision to the society’s bylaws to clearly state that “advocating for the development of national health policies to improve the quality of care for renal patients” is in fact one of our missions. Pursuant to the recommendations that emerged from a strategic retreat, we are forming a Public Policy Board. I am pleased to announce that Dr. Jonathan Himmelfarb has accepted the position as chair and will formally take on this role at the conclusion of our annual meeting. In the spirit of collaboration that underlies my message, over the past year we have worked closely with our colleagues at both the Renal Physician Association and the National Kidney Foundation to coordinate our activities and to speak in unison to governmental agencies (Figure 1D). We have undertaken under our auspices common visits to the Center for Medicare and Medicaid Services (CMS) and, using the society’s often-quoted publication on the application of the P4P model to renal disease, emerged with common guidelines as to how this high-priority initiative may best be instituted in our specialty. Much work remains in this arena, and we are joining with Kidney Care Partners to ensure the development of an outstanding, quality-initiative process to the benefit of all stakeholders. It is customary at this juncture for the ASN president to recall prominent leaders or awardees of the society who have left us in the past year. To my knowledge, there is no such individual this year, although I do want to note the sad passing of Dr. Jaime Herrera (Figure 4), a leader and pioneer within our sister society in Mexico. Dr. Herrera was a gentleman with a gentle demeanor. I recall vividly his enthusiasm for science when I visited his laboratory not long before he died. He collaborated with many members of the ASN, and his investigational and clinical careers solidly cemented relations between us and the robust presence of nephrology in Mexico. I cannot but note the tragedy that befell so many of our fellow citizens in the wake of the Katrina hurricane. The renal community did not go unscathed as physicians, trainees, and patients were victims of this catastrophe. Many of our society’s members became true heroes in the midst of this disaster, and although I certainly cannot mention them all, I want to pay tribute to our colleague Dr. Lee Hamm, who, as chair of his department, operated under the most adverse conditions and coordinated the evacuation of the patients in his hospital. The experiences and lessons are many; some will be shared by those who participated in a special session scheduled at these meetings. It is clear, however, that we need a more effective emergency system to better care for our patients, should such a catastrophe occur again. The ASN will actively participate in forming a task force that will provide suggestions for further action. This year you entrusted me with the extraordinary opportunity to lead the American Society of Nephrology. I want to heartily thank you all, who with your vote provided me with this unique, cherished responsibility. However, I would have never reached this juncture had it not been for the mentorship of my dear, lifelong friend, Dr. Robert Schrier. Dr. Schrier taught me the tools of research, the value of perseverance, and set me on this path. This year we have chosen to recognize him by establishing the Robert W. Schrier Lectureship. Dr. Peter Agre holds the honor of delivering the first of these lectures. Nor would have I reached this point in my profession had it not been for the collaborative relationships with the fellows and faculty at the University of Colorado and many other scientists around the world over the last 35 yr (Table 3). I am grateful for the example set by those who preceded me as presidents and on the council, particularly Drs. Hostetter, Alpern, Blantz, Siegel, Mitch, and Stokes. The decisions I have had to make this year were all made in close consultation with those who served on the council with me this year: Drs. Mitch, Du Bose, Krensky, Henrich, Aronson, Coffman, and Anderson. I am most thankful to each of them for their continued support. This year might have been a most difficult one were it not for the consistent and loving support of my best friend and counselor, my dear wife Diane. She gracefully bore my innumerable conference calls, frequent travels, and most of all my mental absences even when we were together. I could always turn to her for wise and balanced advice and find solace in her words if I felt discouraged. Finally, the society could not function without an extraordinary staff in Washington. While I cannot mention all those who deserve to be recognized, they work under the devoted leadership of our most competent and extraordinary executive director, Dr. Karen Campbell. I want to close by telling our younger colleagues of a book that persuaded many of my generation to pursue the science of nephrology. The book is called From Fish to Philosopher, published in 1953 by Dr. Homer Smith, a true giant in our field and, incidentally, a Colorado native and professor at the NYU School of Medicine. In the tradition of giants who stand on the shoulders of earlier giants, Dr. Smith opens his book by recalling Claude Bernard, the 19th-century French physiologist who was the first to point out that the true medium in which we live is neither the external air nor water but the plasma that bathes our organs in our “internal environment.” Bernard appears to have understood the importance of collaborative efforts and was fond of the woodcut depicted (Figure 5). It took no less than four physicians to study a urine sample in this patient with dropsy. And in keeping with the collaborative message I share with you today, it is of interest that Bernard distinguished between what he referred to as the “personality of Art” and the “impersonality of Science.” He said: “Art is I. Science is We.” This week in Philadelphia, the “We” belong to the American Society of Nephrologists, and We hope you come away from this week, energized to pursue your very important work. We hope you will utilize ASN′s vast resources so that your minds and your hands will fit together a few more pieces in the year ahead.Figure 1: American Society of Nephrology’s (ASN′s) collaborative efforts in 2005. (A) Collaboration at the National Institutes of Health (NIH). (B) Collaboration with the American Heart Association (AHA). (C) Collaboration with renal societies outside the United States. (D) Collaboration for advocacy at CMS.Figure 2: Significant increase in authors and institutions per manuscript from 1980 to 2005 in the Journal of Clinical Investigation.Figure 3: ASN′s expenditures for grants from 2000 to 2005.Figure 4: Dr. Jaime Herrera.Figure 5: Physicians studying urine sample.TABLE 1: 2005 ASN Program CommitteeTABLE 2: Postgraduate Education CommitteeTABLE 3: CollaboratorsI thank Dyana Furmansky and Kate Hoch for assistance in the preparation of this speech and manuscript, respectively.