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Jerry Avorn, MD, Professor of Medicine, Harvard Medical School, Co-founder and Special Adviser, NaRCAD, Author, “Rethinking Medications: Truth, Power, and the Drugs You Take.” Tags: Evidence Based Medicine, Jerry Avorn  Photo: Tim Gouw, via Unsplash For twenty years, I gave an end-of-year talk to members of our growing Division of Pharmaco-epidemiology (DoPE) at Harvard, the birthplace of NaRCAD. The other day, because we are about to be evicted from our offices to make way for programs that will generate more clinical revenue, I was cleaning out some old boxes whose contents spanned decades of my career, and found the following document. It was the text of a talk I gave to our faculty and staff exactly ten years ago, in December of 2015. Like now, that was also a time of stress; our work was often stymied by a staunchly conservative Congress that took every opportunity to limit federal spending, including for medical research. (Sound familiar?) But DoPE and NaRCAD were blossoming, and back then I tried to offer the group some solace based on the insights of a wise old man who had recently died. I hope this brings a smile to your face in this new stressful time. Feel free to circulate it to colleagues, friends, and family – especially the last paragraph. –JA December, 2015 Dear colleagues, Season’s greetings. Mentoring has always been an important value in our Division, and one reason our research has gone well is that members of our group nurture one another so effectively. I never really had a mentor of my own; the closest I came was a vicarious relationship with someone I never met, baseball star Yogi Berra, even though I have absolutely no interest in baseball. Berra died earlier this year [2015], and upon his death USA Today published a collection of his most famous quotations. His words can provide some perspective as we look back on our challenges and accomplishments of the past year, and look forward to our work in the next. It's not widely known, but Berra made several keen observations about epidemiology and the documentation of clinical choices: “You can observe a lot by just watching.” “If I hadn't believed it, I wouldn't have seen it!” He warned us of the need to be cautious about projecting our findings onto new outcomes, a problem I've previously described as "premature extrapolation": "It's hard to make predictions, especially about the future.” But to be fair, like too many of us he wasn’t always so precise in his quantitative analysis: "Baseball is 90% mental and the other half is physical.” "You better cut the pizza in four pieces, because I'm not hungry enough to eat six.” Yogi liked to reminisce about his early career, reminding me of the initial days of our own programs before academic detailing and pharmaco-epidemiology were respected fields, and before we had so many talented collaborators: [on the 1973 Mets]: “We were overwhelming underdogs … and we made too many wrong mistakes.” A fine group of smart young people joined our programs when they were just starting out, including NaRCAD’s Mike Fischer. Each year, more and more bright newcomers join our movement: "It's like déjà vu all over again.” So that now, “We have deep depth.” Our programs have brought together physicians, pharmacists, nurses, other clinical professionals, epidemiologists, and health services researchers, among other disciplines. Some of you are two or three of these at the same time. Yogi could have been referring to many in the field when he said of one player, "He hits from both sides of the plate. He's amphibious.” Berra anticipated our interdisciplinary work groups when he told his players, "Go and pair up in threes.” In these difficult times for health care in general and for academic detailing in particular, it helps to remember this advice: “Somebody's gotta win, somebody's gotta lose. Don't fight about it. Just try to get better.” Many interdisciplinary groups have trouble making this work, as Yogi explained about one gathering he attended: "It was impossible to get a conversation going, everybody was talking too much." Today, our funding is harder to get, and budgets are more constrained than ever. In his words, "A nickel ain't worth a dime anymore.” We can get frustrated that it sometimes takes several tries to get much-needed support for our activities. So it helps to have this attitude: "Slump? I ain't in no slump… I just ain't hitting.” "I never blame myself when I'm not hitting; I just blame the bat. If it keeps up I change bats. After all, if it isn't my fault that I'm not hitting, I can't get mad at myself.” He advised us to relax into our work: "You don't have to swing hard to hit a home run. If you've got the timing, it'll go.” And he offered perhaps the wisest insight for anyone in this line of work: "You've got to be very careful if you don't know where you're going, because you might not get there.” Berra also had good advice for those of us who are more senior: "If you ask me anything I don't know, I'm not going to answer.” And for those of us who are getting on in years, this suggestion: "Always go to other people's funerals, otherwise they won't come to yours.” There was this on being humble and not resting on your laurels: "Even Napoleon had his Watergate.” We all have our skills and our flaws, as Yogi understood: "So I'm ugly. But I never saw anyone hit with his face.” I should wrap up this short talk now. It's December, and the days are getting shorter, as he observed: "It gets late early out here.” Pharmacoepidemiology and academic detailing have come a long way from their first origins back in the 1980s. Now the field has many more participants… perhaps too much so! As Yogi said about a popular nightclub, "No one goes there anymore, it's too crowded.” We’re closing out a difficult year of 2015 and there’s no guarantee that the next one will be any easier: "The future ain't what it used to be.” But as we move together into the coming year, let’s remember one of Yogi's wisest and best-known aphorisms: "When you get to a fork in the road, take it.” That advice wasn’t as goofy as it sounded. I’m told he lived at the top of a hill, and the road to get to his house divided into two branches, both of which ended up at his door. So there was good advice there, both geographically and spiritually. Finally, as Yogi said at a commemorative event to honor him, "I'm a lucky guy and I'm happy to be with the Yankees. And I want to thank everyone for making this night necessary.” As for me, I'm proud to have had the privilege of working with you all throughout 2015, and I look forward to the coming year, with all the ups and downs it will bring. As we confront the stresses of the moment, let’s remember one of Yogi’s most famous insights: "It ain't over till it's over.”  December 2025 postscript : Striking a blow for evidence-based medicine: NaRCAD and DoPE continue to work hard to improve prescription drug use, but suddenly those values seem to be drowning in chaos at the national level. I’ve tried to bring some sanity to these issues in my book “Rethinking Medications,” and will be donating a portion of its proceeds to charity. So I’m not embarrassed to ask you to consider giving it as a gift to family, friends, and colleagues. That could help spread a bit more understanding of how all of us – patients, clinicians, policymakers, regular citizens – can use science and not ideology to guide the way we regulate and use medical interventions. And it has a whole chapter on academic detailing: Chapter18, ‘Better Signals.’ More information is at www.RethinkMeds.info. Warm wishes for the holiday season, and for a healthy, fulfilling, and less deranged new year. –Jerry A. Biography.
Jerry Avorn, MD, Co-Founder & Special Adviser, NaRCAD Dr. Avorn is Professor of Medicine at Harvard Medical School and Chief Emeritus of the Division of Pharmacoepidemiology and Pharmacoeconomics (DoPE) at Brigham & Women's Hospital. A general internist, geriatrician, and drug epidemiologist, he pioneered the concept of academic detailing and is recognized internationally as a leading expert on this topic and on optimal medication use, particularly in the elderly. Read More. Comments are closed.
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