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Introduction of Samuel O. Thier, MD: 2008 Association of American Physicians George M. Kober Medal
Dennis A. Ausiello
Find articles by Ausiello, D. in: JCI | PubMed | Google Scholar
Published November 3, 2008 - More info
J Clin Invest. 2008;118(11):3805–3811. https://doi.org/10.1172/JCI37666.
© 2008 The American Society for Clinical Investigation
It is a pleasure to have the opportunity to describe the life and accomplishments of the 2008 Kober Medal winner, Samuel Osiah Thier (Figure 1), who was born in Brooklyn, groomed in Boston, and who has dedicated his career to changing the landscape of American medicine. Sam’s saga starts like many of his generation — in the neighborhoods of Brooklyn.
His father, Sidney Thier, a dedicated physician himself, was educated at Columbia University and Long Island College School of Medicine, where Sam was born in 1937. Sam’s close friend in later life, Steve Goldfinger, MD, grew up 2 blocks from Sam in Brooklyn, and his father, a general practitioner, shared call with Sam’s dad. This is a practice that Steve and Sam would duplicate many years later as house officers at the MGH.
Unknown to most of us, Sam actually spent time in the South during his early childhood, where his father was a physician during World War II. Upon return to New York City with a Southern drawl, the school authorities noted his sojourn and suggested to his father that he be kept back a year so that he could “catch up” with the presumed more advanced students of his age. Sam’s father suggested he be tested and, lo and behold, Sam was promoted to a grade higher than his peers. This was a trend that would continue throughout Sam’s educational and professional life.
Sam is known for his competitive drive and his love of sports. Both of these traits began early in his life. He saw his first baseball game at Ebbets Field with his Uncle Jerry, and forever after Sam has been a huge baseball fan, in good times as well as after disappointments, such as the famous Brooklyn Dodgers vs. New York Giants game of 1951 with “the shot heard ‘round the world.” Sam was able in later life to actually embrace both Ralph Branca and Bobby Thomson at an event during his tenure as CEO of Partners HealthCare. While his first love was the Brooklyn Dodgers, in recent years, the Boston Red Sox have become his team. During his high school years, Sam was a member of the tennis team, and began a lifelong passion with that sport as well.
Moved ahead again, Sam graduated from Brooklyn’s James Madison High School just before his sixteenth birthday. It should be noted that several decades later, Sam would be elected to the Hall of Fame at this high school, along with several Nobel laureates, senators, and distinguished members of the court — including Chuck Schumer, Ruth Bader Ginsburg, and Judge Judy.
Sam, by this time, had already demonstrated his enormous intellectual capacity, honed at the dinner table with challenging conversations with his father and by listening to the durable wisdom of his Grandpa David. His joie de vivre was also evident, a reflection of the joy of his family life with his parents and beloved sisters, and reflected in his becoming an expert dancer, particularly the Charleston, under his mother’s tutelage.
While both Harvard and Yale were interested in Sam as a student, they felt his young age would be an impediment, and both strongly suggested that he take a year off to pursue other activities. Sam saw no advantage to that, and since he had been admitted to Cornell, he matriculated there at the age of 16. I think it is fair to say that both Yale and Harvard would reap the benefits, as well as the wrath, of Sam Thier later in his career.
While Sam’s enormous intellectual curiosity was evident, he had a knack for focusing on the important, and was not shy about telling his superiors of the value of their activities. Sam was a zoology major at Cornell when he was not quarterbacking the intramural football team, and not having his leg seriously damaged by his fraternity pal, Don Pasquale. Sam found going to class as an impediment to his learning, and for all intents and purposes he did not. He succeeded, of course, in generating a spectacular academic record that allowed him to head to medical school after only 3 years at Cornell — short of graduating. His most significant achievement during that period of time was that he began to date his wife, now of over 50 years, Paula Finkelstein. A few years later, Sam and Paula were married a few days after his twenty-first birthday (Figure 2).
Paula’s enormous strength of character, warmth, and calm confidence would be a lifelong asset to Sam, and strongly influenced his development of a self-confidence that was unpretentious, a man willing to help anyone who asked with a professional or personal problem.
Sam next headed to Syracuse, where he matriculated at Upstate Medical College. His penchant for feeling that boring lectures were not the most effective use of his time persisted into medical school. One distinguished member of his medical school faculty, upon preparing what he believed to be a very elegant presentation, personally telephoned Sam and asked if he would be interested in attending his lecture. Sam did.
Not surprisingly, Sam was attracted to those intellectually talented, vigorous, and passionate faculty members at his institution, such as Henry DeStefano, Professor of Anatomy; Jim Preston, Chairman of Physiology; and Phil Armstrong, who also was the Director of the Marine Biology labs at Woods Hole. Sam was always intellectually inquisitive, as the diversity of his activities reflected. Through all of this, Sam surprisingly found that his major interest gravitated to a surgical career. Indeed, he was so deliberate in his desire to pursue this that the Chairman of Medicine at Syracuse refused even to write letters of recommendation for him. In collaboration with the Chairman of Surgery, C. Barber Miller, he applied to 2 residency programs. His number-one choice was surgery at the Peter Bent Brigham Hospital, as it was then known. His second choice was medicine at the Massachusetts General Hospital. Fortunately, for all of us, the surgeons rejected Sam, and a portrait of Sam in surgical garb never came to pass. Medicine, however, welcomed him.
Holly Smith, a former Kober Medal awardee, was on the intern selection committee at the MGH at that time. He once asked Sam how he managed to be so calm and collected during what in those days was a grilling interview. Sam simply said, “MGH was my second choice.” So, in the summer of 1960, 12 young men, indeed they were all men, arrived as house officers at the MGH to begin what for almost all of them would be a distinguished career in American medicine.
Sam was the first individual ever chosen from his medical school to come to MGH in medicine. Uncertain as to what to expect, they started him on elective rotations. He notes that for the first time in his life (I would posit the only time in his life), he looked out across the Charles River and wondered whether he truly belonged at the MGH. Those doubts very rapidly dissipated. He soon came under the wing of Dr. Walter Bauer, the cherished Chairman of Medicine at the time (Figure 3).
Sam’s clinical acumen and logical approach to complex problems clearly distinguished him among his peers. So much so that when Walter Bauer, who by then was suffering from severe COPD, was admitted to the hospital, and, as was his wont, demanded a house officer to work him up, John Knowles, then head of the Pulmonary Unit, sought no one else other than Sam Thier to fulfill this duty. Sam’s intense commitment to patient care and to the individual patient that he is caring for is clearly a reflection of the lessons learned from Walter Bauer. Dr. Bauer would say to the residents that they were chosen because of their eclectic successes and excellence in a wide variety of areas, but if ever for once during their tenure as a house officer they did not put the care of the patient first, he would fire them. Sam has both lived and taught that ideal ever since.
Sam, like many of his colleagues, went to the National Institutes of Health following his residency. Sam entered the laboratory of Dr. Stanton Siegel, a renowned renal physiologist, where he began his work on aminoacidurias, and particularly cystinuria. He also befriended Leon Rosenberg. Both of these relationships have lasted a lifetime. Sam was later reunited with Stan at the University of Pennsylvania, and with Leon later at Yale, where Dr. Rosenberg was Dean of the medical school.
What excited Sam the most, of course, were the intellectual challenges posed to him and the creative excitement. While initially leaning toward a career in endocrinology, Sam wanted to be part of more action in clinical medicine, and he saw nephrology as more immediately satisfying those requirements.
Sam returned to the MGH as a senior resident, and ultimately the chief resident in medicine (Figure 4). He subsequently entered a Renal fellowship with the soon to be Chairman of Medicine, Dr. Alexander Leaf. After Dr. Leaf’s ascension, Sam became head of the clinical Renal Unit and dramatically improved both the quality and quantity of the services provided in that subspecialty. During this time, Sam became associated with many of the Boston giants in nephrology, including Arnold “Bud” Relman, then at Boston University. When Bud Relman went to the University of Pennsylvania to become Chairman of Medicine in the late 1960s, he immediately tapped Sam Thier to be his Associate Chief.
At Penn, Sam’s strengths of personal charisma, intellectual integrity, and clear vision strongly influenced the development of novel and innovative approaches to education and to the practice of medicine. The era around 1970 was a challenging time in American medicine. Many of the most distinguished medical schools, including the University of Pennsylvania, were entering transitions from private practices to a more orchestrated and evidence-based approach to medicine. Sam became a pied piper for attracting some of the very best house staff in the country into this new environment, making the University of Pennsylvania one of the most competitive medical residencies anywhere.
Sam lived by the mottos that he had learned at MGH, and now under Bud Relman, where his most important lesson, he claims, “was to tell the truth exactly as you understand it, so you do not have to remember what you said.” He was known for transparency and fairness. He was rigorous in developing the standards of promotions and was elegant in his ability to divide responsibility to facilitate organizational growth. This preparation was the foundation for which Sam would now move on and leave his mark in American medicine.
In 1975, Sam was tapped to become, at the age of 37, the Chairman of Medicine at Yale. The Dean was Bob Berliner, one of the most distinguished renal physiologists of the twentieth century, who clearly recognized in Sam the capacity to initiate change. Yale, at the time, was, to quote Sam, “in diastole.” They had many good people, but needed to transition into a more coherent and decisive force in American medicine. There was much joking about Sam’s age. One colleague quipped to him, “Being Chairman of Medicine at Yale is going to be a lot tougher than being chief resident at MGH.” To that, Sam said a resounding, “No!”
Sam set out to bring in new blood, which included Dick Root in Infectious Disease, Herb Reynolds in Pulmonary, James Boyer in GI, and Bernie Forget in Hematology, and supported the growth of young investigators throughout the institution. He fostered, for the first time at Yale, the integration of divisions within medicine with the basic science departments, so there was both intellectual and resource sharing which facilitated the recruitment and retention of talented young investigators. Of course, he continued to demonstrate his enormous talent for clarity and intellectual rigor in education. Sam never asked more of a resident than he thought they could achieve. However, his capacity for demanding continuous improvement often masked this fact. One resident, reaching a high level of anxiety as the time approached for him to present a case to Sam, proceeded to faint. This has forever lent the sobriquet of “Syncope Sam” to the legendary Dr. Thier.
Sam had the vision early on of the transition of academic health centers and their role in translational medicine, and quickly sought to secure the resources to facilitate that at Yale. He also saw the need, not perceived by many other institutions for another decade, to broaden the scope and engagement of Yale Medical School and Yale–New Haven Hospital throughout the local and regional community. He began the Yale Hospital network, which still exists today, largely as an educational endeavor to facilitate the diversity of training in primary care and other clinical specialties, but also to facilitate a close and collegial collaboration among primary and tertiary caregivers, improving the health care in the Connecticut environs.
Like most things that Sam did, he did it with thoughtfulness, clear intent, and attention to detail, stunning some, but for the most part facilitating an enthusiastic and supportive group to reach their goals. One senior faculty member, upon Sam’s arrival, said, “I think you will destroy this department.” Sam said, “Come back in 5 years and tell me whether you were right or not.” Not surprising, that faculty member came back 5 years later and said, “You were right, you brought us back.”
Sam Thier had created a model Department of Medicine. He established and celebrated not only outstanding clinicians but clinician-teachers, such as Tom Duffy, Bob Gifford, and Leo Cooney, who still are active at Yale today. Most importantly, Sam Thier reset the bar high for the faculty, historically one of the best in American medicine, now restored to that level.
We now enter the era of what I call the “3 presidencies.” After a decade at Yale, a variety of chairmanships of national committees such as the American Board of Internal Medicine and the Health Policy Committee at the Institute of Medicine, Sam became more interested in the growing pressures on the academic health center. Reminiscent of today, the area of research funding was most challenging, resulting in the diminution in the number of young people seeing the physician-scientist as a career opportunity. And of equal concern to Sam was the survival of academic hospitals themselves, with the financial pressures exerted from the introduction of prospective payments by the payers, better known to us as DRGs.
These growing interests in health care delivery and health policy led Sam to accept the Presidency of the Institute of Medicine. The IOM had been in existence for 15 years and had provided small but high-quality work on just these issues. The Institute of Medicine, however, was still in the medical and political background, and a stepchild to the National Academies as a whole, whose voice and prestige were the bellwether for influencing science and scientific policy in the government. However, the mission of the IOM within the National Academies was to provide wisdom and judgment about medicine, and who better to do that than Sam Thier, now in his mid-40s, an avid learner from his experiences at multiple institutions and passionate about the issues important to medicine in the 1980s.
The IOM had largely been a supplicant to those that could bring it funding to conduct studies. Sam, in his inimitable way, took on the job in 1985 and immediately went to the President of the National Academy, Frank Press, and said, “We have an AIDS epidemic out there. We need good information, good insight, and thought leaders to inform government, the public, and physicians alike.”
Although reluctant to support anything other than pure science, Sam convinced Frank Press that the National Academy should invest in this ambitious but needed committee, and thus was born one of the most important actions of the Institute of Medicine in the last 25 years. Sam selected David Baltimore and Sheldon Wolf as chairs of 2 committees dealing with the science and medical issues surrounding the AIDS epidemic, respectively. In 6 months, an extraordinarily short period of time, a landmark report was issued (1). It alerted all that the problem was being avoided, that it was not a unique problem to the gay community, and that it was a national and international disaster.
The New York Times later noted that this was a report that was the model for how to deal with these issues now and in the future. We take for granted the enormous activities that have followed since the 1986 report. Last year’s Kober Medal winner, Dr. Tony Fauci, has dedicated his life to dealing with the HIV epidemic. In talking to Tony about the importance of this particular IOM report, he said:
Sam Thier through his visionary leadership as President of the IOM presided in 1986 over the development of the first comprehensive and seminal public health document on the HIV pandemic entitled Confronting AIDS. Upon reading that treatise today, it is clear that it has served as the blueprint for the nation’s response to the AIDS pandemic involving the mobilization of government resources, the development of a research agenda, the importance of an aggressive prevention agenda, the care of the HIV-infected individual, and the global implications of the pandemic. It stands as one of Dr. Thier’s many outstanding accomplishments as the President of the IOM.
With one passionate and thoughtful report, Sam had reenergized the Institute of Medicine and made it an appropriate forum for the medical issues at hand. During his 6-year tenure as president, the rate of production and the impact of the reports increased enormously. They dealt with such diverse topics as the quality of medical care, technology assessment, drug development, and vaccine injury.
Sam used his energy to also push agendas that had traditionally been orphaned in our society. Good examples include one of the first reports on the abysmal state of pediatric psychiatric research, which led to changes in research funding, particularly from the National Institutes of Health. Other aspects of Sam’s role as the Institute President have remained in place today. There is a much closer cooperation and partnership with the National Academies, and there is the continued preservation of the IOM’s independence.
In his 6 years at the Institute of Medicine, its successes brought him intimate knowledge of how policy is made and how to influence that process. He could take great pride in the fact that his leadership had led to the Institute of Medicine raising the bar for its own success. At the National Research Council, a joint effort between the academies, including the Institute of Medicine, he found a new interest in the Government-University-Industry Research Roundtable, which led to a growing appreciation for the role and importance of the research university. Not surprising given his prior successes, many such universities became interested in Sam Thier. He made an interesting choice.
In the fall of 1991, he was appointed as the sixth President of Brandeis University in Waltham, Massachusetts, just outside of Boston. As always, Sam showed energy and enthusiasm for tough problems. Brandeis at that point was at a crossroads, just right for Sam’s leadership. And of course by now Sam had the reputation as the “turnaround man.” One faculty insider, knowing that Sam Thier was going to be appointed as the next president of Brandeis University, mentioned to a fellow colleague, “Did you hear who our next president is?” When told that it was Sam Thier, the faculty member commented, “Gee, I did not know we were in that much trouble.”
Committed now to the concept of the research university, he helped in his very first months to sustain the legacy at Brandeis and improve it, rather than converting it into an Amherst, Williams, or Wesleyan, as was the thinking at the time. The same skill sets that had worked so well at Yale and the Institute of Medicine again yielded great success at Brandeis. A man who served as Sam’s provost at the time, Jehuda Reinharz, and who also succeeded him as President of Brandeis University, made the following comments on Sam’s presidency:
Sam brought enormous leadership skills. He approached Brandeis with the mindset of a physician, healed the fissures in the institution, and he did it with the same self-confidence that he took on with all other problems in his medical career. Sam went to every department, listening to their issues, problems, and successes. He unlocked the paralysis that the University found itself in.
While Sam very much enjoyed being a faculty member at Brandeis, he could not avoid the lure of returning to the medical academy, and particularly to the home that was the catapult for his career, the Massachusetts General Hospital. In the fall of 1993, the MGH was searching for a new president. Difficult as it was to leave Brandeis after such short a time — indeed, he had turned down just months before the opportunity to be president of one of the most distinguished universities in the nation — Sam felt he was coming home.
The homecoming, however, was not without surprises. Three days before officially taking office in January of 1994, he was told that there was consummation of a new partnership between 2 arch rivals in Boston, the Brigham and Women’s Hospital and MGH. This indeed was an unexpected and somewhat provocative partnership.
One of the most distinguished faculty members at the MGH and Harvard was quoted at the time as follows: “As I was growing up, there were 3 very clear enemies: Communism, Yale, and the Brigham and Women’s Hospital. Here in 1994, all I have left is Yale.” Well, again Sam stepped into the breach. First he found, unexpectedly, that things at the MGH were a bit more chaotic and fragile than he had realized, but he worked to change that by streamlining administration, by building up transparent relationships between faculty and administration, and by looking at the cultural clashes that existed between the MGH and the Brigham. Most important among them was the fact that the MGH had complexity to its command and control environment. Some might even argue it had no command and control at all. But in under 2 years, Sam brought the faculty back again to a positive attitude about its world-class institution, about the caliber of the administration that could lead it, and about the partnerships that would be necessary to sustain the very important mission, where the quality of research and education directly led to the quality of clinical care.
Sam next turned his attention to Partners HealthCare, Inc., one of the few such partnerships in the United States that has set a paradigm for American medicine and facilitated success despite the stresses of a very hostile environment. When Sam took over as the CEO of Partners, he needed to convince a very talented group of individuals at both institutions, who had not traditionally worked well together, into taking risks and being creative to sustain 2 of the most esteemed institutions in American medicine. Fractious faculties often provided roadblocks to Sam’s initiatives. But as usual, with a firm hand coupled with transparency and logic, Sam was able to begin to make changes without turmoil.
In order to look at the importance of this initiative, one has to take stock of the environment in the mid-1990s. The first wave of managed care was coming to bear on academic health centers. MGH and the Brigham were not immune. The MGH had experienced a 20% decrease in its beds, the Brigham 15%. While Sam was not opposed to the concept of managed care, what the insurers were providing was managed cost, and the payers cared little for the quality of care of the patient. So Sam saw immediately the importance of this new partnership: To take back the care of the patient and provide a wake-up call to his institutions that major shifts needed to occur not simply to sustain the status quo, but to be more efficient and more creative in the clinical environment. Only then would the research and education missions associated with investments by the academic health centers survive.
The first initiative, with the help of former Kober Medal winner Gene Braunwald, was to put together a rational plan on how to protect at least 1 of the best of everything that both institutions had spent a couple of hundred years collectively building. With time, small steps, and incremental waiting to prove success to a still doubting faculty, great strides were made in blending subspecialty education and fellowships, utilizing common resources, and in some services, such as neurology and pediatrics, actually taking significant leadership in patient care and management of certain disease entities.
In addition, there was tremendous outreach to the community. This facilitated, in some cases, the salvation of outstanding clinical hospitals such as the Faulkner and Newton-Wellesley Hospitals, and in enhancing opportunities for training and clinical programs. While it is impossible to do the knockout experiment, it is clear that without this bold leadership, both institutions would have been smaller, more resource depleted, and limited in their capacity for their investments in the missions that we hold so dear. Sam realized that the clumsy attempt at the initiation of managed care gave Partners HealthCare some leeway in creating a formidable force to deal with the managed cost initiative in the late 1990s. However, Sam knew that it was only the first wave of cost containment, and it would become more thoughtful and more energetic on the part of the payers. We are now seeing this today. But what Sam put into place was an academic health partnership that was better poised for the future, based on emphasis not only on quality of care, but on efficiency of care, providing a greater value for the clinical care of the patient. Because of these measures, Partners HealthCare has remained a vibrant academic center continuing to invest in those missions that we in the AAP hold most dear: research, education, and training. For all of this, we can be grateful to the legacy that Sam has bestowed upon American medicine, and I want to reassure all of you that the proud Thier legacy goes on, thanks to the best efforts of Sam’s beloved 3 daughters, Sara, Audrey, and Stephanie, and their families (Figure 5).
I want to close with a quote by Samuel Johnson about Oliver Goldsmith, a writer, poet, and physician, that was brought to my attention by Holly Smith. These words can equally be said of Sam Thier: “He touched nothing that he did not adorn. Of all the passions, whether smiles were to move or tears, a powerful yet gentle master. In genius, vivid, versatile, sublime. In style, clear, elevated, elegant.”
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