Opinion | Have We Lost Democracy and Science at Our National Medical Meetings?

It was only a few decades ago when physicians would approach their attendance at scientific meetings with great anticipation. Regardless of the stage of their career, the annual scientific meeting was the academic highlight of the year. It was a time when we would learn, challenge and be challenged, and celebrate or be humbled, in the hopes of returning home with a renewed sense of energy and purpose. If your medical specialty had two or three scientific meetings a year, you were particularly fortunate.

In the 1980s, our small heart failure research group at Mount Sinai practiced every night for weeks before the start of each congress. Everyone who had an abstract presentation developed their slides and texts with extreme devotion. The goal was to present new data accurately and clearly; the slides needed to be succinct and uncluttered. But our primary focus was preparing for the 5-minute question period, during which we might expect every conceivable point of contention. We taught our young presenters how to listen carefully and respond appropriately; how to answer a question; and most critically, how to remain calm when under fire.

Only the younger members of our research group gave presentations. It did not matter if they were a physician, an exercise physiologist, or a research nurse. They would benefit from the experience far more than the older faculty. It was an ideal time for personal and professional growth.

Our group also reviewed the planned presentations of our colleagues in the same field before we arrived at the conference. We discussed what others were going to show, what methods they might have used, and what implications their work might have for our own projects.

The congress center was filled with thousands of people, often tens of thousands of people. When a member of our research group was scheduled to present, the room typically had between 500 to 1,000 people in attendance, if not more. Because the presentation had been rehearsed so many times, it typically went very smoothly.

But then, the moment of truth arrived: the question and answer period.

The session chairs would announce it with the formulaic phrase, “This presentation is now open for discussion,” and 10 to 20 people would walk (or race) to the floor microphones, waiting to be recognized. Anyone — literally anyone — could ask a question or make a comment. There was no prescreening, and people could say almost anything. But in general, most did not make the journey to the floor microphones to make laudatory remarks.

You knew you were in trouble when the person at the microphone began with, “Very nice presentation.” Yes, many people who said these words may have meant them, but typically, they were a foreboding to something more sinister:

“You do realize we published the same observations years ago. And you did not recognize our work in your presentation.”

“You understand that you used the wrong medication at the wrong dose in the wrong patient population. Do you not think that should cause you to question the validity of your conclusions?”

“Your work is based on assumptions about how the body works, and those assumptions are simply wrong. I have no idea what your observations might possibly mean.”

Very few people ever went to the microphone to convey sincere congratulations. If someone truly admired or enjoyed the presentation, they would generally approach the presenter privately after the presentation was over.

During the presentation, every member of our research group was in the audience. When the young presenter returned to their seat, they would typically look towards me to see my reaction. These were the days before one might silently clap or give a thumbs-up sign. The most positive feedback I could provide to the young presenter was a smile and a slow, approving nodding of the head.

As a “mid-career” member in my field, it was my responsibility to go to every relevant presentation and ask my own questions at the open floor microphones. These floor microphones were “democracy in action.” Even at major presentations that attracted 3,000 to 5,000 people, all questions were taken from floor microphones. Again, anyone could ask a question.

When we returned home after each meeting, our research group had a major debriefing. What had we learned? What could we have done better? How would our research program change? Altogether, it was an exhilarating experience that promoted personal and professional growth.

But now, 30 years later, our annual meetings have changed — a great deal.

The number of scientific sessions that present original data has shrunk. Some sessions are devoted to “experiences” rather than “data.” Today, the program is not designed to expand the mind, but to comfort the soul. Social reinforcement — rather than scientific discourse — are the priority for attendees.

To be sure, there are still abstract presentations given by young faculty. But the rooms are sparsely attended. In general, mid-level and senior leadership are not present; they are busy attending off-site meetings. When the young presenters finish their 10-minute talk, the moderator opens the session for questions. But hardly anyone walks to the floor microphones.

Should the moderator invent some questions? It is current practice for the chair to laud the presentation, whether or not they think it is worthwhile. The actual work may have been terribly flawed with substantial methodological issues — but it is no longer considered appropriate for anyone to make anyone else uncomfortable.

The situation is even worse for the major presentations. At many meetings, the presentation of megatrials draw a big audience. But there are no open microphones. Instead, the congress organizers have selected a “designated discussant” who has 5 minutes to “represent the view of the audience.”

The designated discussant is well-positioned to present a critical analysis of the presentation, and sometimes, that happens. But more typically, the designated discussant simply repeats a few highlights from the preceding talk. And nearly always, they begin and end their short presentation with the words: “The investigators are to be congratulated for doing a very fine study.” The real goal of the designated discussant is to inform the audience that all is well — even if it is not.

Are young physicians and investigators involved in these major presentations? They are absent. They are typically not doing the presenting; they are not designated discussants; and they can ask questions only through an electronic submission system in which all questions are prescreened and modified.

What lessons are our national meetings leaving to the next generation? Are we telling them we do not value those who rock the boat or those who might make anyone uncomfortable? Will we be satisfied reinforcing what they already know, even if it is incorrect? To some societies, young physicians at national meetings matter only if they have more than 10,000 Twitter followers.

In my view, this is not science, and it is not democracy.

I want to be clear: I am not saying young physicians are not getting rigorous training at their home institutions. Most top-tier academic programs still do extensive preparation of their young fellows and faculty before a major meeting. But in the past, much of the professional growth of young physicians took place at national meetings where they interacted with senior faculty from other institutions, who typically had ideas and conceptual frameworks quite different from those that dominated their home base. These interactions were the essence of democracy, but now, they are virtually gone.

The loss of science and democracy at national meetings is so profound that — at least in cardiology — a group of young physicians known as “CardioNerds” have banded together to create a website intended to democratize cardiovascular education and invigorate a love for cardiovascular medicine and science. If you have not visited their website, I highly recommend it. My interactions with them helped to inspire this essay.

Some may say my description of national meetings pertains to the way medical meetings took place before the COVID-19 pandemic. But the pandemic has not made things better. When the pandemic is over, the issues with national meetings will still be there, and they are likely to be worse.

Many will rightfully say this essay represents the musings of an aging physician who remembers the past with too much fondness — a yearning for the “good old days.” He has not kept up with a changing world, and he has idyllic memories of a privileged career development, which cannot — and should not — be replicated in the current era. If anyone believes that, it is only because they simply weren’t there. And they do not realize how much democracy and science — especially for young physicians — has been lost. Indeed, the loss of democracy is a secular trend. Freedom House reports that global political freedom has declined every year since 2006.

Personally, I cannot forget what democracy and scientific discourse was like only a short time ago. Those who share those memories are getting older, much older. And soon, we will not be able to tell our stories — either because we will not be permitted to do so or because our states of dementia will have progressed to the point that we will not know whether our stories ever represented reality. Or we will have passed on.

Yet, those of us who remember the magic of medical meetings of the past will not have truly aged. As Steven Kurutz recently noted in The New York Times, aging is not merely a biological process; it is better defined as a sapping of the spirit. It is not the appearance of wrinkles, the graying of hair, or the creakiness of gait. It is the loss of the ability to engage in the wonderment of being able to think differently and with joy; to be challenged and to challenge others from many other places; and to make your colleagues feel uncomfortable, because only discomfort yields progress.

So perhaps it is the annual medical meeting that has aged, and not I.