216 C
mentary
Can a Clinician Be a Scientist? WILLIAM P. LONGMIRE, Jr, MD, Los Angeles, California
Presented at the 1990 Annual Scientific Session of the California Medical Association in March 1990, Anaheim, California. e might define a scientist as one concerned with establishing new facts, principles, or methods by experiments. And we might define a clinician as an expert in or practitioner of clinical medicine, one who attempts to improve the well-being of patients. The question then is, can a practitioner of clinical medicine ever also be a specialist in a branch of knowledge concerned with establishing new facts, principles, or methods by experiments? During the first century and a half of this country's existence, what passed as basic science teaching in most of our schools was done exclusively by faculty holding the MD degree. They were practicing physicians who made some effort, often not very great, to have additional or special knowledge in a particular science such as anatomy, physiology, and materia medica. There were no true basic scientists in most of our schools. This system of proprietary medical school education, which undoubtedly served a good purpose at one stage in the development of this country, was abused and grossly outmoded when it was finally forced out of existence during the second decade of the 1900s by the release of the Flexner Report. Although few writers have given him due credit, the dramatic improvement in medical education in this country was really initiated by Dr Arthur Dean Beven, founder of the Council on Medical Education of the American Medical Association and its chair for 24 years. After several years of somewhat ineffective efforts on its own to improve American medical schools, the Council on Medical Education joined forces with Dr Henry S. Pritchett, president of the Carnegie Foundation, and Mr Abraham Flexner was selected to survey and evaluate the medical schools in this country. His findings were published as the Flexner Report of 1910. The report was labeled, "a classic of muckraking journalism," but it caught the attention of the medical profession. It also stirred the concern of the public and permitted the Council on Medical Education to close or combine 92 of the 155 schools then in existence, thereby bringing about a most remarkable improvement in the standards of medical education. The two principles Flexner stressed in his ideal medical education were that physics, chemistry, and biology (the basic sciences) provided the intellectual foundation of modern medicine and that the scientific method applied to the practice of medicine as well as to research. It makes no difference to science, said Flexner, whether usable data be obtained from a slide beneath a microscope or from a sick man stretched out on a cot. Flexner knew that the average family W
doctor would never engage in research, but he insisted that the scientific method was indispensable to the everyday work of good patient care. As a result of these efforts, started in the early part of this century, -we physicians of today have all been educated in scientific medicine and use the principles of logic and assess*ment based on a knowledge of the fundamental sciences. We are, or should be, scientists using the scientific method in the care of each of our patients. There is, however, another level of medical science that most of us would not be prepared to, nor wish to, attain. That is the scientist who is concerned with establishing new knowledge by observation, study, or experimentation. Practicing physicians as medical scientists employ the scientific method using known and established facts in the care of their patients. The second level of medicine is a physician involved in establishing new knowledge that may subsequently be used in the practice of scientific medicine. It is the place of this medically trained investigator in the field of research, or in the creation of new knowledge, that is of major concern today. Lewis Thomas, in his delightfully readable book, The Youngest Science, tells ofthe report of a Presidential committee he chaired in which three levels of medical technology were described: * Genuine high technology, exemplified by the Salk and Sabin poliomyelitis vaccines, which simply decimated a major disease at very low cost by providing protection against three strains of poliovirus; * "Halfway" technology applied to the management of disease when the underlying mechanism is not understood and when medicine is obliged to do whatever it can to shore things up and postpone incapacitation and death at whatever cost-usually very high cost, indeed-illustrated by openheart surgery, coronary artery bypass, and the replacement of damaged organs by transplanting new ones; * Nontechnology, the kind of things physicians do when there is nothing to be done, as in the care of patients with advanced cancer or senile dementia. The committee suggested that the rising cost of health care was resulting from efforts to treat diseases ofthe halfway or nontechnology class, and it recommended that more basic research on these ailments be sponsored by the National Institutes of Health (NIH) so that genuine high technology might be developed to totally eliminate the major diseases.
(Longmire WP Jr: Can a clinician be a scientist? West J Med 1991 Feb; 154:216-217) From the Division of General Surgery, Center for the Health Sciences, University of California, Los Angeles, School of Medicine. Dr Longmire is a recipient of the California Medical Association's 1990 Golden Apple Award. This award spotlights exceptional physicians who have made a lifelong commitment to teaching and are renowned for their charismatic, scientific, and educational talents. Reprint requests to William P. Longmire, Jr, MD, Department of Surgery, Center for the Health Sciences, UCLA School of Medicine, 10833 Le Conte Ave, Los Angeles, CA 90024-1749.
THE WESTERN JOURNAL OF MEDICINE * FEBRUARY 1991
*
154 * 2
This report would seem to categorize medical care in three appropriate classes and to propose a future approach to the health care problem that is intellectually appealing. The summary of the report might be faulted, however, for expressing slight distaste for what were at that time, and are to a great extent today, the newest and most advanced therapies available, even if they only postpone incapacitation and death at extremely high cost. Later in his book, Thomas, after surviving a life-threatening experience himself with exsanguinating hemorrhage from an occult vascular abnormality of the colon, conceded that he was "more than ever a believer in the usefulness of technology, the higher the better," and concluded that the body "runs itself, beyond my management, but needs repairs by experts from time to time." One hopes that all high technology would be as easily and readily transferable to the clinic and to patient care as distributing and administering the Salk vaccine to well children. Undoubtedly, preventing all human illness is the ultimate goal, but in the meantime we cannot afford to drop all halfway technology, a great deal of which is amazingly effective, nor should we abandon efforts to improve or to develop new halfway technologies as we await the millennium of the disease-free world. It is the development or the adaptation of the therapeutic or preventive, genuinely high technology and the development and refinement of the more immediately remedial halfway technology that are being threatened today. Dr David A. Hamburg, former president of the Institute of Medicine, has commented, The authentic biological revolution that has been generated by several decades of intensive basic research is not easily translated into clinically valid applications. An interpreter is needed, and it is the clinical investigator who serves that function. Clinical research remains the vital bridge between advances in basic science on the one hand and improvements in health carediagnostic, therapeutic or preventive-on the other.1
The importance of the clinical investigator may not be fully appreciated even by well-informed persons. Some three decades ago, Albert Tannenbaum, then president of the American Association for Cancer Research, spoke of the importance of basic science research using as an example the problem of postoperative suppuration that plagued England more than 100 years ago. Most major surgical procedures done at that time resulted in death due to suppuration. A growing professional and public concern resulted in the formation of a British Empire suppurative campaign. Meanwhile, a Frenchman was demonstrating that fermentation was caused by living organisms that dropped from the air into wine vessels. This man, of course, was Louis Pasteur. Here, Tannenbaum overlooked a most important aspect of clinical research when he stated that Pasteur's work led to antiseptic surgery and largely to the solution to the suppuration prob-
217
lem. Tannenbaum omitted an essential step: It was Lister, a clinical surgeon concerned with suppuration of wounds in his patients, who applied Pasteur's basic observations of the importance of airborne organisms to clinical surgery. It was the clinician seeking the solution to a clinical problem who seized upon the observations of the basic scientist for the answer. The essential role of the clinical investigator or scientist is well illustrated in this historical anecdote. Dr James Wyngaarden, former Director of the National Institutes of Health, has also expressed concern about this problem and how it has affected the applications for research funds to the NIH: "New MD applicants are competing less well than new PhD applicants." Wyngaarden proposes an answer for this decline in clinical investigators or scientists: Success for an MD investigator is increasingly dependent on substantial training with the methodologies of complex modern science. If a young physician today wishes to contribute new knowledge to medicine, he must spend time, generally speaking, 2 years, in the study of methodologies of complex medical science. Gone are the days when a 3 month or 6 month rotation in a laboratory, frequently the hospital pathology department, could qualify a young physician as an academician or a scientist. I
Despite the obvious need for appropriately trained physicians to transfer today's dramatic scientific advances to bedside medicine, all the evidence indicates that we are moving in the opposite direction. Dr Rudi Schmid, former dean of the School of Medicine, University of California, San Francisco, reported to the Advisory Committee to the Director of the NIH that fellowship and training support, which had composed about 10% of the total NIH research budget in 1975, had dropped to only 5% ten years later, and it now represents about 4%. During a two-year period of the mid1960s, about 1,300 research training positions were eliminated, largely based on the belief that most clinical research trainees failed to continue in an academic or research career. A recent NIH study has verified, however, that NIH extramural research fellowship support over several decades produced researchers and teachers in 83% of trainees. America cannot hope to maintain its eminence in scientific medicine unless means can be found to support and to develop succeeding generations of new clinical scientists who are prepared to apply the newest and latest scientific developments and technologies to the problems of clinical medicine and to assist in proving them safe and effective for general medical use. As Wyngaarden says, to be a first-rate scientist and a well-qualified physician is a demanding calling. Those young physicians able and willing to enter into this difficult career must be encouraged and supported by every available means if we are to maintain our position in the forefront of scientific world medicine. REFERENCE 1. Wyngaarden JB: The future of clinical investigation. Cleveland Clin Q 1984;
51:567-574
mentary
Can a Clinician Be a Scientist? WILLIAM P. LONGMIRE, Jr, MD, Los Angeles, California
Presented at the 1990 Annual Scientific Session of the California Medical Association in March 1990, Anaheim, California. e might define a scientist as one concerned with establishing new facts, principles, or methods by experiments. And we might define a clinician as an expert in or practitioner of clinical medicine, one who attempts to improve the well-being of patients. The question then is, can a practitioner of clinical medicine ever also be a specialist in a branch of knowledge concerned with establishing new facts, principles, or methods by experiments? During the first century and a half of this country's existence, what passed as basic science teaching in most of our schools was done exclusively by faculty holding the MD degree. They were practicing physicians who made some effort, often not very great, to have additional or special knowledge in a particular science such as anatomy, physiology, and materia medica. There were no true basic scientists in most of our schools. This system of proprietary medical school education, which undoubtedly served a good purpose at one stage in the development of this country, was abused and grossly outmoded when it was finally forced out of existence during the second decade of the 1900s by the release of the Flexner Report. Although few writers have given him due credit, the dramatic improvement in medical education in this country was really initiated by Dr Arthur Dean Beven, founder of the Council on Medical Education of the American Medical Association and its chair for 24 years. After several years of somewhat ineffective efforts on its own to improve American medical schools, the Council on Medical Education joined forces with Dr Henry S. Pritchett, president of the Carnegie Foundation, and Mr Abraham Flexner was selected to survey and evaluate the medical schools in this country. His findings were published as the Flexner Report of 1910. The report was labeled, "a classic of muckraking journalism," but it caught the attention of the medical profession. It also stirred the concern of the public and permitted the Council on Medical Education to close or combine 92 of the 155 schools then in existence, thereby bringing about a most remarkable improvement in the standards of medical education. The two principles Flexner stressed in his ideal medical education were that physics, chemistry, and biology (the basic sciences) provided the intellectual foundation of modern medicine and that the scientific method applied to the practice of medicine as well as to research. It makes no difference to science, said Flexner, whether usable data be obtained from a slide beneath a microscope or from a sick man stretched out on a cot. Flexner knew that the average family W
doctor would never engage in research, but he insisted that the scientific method was indispensable to the everyday work of good patient care. As a result of these efforts, started in the early part of this century, -we physicians of today have all been educated in scientific medicine and use the principles of logic and assess*ment based on a knowledge of the fundamental sciences. We are, or should be, scientists using the scientific method in the care of each of our patients. There is, however, another level of medical science that most of us would not be prepared to, nor wish to, attain. That is the scientist who is concerned with establishing new knowledge by observation, study, or experimentation. Practicing physicians as medical scientists employ the scientific method using known and established facts in the care of their patients. The second level of medicine is a physician involved in establishing new knowledge that may subsequently be used in the practice of scientific medicine. It is the place of this medically trained investigator in the field of research, or in the creation of new knowledge, that is of major concern today. Lewis Thomas, in his delightfully readable book, The Youngest Science, tells ofthe report of a Presidential committee he chaired in which three levels of medical technology were described: * Genuine high technology, exemplified by the Salk and Sabin poliomyelitis vaccines, which simply decimated a major disease at very low cost by providing protection against three strains of poliovirus; * "Halfway" technology applied to the management of disease when the underlying mechanism is not understood and when medicine is obliged to do whatever it can to shore things up and postpone incapacitation and death at whatever cost-usually very high cost, indeed-illustrated by openheart surgery, coronary artery bypass, and the replacement of damaged organs by transplanting new ones; * Nontechnology, the kind of things physicians do when there is nothing to be done, as in the care of patients with advanced cancer or senile dementia. The committee suggested that the rising cost of health care was resulting from efforts to treat diseases ofthe halfway or nontechnology class, and it recommended that more basic research on these ailments be sponsored by the National Institutes of Health (NIH) so that genuine high technology might be developed to totally eliminate the major diseases.
(Longmire WP Jr: Can a clinician be a scientist? West J Med 1991 Feb; 154:216-217) From the Division of General Surgery, Center for the Health Sciences, University of California, Los Angeles, School of Medicine. Dr Longmire is a recipient of the California Medical Association's 1990 Golden Apple Award. This award spotlights exceptional physicians who have made a lifelong commitment to teaching and are renowned for their charismatic, scientific, and educational talents. Reprint requests to William P. Longmire, Jr, MD, Department of Surgery, Center for the Health Sciences, UCLA School of Medicine, 10833 Le Conte Ave, Los Angeles, CA 90024-1749.
THE WESTERN JOURNAL OF MEDICINE * FEBRUARY 1991
*
154 * 2
This report would seem to categorize medical care in three appropriate classes and to propose a future approach to the health care problem that is intellectually appealing. The summary of the report might be faulted, however, for expressing slight distaste for what were at that time, and are to a great extent today, the newest and most advanced therapies available, even if they only postpone incapacitation and death at extremely high cost. Later in his book, Thomas, after surviving a life-threatening experience himself with exsanguinating hemorrhage from an occult vascular abnormality of the colon, conceded that he was "more than ever a believer in the usefulness of technology, the higher the better," and concluded that the body "runs itself, beyond my management, but needs repairs by experts from time to time." One hopes that all high technology would be as easily and readily transferable to the clinic and to patient care as distributing and administering the Salk vaccine to well children. Undoubtedly, preventing all human illness is the ultimate goal, but in the meantime we cannot afford to drop all halfway technology, a great deal of which is amazingly effective, nor should we abandon efforts to improve or to develop new halfway technologies as we await the millennium of the disease-free world. It is the development or the adaptation of the therapeutic or preventive, genuinely high technology and the development and refinement of the more immediately remedial halfway technology that are being threatened today. Dr David A. Hamburg, former president of the Institute of Medicine, has commented, The authentic biological revolution that has been generated by several decades of intensive basic research is not easily translated into clinically valid applications. An interpreter is needed, and it is the clinical investigator who serves that function. Clinical research remains the vital bridge between advances in basic science on the one hand and improvements in health carediagnostic, therapeutic or preventive-on the other.1
The importance of the clinical investigator may not be fully appreciated even by well-informed persons. Some three decades ago, Albert Tannenbaum, then president of the American Association for Cancer Research, spoke of the importance of basic science research using as an example the problem of postoperative suppuration that plagued England more than 100 years ago. Most major surgical procedures done at that time resulted in death due to suppuration. A growing professional and public concern resulted in the formation of a British Empire suppurative campaign. Meanwhile, a Frenchman was demonstrating that fermentation was caused by living organisms that dropped from the air into wine vessels. This man, of course, was Louis Pasteur. Here, Tannenbaum overlooked a most important aspect of clinical research when he stated that Pasteur's work led to antiseptic surgery and largely to the solution to the suppuration prob-
217
lem. Tannenbaum omitted an essential step: It was Lister, a clinical surgeon concerned with suppuration of wounds in his patients, who applied Pasteur's basic observations of the importance of airborne organisms to clinical surgery. It was the clinician seeking the solution to a clinical problem who seized upon the observations of the basic scientist for the answer. The essential role of the clinical investigator or scientist is well illustrated in this historical anecdote. Dr James Wyngaarden, former Director of the National Institutes of Health, has also expressed concern about this problem and how it has affected the applications for research funds to the NIH: "New MD applicants are competing less well than new PhD applicants." Wyngaarden proposes an answer for this decline in clinical investigators or scientists: Success for an MD investigator is increasingly dependent on substantial training with the methodologies of complex modern science. If a young physician today wishes to contribute new knowledge to medicine, he must spend time, generally speaking, 2 years, in the study of methodologies of complex medical science. Gone are the days when a 3 month or 6 month rotation in a laboratory, frequently the hospital pathology department, could qualify a young physician as an academician or a scientist. I
Despite the obvious need for appropriately trained physicians to transfer today's dramatic scientific advances to bedside medicine, all the evidence indicates that we are moving in the opposite direction. Dr Rudi Schmid, former dean of the School of Medicine, University of California, San Francisco, reported to the Advisory Committee to the Director of the NIH that fellowship and training support, which had composed about 10% of the total NIH research budget in 1975, had dropped to only 5% ten years later, and it now represents about 4%. During a two-year period of the mid1960s, about 1,300 research training positions were eliminated, largely based on the belief that most clinical research trainees failed to continue in an academic or research career. A recent NIH study has verified, however, that NIH extramural research fellowship support over several decades produced researchers and teachers in 83% of trainees. America cannot hope to maintain its eminence in scientific medicine unless means can be found to support and to develop succeeding generations of new clinical scientists who are prepared to apply the newest and latest scientific developments and technologies to the problems of clinical medicine and to assist in proving them safe and effective for general medical use. As Wyngaarden says, to be a first-rate scientist and a well-qualified physician is a demanding calling. Those young physicians able and willing to enter into this difficult career must be encouraged and supported by every available means if we are to maintain our position in the forefront of scientific world medicine. REFERENCE 1. Wyngaarden JB: The future of clinical investigation. Cleveland Clin Q 1984;
51:567-574
