SYMPOSIUM * COLLOQUE
Enormious challenge, enorimous prominse:* Integrating molecular biology into clinical medicine
David Spurgeon tients more closely in touch with biomedical research. Participants felt it provided an unusually lively, frank and stimulating exchange. Dr. John Potts, the chief of medical services at the Massachusetts General Hospital, described "how molecular biology has changed the field that I have worked in" and "has speeded up and transformed the pace and scope of what we do". Potts said the impact has been tremendous: "In disease pathogenesis we are beginning to see at the molecular level exactly why certain deficient states exist." In disease prognosis, the ability to examine gene rearrangements is providing a new way of staging disease. Gene amplification is beginning to explain why tumours "undergo a further malignant deterioration after the initial malignant event" and increase knowledge about the "escape of tumours from chemotherapy". Recombinant DNA products manufactured from mammalian and bacterial cells are already commonly used and gene-replacement therapy is no longer a distant prospect, said Potts. Many cytokines and hormones cloned David Spurggeon is a fteelance writer living 10 to 15 years ago are now available for therapy "and for careful ii.noln Tremnblant, PQ.
olecular biology is bringing about fundamental changes in clinical medicine and training. The changes are confusing and difficult to adapt to, but both the challenge and the promise of integrating molecular biology into clinical medicine are enormous. That was the message that emerged clearly from an International Symposium on Biomedical Research held at the Institut de recherches cliniques de Montreal (IRCM) on Apr. 2. Speakers included senior scientists from leading university medical faculties and research institutes in Canada, the United States and Great Britain. Organized by Dr. Michel Chretien, IRCM's scientific director and chief executive officer, and consultant Dr. Jacques Genest, both professors of medicine at the universite de Montreal, the symposium was designed partly to help clear up what clinical scientists see as confusion among Canadian funding bodies and others about the nature of clinical research. Another aim was to help put physicians dealing with paM
1304
CAN MED ASSOC J 1990; 142(11)
dissection in terms of analogs that can be prepared and introduced into clinical medicine.... The idea of making parathyroid hormone in bacteria and mammalian cells opens up a variety of approaches that would have been undreamed of 10 or 15 years ago.... There are tantalizing possibilities in therapy as one asks a different kind of question using the molecular biologic techniques".
Concerning oncogenes, Potts said: "It's clear we know a lot of the players but we don't have the script and we don't see the whole play unfolding." Another fascinating story is the antioncogene concept. Instead of causing excessive production of growth factor, as oncogenes do, antioncogenes act as "a sort of cellular brake". The prototype is retinoblastoma. Potts said it is important to train physicians in molecular biology: "For physicians to be unable to have among their ranks anyone who's familiar with this to my mind is very dangerous and would probably impede progress." To meet the new training needs, the Massachusetts General Hospital has been taking physicians interested in molecular biology and encouraging them, after full clinical training, to commit
1-
themselves to another 4 to 5 years in the subject. Such people have brought a new perspective to medicine. Most have not had PhD training and find it very challenging to begin another career. "So I've developed a sort of 'den mother' or 'safe harbour' club", said Potts. Four times a year the group goes to his house for a sherry hour and informal dinner, where one of them presents a paper. In addition, Potts visits every one of them during the year to check on progress and to ensure they're receiving adequate support. A committee also reviews their progress once a year. Potts said the experiment is proving successful. "It's their own energy that is the key element in their success, but we're there to support them, to follow what's happening and to guide them into faculty careers upon the completion of this training experience. What they bring back after 3 or 4 years in these laboratories - and they're working with the very best - is a great sense about the excitement of molecular biology and modern cellular biology.... They have a sense of what PhDs are doing in the laboratory and are protective towards them. They can also interact with their medical colleagues. They tend to spend time as attending physicians in the ward, and they bring a particular perspective on where the challenges for tomorrow might lie. "My conviction is that for the right people - and a certain number only in the department - this is a challenging career that I believe is essential to maintain the close ties that can exist between the most advanced biological research and clinical medicine." Dr. George Cahill, senior scientist and assistant to the president of the Howard Hughes Medical Institute and professor of medicine at Harvard Medical School, said clinical science has traditionally involved "looking at patients, looking at disease processes and
Can FPs.. be trained to-keep. up with me.dical advances?... Where will-all the current em.molecular biology phasis. on leave .the .family physician? How will he be trained to keep up with medical advances? This question arose after the presentation by Dr. George Cahill, a professor of medicine at Harvard University Medical School. His reply: "One does not want. to.. downgrade or create a. seond-class citizen, but on .the o.ther: hand -one can't afford to.: give [family physicians] absolutely cutting-edge
biomedical science and have. the`m .`spe.nd ..a. year in a labor.a-
tory. on. .molecular biology'. Sure, the gu,y who is going to be. a family practitioner would be a better doctor. if he did, no question about it, but we can't afford to do that to the 16 000 to 20 000 graduates coming out of American medical schools each. year. I think eventually it will end up..as a kind of two-tier. system, but hopeffully with a.ppropriate recognition of. each". Other, with respect."
The challenge to medicine is interventions, and assessing them statistically to see whether you've to train physicians familiar with done something or not". Continu- this field and its impact, within ing in this vein is still crucial, one reasonable lifetime and with"but there's now a whole new phase of science - the fundamental scientist in the clinical setting" who spends 90% or more of his time in the laboratory doing "fundamental, cutting edge molecular
biology". Mouse genetics is becoming highly important in the understanding of human disease, Cahill said. By crossing two different strains of mice and mapping genes, all their genetic characteristics can be traced - about onethird of the mouse gene has already been mapped. "This is going to absolutely open up the finding of disease loci and disease genes in man", he said. "It's going to be an entirely new field. Coupled with that, it is now possible to make specific mutations in specific diseases in experimental animals, and to put those genes back in another animal, and with genetic recombination technology one can then map and follow on where other genes are near it.... The person in clinical research is going to have to know all about these activities."
out too much expense. "For the past 5 years I've been responsible for some 40 or 50 medical students coming to the NIH [National Institutes of Health] to study in depth fundamental science", Cahill said. "Some of these youngsters are superb biologists and they should race through their MD degree and then get right into a lab." He questioned whether all should even bother with the MD degree, considering the time, effort and expense necessary. "When I meet them, I ask them about how much it means to them to have a person-to-person contact", he said. "About nine-tenths say it's crucial and that's why they came to medical school, so I tell them to go ahead and get the MD degree anyway." He advises those who do to try to complete the course more quickly than usual and while doing so to keep up some lab work.' There are now six medical schools in the US that offer 1 year of obligatory research experience, he said. Several are considering granting a master's degree in biCAN MED ASSOC J 1990; 142 (I 1)
1305
- -0
omedical science for that year. For the average physician to become a clinical scientist, the traditional preparation is totally inadequate, Cahill maintained. The doctor needs "in-depth, hands-on, wet-lab experience" to be able to compete satisfactorily. How? By making training "openended, versatile, patterned, elitist in a way". The MD/PhD route is the most successful. But, it is impossible to give large numbers of physicians such training, he said. Only about 200 can be trained annually in the US - just over one per American medical school. This route has been popular because those who enter it are outstanding students and because their way is paid by the federal government or other sources. "At graduation from a state school in the United States an average medical student now is $40 000 in debt. [Education at] a private school may lead to debts of $85 000. How is that individual going to dedicate her or himself to a career in biomedical research on a modest salary, with the unpredictability of getting research grants? The only way is tremendous determination and dedication. I saw one student several months ago who was $135 000 in debt. Her father is an engineer at General Motors, making about $95 000 a year, which makes her ineligible for support: the middle class are rich enough not to get support funds or scholarships. She has three siblings, all of whom went through private school. She paid her way through Bryn Mawr and medical school. How is she going to repay that debt on the $25 000 to $35 000 income that the general postgraduate job provides?" No matter what training route they take, physicians and PhD holders will probably end up working together in a collegial atmosphere, understanding each other's approach, Cahill said. 1306
(\AN NiI) XSNUC
J 990 142 (I
Siminovitch: best setting for research is the research institute
"I'm really not quite sure what clinical science is today. I'm certain that there can be no fixed route to train people: it has to be highly variable.... We may have to become more elitist, with two tiers - a clinical and an academic setting." A different perspective was provided by Dr. Alvin Feinstein, director of the Robert Wood Johnson Clinical Scholars Program and professor of medicine and clinical epidemiology at Yale University Medical School. He posed this question: Do real challenges still remain in clinical medicine in an era dominated by molecular biology? "(I want to make clear I have nothing but awed admiration for the accomplishments of molecular biology. I am asking, however, is there another side to that coin?" He declared that an intellectual hierarchy exists that says "that explication is basic, important, fundamental, worthy of firstrate minds, and that intervention is applied, less worthy, suitable for people who are not bright enough to do basic research". If this is so, he wondered, "why do we have so many unresolved problems in clinical science in the last part of the 20th century?" He
asked if there is any connection between some of these problems in diagnosis, therapies and the delivery of care "and the fact that we have systematically now for almost a century told our best and brightest that the only place to use a good mind is in the lab". Many clinical problems that pose real challenges remain, he contended, and clinical and laboratory research are very different and need different kinds of investigators asking different types of questions. "Pathophysiology has become passe", said Feinstein. Yet the molecular biologists are still going to need someone around to explain certain events such as why atherosclerotic plaques develop at branching points in a vessel or at other locations. Or why ischemia is painful only in some patients. Such questions can only be answered by persons familiar with pathophysiology, he claimed, and if it is neglected there will be absolutely no connection between molecular-cellular discoveries and clinical phenomena. Feinstein said basic scientific challenges occur in medicine at three different levels: the person, organs and systems; cells; and molecules. All three are equally important and should be interdependent. All need bright investigators, creative thinking and enthusiastic support. If not connected in some way to clinical phenomena, clinical investigation will not continue to attract first-rate scientists - and it might also have difficulty continuing to attract public support. Dr. John Stobo, chairman of the Department of Medicine at Johns Hopkins Hospital and University, described his hospital's attempt to find the best way to support research in a clinical department of medicine. A physician-basic scientist, Stobo is director of the Department of Medicine and a physician-clinical scientist is deputy director. The ad-
In Great Britain the health service has priority over advancement of knowledge [he background to the current dilfficult situation in which :reat Britain's medical rc searchers find themselves was described to conference particlpants with a certain ironv bh i)r, Michael Oliver, director n! thc W7s nn Institute for Metbolic Research, London. In Great Britain, he said 1[he health service has taken priority at the expense of ad.-ancement of knowledge. "OXL1r problemi has been that we've had a series of anti-intellectual governments, and there's none rnore anti-intellectual than the one we have at the moanien A- nd it is probable.
vantage of such a dual-leadership model is that "it puts round pegs into round holes and square pegs into square holes instead of the other way round". It allows basic scientists to do what they do best, and lets someone who is an outstanding teacher and clinician use patients as a laboratory. "It sends a strong message as to the importance of a physicianclinical scientist", he said. "It serves to mark this kind of individual as an important contributing member to the department." For this model to work, he said, both the director and deputy director must be high-quality leaders and must recognize the importance of clinical care, teaching and research in the overall success of the department. They must also work together in mutual respect, with responsibility and authority divided between them. Research infrastructures have gained a new importance in Canada as a result of the influence of molecular biology, said Louis Siminovitch, PhD, director of research at the Samuel Lunenfeld 1308
(ANMEDASSOCJ 1990; 142(11)
suspect. with the pragmatism ot politicians, that this will .:-tintnuc T'The anti-intellectual acpl ities have been coupled with state health service which has ncC n totail\-- com prehensk\-e ft) *4- \ears. [It has also been coupled with] a university svsIecm"r. which is supposed to have provided everything for evervbody forever, as indeed the health service is supposed to Jo which of course it should ,'iCeVet have attenmpted to do in the first place.' Xfter the Second World Wan- said Oliver the situation (Gr*eat Britain was verx dif-
Research Institute of Mount Sinai Hospital, Toronto. It has also raised a question. Can researchers prosper best in a university departmental setting or in a research institute? Examples of the way medical science operates today are found in the cloning of the cystic fibrosis and the muscular dystrophy genes, Siminovitch said. Two of those responsible for these achievements at Toronto's Hospital for Sick Children - Lap-Chee Tsui and Ronald Worton - are basic scientists who knew nothing of the diseases they eventually worked on when recruited to the hospital's genetics department. Tsui was a phage scientist who used to work on bacterial viruses, while Worton was a biophysicist. They were offered positions because they were good scientists, not because of expertise in a specific disease area. Siminovitch contends that the best infrastructure to accommodate medical research in a hospital setting in Canada today is the research institute, not a uni-
terent tronm that In the t..'t\ tt" States. where l.-here was a --i1. Si Xe- increase itf riesearcl,i an,- Ing. "WFe didr h-ave i ot the kind W(t 'vc hiad six increasc whatevei >' U i sitarited off lo\- We -took ofl. -too Tnuch b- giving evc rytthnl to eveIrbody in the health Sie Vice., and we tried to structur; the University and the medlOic schools in a wvay befitting WhIf we assumed w;ould be ,-
panding economry.Instead of thtixpeete e22conomic eIxLpansio). Sail ver- we've hial eralrSo aa. .nv state anid r1.()w hav -*; cm Lir beli.
versity department, although there will inevitably be connections between the two. "The institute setting allows you to recruit people independently of their discipline, to change quickly and to integrate your basic and clinical scientists", he explained. In an institute scientists do some teaching and provide some hospital service, but their major responsibility is research. They are not offered tenure and this allows for the staff turnover that is necessary because "in an institute you can't have people who are not doing research". It also tends to select those who "are motivated and willing to stake their future on their research". Resources available to universities are dwindling, and their departments cannot go to the private sector for funds as hospital research institutes can. University management structures have become extremely cumbersome because of their need to develop all their sectors with diminishing in-
come.-
Enormious challenge, enorimous prominse:* Integrating molecular biology into clinical medicine
David Spurgeon tients more closely in touch with biomedical research. Participants felt it provided an unusually lively, frank and stimulating exchange. Dr. John Potts, the chief of medical services at the Massachusetts General Hospital, described "how molecular biology has changed the field that I have worked in" and "has speeded up and transformed the pace and scope of what we do". Potts said the impact has been tremendous: "In disease pathogenesis we are beginning to see at the molecular level exactly why certain deficient states exist." In disease prognosis, the ability to examine gene rearrangements is providing a new way of staging disease. Gene amplification is beginning to explain why tumours "undergo a further malignant deterioration after the initial malignant event" and increase knowledge about the "escape of tumours from chemotherapy". Recombinant DNA products manufactured from mammalian and bacterial cells are already commonly used and gene-replacement therapy is no longer a distant prospect, said Potts. Many cytokines and hormones cloned David Spurggeon is a fteelance writer living 10 to 15 years ago are now available for therapy "and for careful ii.noln Tremnblant, PQ.
olecular biology is bringing about fundamental changes in clinical medicine and training. The changes are confusing and difficult to adapt to, but both the challenge and the promise of integrating molecular biology into clinical medicine are enormous. That was the message that emerged clearly from an International Symposium on Biomedical Research held at the Institut de recherches cliniques de Montreal (IRCM) on Apr. 2. Speakers included senior scientists from leading university medical faculties and research institutes in Canada, the United States and Great Britain. Organized by Dr. Michel Chretien, IRCM's scientific director and chief executive officer, and consultant Dr. Jacques Genest, both professors of medicine at the universite de Montreal, the symposium was designed partly to help clear up what clinical scientists see as confusion among Canadian funding bodies and others about the nature of clinical research. Another aim was to help put physicians dealing with paM
1304
CAN MED ASSOC J 1990; 142(11)
dissection in terms of analogs that can be prepared and introduced into clinical medicine.... The idea of making parathyroid hormone in bacteria and mammalian cells opens up a variety of approaches that would have been undreamed of 10 or 15 years ago.... There are tantalizing possibilities in therapy as one asks a different kind of question using the molecular biologic techniques".
Concerning oncogenes, Potts said: "It's clear we know a lot of the players but we don't have the script and we don't see the whole play unfolding." Another fascinating story is the antioncogene concept. Instead of causing excessive production of growth factor, as oncogenes do, antioncogenes act as "a sort of cellular brake". The prototype is retinoblastoma. Potts said it is important to train physicians in molecular biology: "For physicians to be unable to have among their ranks anyone who's familiar with this to my mind is very dangerous and would probably impede progress." To meet the new training needs, the Massachusetts General Hospital has been taking physicians interested in molecular biology and encouraging them, after full clinical training, to commit
1-
themselves to another 4 to 5 years in the subject. Such people have brought a new perspective to medicine. Most have not had PhD training and find it very challenging to begin another career. "So I've developed a sort of 'den mother' or 'safe harbour' club", said Potts. Four times a year the group goes to his house for a sherry hour and informal dinner, where one of them presents a paper. In addition, Potts visits every one of them during the year to check on progress and to ensure they're receiving adequate support. A committee also reviews their progress once a year. Potts said the experiment is proving successful. "It's their own energy that is the key element in their success, but we're there to support them, to follow what's happening and to guide them into faculty careers upon the completion of this training experience. What they bring back after 3 or 4 years in these laboratories - and they're working with the very best - is a great sense about the excitement of molecular biology and modern cellular biology.... They have a sense of what PhDs are doing in the laboratory and are protective towards them. They can also interact with their medical colleagues. They tend to spend time as attending physicians in the ward, and they bring a particular perspective on where the challenges for tomorrow might lie. "My conviction is that for the right people - and a certain number only in the department - this is a challenging career that I believe is essential to maintain the close ties that can exist between the most advanced biological research and clinical medicine." Dr. George Cahill, senior scientist and assistant to the president of the Howard Hughes Medical Institute and professor of medicine at Harvard Medical School, said clinical science has traditionally involved "looking at patients, looking at disease processes and
Can FPs.. be trained to-keep. up with me.dical advances?... Where will-all the current em.molecular biology phasis. on leave .the .family physician? How will he be trained to keep up with medical advances? This question arose after the presentation by Dr. George Cahill, a professor of medicine at Harvard University Medical School. His reply: "One does not want. to.. downgrade or create a. seond-class citizen, but on .the o.ther: hand -one can't afford to.: give [family physicians] absolutely cutting-edge
biomedical science and have. the`m .`spe.nd ..a. year in a labor.a-
tory. on. .molecular biology'. Sure, the gu,y who is going to be. a family practitioner would be a better doctor. if he did, no question about it, but we can't afford to do that to the 16 000 to 20 000 graduates coming out of American medical schools each. year. I think eventually it will end up..as a kind of two-tier. system, but hopeffully with a.ppropriate recognition of. each". Other, with respect."
The challenge to medicine is interventions, and assessing them statistically to see whether you've to train physicians familiar with done something or not". Continu- this field and its impact, within ing in this vein is still crucial, one reasonable lifetime and with"but there's now a whole new phase of science - the fundamental scientist in the clinical setting" who spends 90% or more of his time in the laboratory doing "fundamental, cutting edge molecular
biology". Mouse genetics is becoming highly important in the understanding of human disease, Cahill said. By crossing two different strains of mice and mapping genes, all their genetic characteristics can be traced - about onethird of the mouse gene has already been mapped. "This is going to absolutely open up the finding of disease loci and disease genes in man", he said. "It's going to be an entirely new field. Coupled with that, it is now possible to make specific mutations in specific diseases in experimental animals, and to put those genes back in another animal, and with genetic recombination technology one can then map and follow on where other genes are near it.... The person in clinical research is going to have to know all about these activities."
out too much expense. "For the past 5 years I've been responsible for some 40 or 50 medical students coming to the NIH [National Institutes of Health] to study in depth fundamental science", Cahill said. "Some of these youngsters are superb biologists and they should race through their MD degree and then get right into a lab." He questioned whether all should even bother with the MD degree, considering the time, effort and expense necessary. "When I meet them, I ask them about how much it means to them to have a person-to-person contact", he said. "About nine-tenths say it's crucial and that's why they came to medical school, so I tell them to go ahead and get the MD degree anyway." He advises those who do to try to complete the course more quickly than usual and while doing so to keep up some lab work.' There are now six medical schools in the US that offer 1 year of obligatory research experience, he said. Several are considering granting a master's degree in biCAN MED ASSOC J 1990; 142 (I 1)
1305
- -0
omedical science for that year. For the average physician to become a clinical scientist, the traditional preparation is totally inadequate, Cahill maintained. The doctor needs "in-depth, hands-on, wet-lab experience" to be able to compete satisfactorily. How? By making training "openended, versatile, patterned, elitist in a way". The MD/PhD route is the most successful. But, it is impossible to give large numbers of physicians such training, he said. Only about 200 can be trained annually in the US - just over one per American medical school. This route has been popular because those who enter it are outstanding students and because their way is paid by the federal government or other sources. "At graduation from a state school in the United States an average medical student now is $40 000 in debt. [Education at] a private school may lead to debts of $85 000. How is that individual going to dedicate her or himself to a career in biomedical research on a modest salary, with the unpredictability of getting research grants? The only way is tremendous determination and dedication. I saw one student several months ago who was $135 000 in debt. Her father is an engineer at General Motors, making about $95 000 a year, which makes her ineligible for support: the middle class are rich enough not to get support funds or scholarships. She has three siblings, all of whom went through private school. She paid her way through Bryn Mawr and medical school. How is she going to repay that debt on the $25 000 to $35 000 income that the general postgraduate job provides?" No matter what training route they take, physicians and PhD holders will probably end up working together in a collegial atmosphere, understanding each other's approach, Cahill said. 1306
(\AN NiI) XSNUC
J 990 142 (I
Siminovitch: best setting for research is the research institute
"I'm really not quite sure what clinical science is today. I'm certain that there can be no fixed route to train people: it has to be highly variable.... We may have to become more elitist, with two tiers - a clinical and an academic setting." A different perspective was provided by Dr. Alvin Feinstein, director of the Robert Wood Johnson Clinical Scholars Program and professor of medicine and clinical epidemiology at Yale University Medical School. He posed this question: Do real challenges still remain in clinical medicine in an era dominated by molecular biology? "(I want to make clear I have nothing but awed admiration for the accomplishments of molecular biology. I am asking, however, is there another side to that coin?" He declared that an intellectual hierarchy exists that says "that explication is basic, important, fundamental, worthy of firstrate minds, and that intervention is applied, less worthy, suitable for people who are not bright enough to do basic research". If this is so, he wondered, "why do we have so many unresolved problems in clinical science in the last part of the 20th century?" He
asked if there is any connection between some of these problems in diagnosis, therapies and the delivery of care "and the fact that we have systematically now for almost a century told our best and brightest that the only place to use a good mind is in the lab". Many clinical problems that pose real challenges remain, he contended, and clinical and laboratory research are very different and need different kinds of investigators asking different types of questions. "Pathophysiology has become passe", said Feinstein. Yet the molecular biologists are still going to need someone around to explain certain events such as why atherosclerotic plaques develop at branching points in a vessel or at other locations. Or why ischemia is painful only in some patients. Such questions can only be answered by persons familiar with pathophysiology, he claimed, and if it is neglected there will be absolutely no connection between molecular-cellular discoveries and clinical phenomena. Feinstein said basic scientific challenges occur in medicine at three different levels: the person, organs and systems; cells; and molecules. All three are equally important and should be interdependent. All need bright investigators, creative thinking and enthusiastic support. If not connected in some way to clinical phenomena, clinical investigation will not continue to attract first-rate scientists - and it might also have difficulty continuing to attract public support. Dr. John Stobo, chairman of the Department of Medicine at Johns Hopkins Hospital and University, described his hospital's attempt to find the best way to support research in a clinical department of medicine. A physician-basic scientist, Stobo is director of the Department of Medicine and a physician-clinical scientist is deputy director. The ad-
In Great Britain the health service has priority over advancement of knowledge [he background to the current dilfficult situation in which :reat Britain's medical rc searchers find themselves was described to conference particlpants with a certain ironv bh i)r, Michael Oliver, director n! thc W7s nn Institute for Metbolic Research, London. In Great Britain, he said 1[he health service has taken priority at the expense of ad.-ancement of knowledge. "OXL1r problemi has been that we've had a series of anti-intellectual governments, and there's none rnore anti-intellectual than the one we have at the moanien A- nd it is probable.
vantage of such a dual-leadership model is that "it puts round pegs into round holes and square pegs into square holes instead of the other way round". It allows basic scientists to do what they do best, and lets someone who is an outstanding teacher and clinician use patients as a laboratory. "It sends a strong message as to the importance of a physicianclinical scientist", he said. "It serves to mark this kind of individual as an important contributing member to the department." For this model to work, he said, both the director and deputy director must be high-quality leaders and must recognize the importance of clinical care, teaching and research in the overall success of the department. They must also work together in mutual respect, with responsibility and authority divided between them. Research infrastructures have gained a new importance in Canada as a result of the influence of molecular biology, said Louis Siminovitch, PhD, director of research at the Samuel Lunenfeld 1308
(ANMEDASSOCJ 1990; 142(11)
suspect. with the pragmatism ot politicians, that this will .:-tintnuc T'The anti-intellectual acpl ities have been coupled with state health service which has ncC n totail\-- com prehensk\-e ft) *4- \ears. [It has also been coupled with] a university svsIecm"r. which is supposed to have provided everything for evervbody forever, as indeed the health service is supposed to Jo which of course it should ,'iCeVet have attenmpted to do in the first place.' Xfter the Second World Wan- said Oliver the situation (Gr*eat Britain was verx dif-
Research Institute of Mount Sinai Hospital, Toronto. It has also raised a question. Can researchers prosper best in a university departmental setting or in a research institute? Examples of the way medical science operates today are found in the cloning of the cystic fibrosis and the muscular dystrophy genes, Siminovitch said. Two of those responsible for these achievements at Toronto's Hospital for Sick Children - Lap-Chee Tsui and Ronald Worton - are basic scientists who knew nothing of the diseases they eventually worked on when recruited to the hospital's genetics department. Tsui was a phage scientist who used to work on bacterial viruses, while Worton was a biophysicist. They were offered positions because they were good scientists, not because of expertise in a specific disease area. Siminovitch contends that the best infrastructure to accommodate medical research in a hospital setting in Canada today is the research institute, not a uni-
terent tronm that In the t..'t\ tt" States. where l.-here was a --i1. Si Xe- increase itf riesearcl,i an,- Ing. "WFe didr h-ave i ot the kind W(t 'vc hiad six increasc whatevei >' U i sitarited off lo\- We -took ofl. -too Tnuch b- giving evc rytthnl to eveIrbody in the health Sie Vice., and we tried to structur; the University and the medlOic schools in a wvay befitting WhIf we assumed w;ould be ,-
panding economry.Instead of thtixpeete e22conomic eIxLpansio). Sail ver- we've hial eralrSo aa. .nv state anid r1.()w hav -*; cm Lir beli.
versity department, although there will inevitably be connections between the two. "The institute setting allows you to recruit people independently of their discipline, to change quickly and to integrate your basic and clinical scientists", he explained. In an institute scientists do some teaching and provide some hospital service, but their major responsibility is research. They are not offered tenure and this allows for the staff turnover that is necessary because "in an institute you can't have people who are not doing research". It also tends to select those who "are motivated and willing to stake their future on their research". Resources available to universities are dwindling, and their departments cannot go to the private sector for funds as hospital research institutes can. University management structures have become extremely cumbersome because of their need to develop all their sectors with diminishing in-
come.-
