July 5, 2014 | 2
Can excellent scientists be excellent physicians at the same time?
“I would like to ask you about a trip to Thailand.”
This is not the kind of question I expected from a patient in my cardiology clinic at the Veterans Administration hospital in Indianapolis. Especially since this patient lived in rural Indiana and did not strike me as the adventurous type.
“A trip to Thailand?”, I mumbled, “Well, ummm…I am sure……ummm…I guess the trip will be ok. Just take your heart medications regularly, avoid getting dehydrated and I hope you have a great vacation there. I am just a cardiologist and if you want to know more about the country you ought to talk to a travel agent.”
I realized that I didn’t even know whether travel agents still existed in the interwebclickopedia world, so I hastily added “Or just use a travel website. With photos. Lots of photos. And videos. Lots of videos.”
Now it was the patient’s turn to look confused.
“Doctor, I didn’t want to ask you about the country. I wanted to know whether you thought it was a good idea for me to travel there to receive stem cell injections for my heart.”
I was thrilled because for the first time in my work as a cardiologist, a patient had asked me a question which directly pertained to my research. My laboratory’s focus was studying the release of growth factors from stem cells and whether they could help improve cardiovascular function. But my excitement was short-lived and gradually gave way to horror when the patient explained the details of the plan. A private clinic in Thailand was marketing bone marrow cell injections to treat heart patients with advanced heart disease. The patient would have to use nearly all his life savings to travel to Thailand and stay at this clinic, have his bone marrow extracted and processed, and then re-injected back into his heart in order to cure his heart disease.
Much to the chagrin of the other patients in the waiting room, I spent the next half hour summarizing the current literature on cardiovascular cell therapies for the patient. I explained that most bone marrow cells were not stem cells and that there was no solid evidence that he would benefit from the injections. He was about to undergo a high-risk procedure with questionable benefits and lose a substantial amount of money. I pleaded with him to avoid such a procedure, and was finally able to convince him.
I remember this anecdote so well because in my career as a physician-scientist, the two worlds of science and clinical medicine rarely overlap and this was one of the few exceptions. Most of my time is spent in my stem cell biology laboratory, studying basic mechanisms of stem cell metabolism and molecular signaling pathways. Roughly twenty percent of my time is devoted to patient care, treating patients with known cardiovascular disease in clinics, inpatient wards and coronary care units.
As scientists, we want to move beyond the current boundaries of knowledge, explore creative ideas and test hypotheses. As physicians, we rely on empathy to communicate with the patient and his or her family, we apply established guidelines of what treatments to use and our patient’s comfort takes precedence over satisfying our intellectual curiosity. The mystique of the physician-scientist suggests that those of us who actively work in both worlds are able to synergize our experiences from scientific work and clinical practice. Being a scientist indeed has some impact on my clinical work, because it makes me evaluate clinical data on a patient and published papers more critically. My clinical work helps me identify areas of research which in the long-run may be most relevant to patient care. But these rather broad forms of crosstalk have little bearing on my day-to-day work, which characterized by mode-switching, vacillating back and forth between my two roles.
Dr. J. Michael Bishop, who received the Nobel Prize in 1989 with Dr. Harold Varmus for their work on retroviral cancer genes (oncogenes), spoke at panel dicussion at the 64th Lindau Nobel Laureate Meeting about the career paths of physician-scientists in the United States. Narrating his own background, he said that after he completed medical school, he began his clinical postgraduate training but then exclusively focused on his research. Dr. Bishop elaborated how physician-scientists in the United States are often given ample opportunities and support to train in both medicine and science, but many eventually drop out from the dual career path and decide to actively pursue only one or the other. The demands of both professions and the financial pressures of having to bring in clinical revenue as well as research grants are among the major reasons for why it is so difficult to remain active as a scientist and a clinician.
To learn more about physician-scientist careers in Germany, I also spoke to Dr. Christiane Opitz who heads a cancer metabolism group at the German Cancer Research Center, DKFZ, in Heidelberg and is an active clinician. She was a Lindau attendee as a young scientist in 2011 and this year has returned as a discussant.
JR: You embody the physician-scientist role, by actively managing neuro-oncology patients at the university hospital in Heidelberg as well as heading your own tumor metabolism research group at the German Cancer Research Center (Deutsches Krebsforschungszentrum or DKFZ in Heidelberg). Is there a lot of crosstalk between these two roles? Does treating patients have a significant influence on your work as a scientist? Does your work as cancer cell biologist affect how you evaluate and treat patients?
CO: In my experience, my being a physician influences me on a personal level and my character but not so much my work as a scientist. Of course I am more aware of patients’ needs when I design scientific experiments but there is not a lot of crosstalk between me as a physician and me as a scientist. I treat patients with malignant brain tumors which is a fatal disease, despite chemotherapy and radiation therapy. We unfortunately have very little to offer these patients. So as a physician, I see my role as being there for the patients, taking time to talk to them, provide comfort, counseling their families because we do not have any definitive therapies. This is very different from my research where my aim is to study basic mechanisms of tumor metabolism.
There are many days when I am forced to tell a patient that his or her tumor has relapsed and that we have no more treatments to offer. Of course these experiences do motivate me to study brain tumor metabolism with the hope that one day my work might help develop a new treatment. But I also know that even if we were lucky enough to uncover a new mechanism, it is very difficult to predict if and when it would contribute to a new treatment. This is why my scientific work is primarily driven by scientific curiosity and guided by the experimental results, whereas the long-term hope for new therapies is part of the bigger picture.
JR: Is it possible that medical thinking doesn’t only help science but can also be problematic for science?
CO: I think in general there is increasing focus on translational science from bench-to-bedside, the aim to develop new treatments. This application-oriented approach may bear the risk of not adequately valuing basic science. We definitely need translational science, because we want patients to benefit from our work in the basic sciences. On the other hand, it is very important to engage in basic science research because that is where – often by serendipity – the real breakthroughs occur. When we conduct basic science experiments, we do not think about applications. Instead, we primarily explore biological mechanisms.
Physicians and scientists have always conducted “translational research”, but it has now become a very popular buzzword. For that reason, I am a bit concerned when too much focus and funding is shifted towards application-oriented science at the expense of basic science, because then we might lose the basis for future scientific breakthroughs. We need a healthy balance of both.
JR: Does the medical training of a physician draw them towards application-oriented translational science and perhaps limit their ability to address the more fundamental mechanistic questions?
CO: In general, I would say it is true that people who were trained purely as scientists are more interested in addressing basic mechanisms and people who were trained as physicians are more interested in understanding applications such as therapies, therapeutic targets and resistance to therapies.
They are exceptions, of course, and it is ultimately dependent on the individual. I have met physicians who are very interested in basic sciences. I also know researchers who were trained in the basic sciences but have now become interested in therapeutic applications.
JR: When physicians decide to engage in basic science, do you think they have to perhaps partially “unlearn” their natural tendency of framing their scientific experiments in terms of therapeutic applications because of their exposure to clinical problems?
CO: We obviously need application-oriented science, too. It is important to encourage physicians who want to pursue translational research in the quest of new therapies, but we should not regard that as superior to basic science. As a physician who is primarily working in the basic sciences, I make a conscious effort to focus on mechanisms instead of pre-defined therapeutic goals.
Looking to the future
Dr. Opitz’s description of how challenging it is to navigate between her clinical work in neuro-oncology and her research mirrors my own experience. I have often heard that the physician-scientist is becoming an “endangered species”, implying that perhaps we used to roam the earth in large numbers and have now become rather rare. I am not sure this is an accurate portrayal. It is true that current financial pressures at research funding agencies and academic institutions are placing increased demands on physician-scientists and make it harder to actively pursue both lines of work. However, independent of these more recent financial pressures, it has always been extremely challenging to concomitantly work in two professions and be good at what you do. Dr. Bishop decided to forsake a clinical career and only focus on his molecular research because he was passionate about the research. His tremendous success as a scientist shows that this was probably a good decision.
As physician-scientists, we are plagued by gnawing self-doubts about the quality of our work. Can we be excellent scientists and excellent physicians at the same time? Even if, for example, the number of days we see patients are reduced to a minimum, can we stay up-to-date in two professions in which a huge amount of new knowledge is produced and published on a daily basis? And even though the reduction in clinical time allows us to develop great research programs, does it compromise our clinical skills to a point where we may not make the best decisions for our patients?
We are often forced to sacrifice our week-ends, the hours we sleep and the time we spend with our families or loved ones so that we can cope with the demands of the two professions. This is probably also valid for other dual professions. Physician-scientists are a rare breed, but so are physician-novelists, banker-poets or philosopher-scientists who try to remain actively engaged in both of their professions.
There will always be a rare population of physician-scientists who are willing to take on the challenge. They need all the available help from academic institutions and research organizations to ensure that they have the research funds, infrastructure and optimized work schedules which allow them to pursue this extremely demanding dual career path. It should not come as a surprise that, despite the best support structure, a substantial proportion of physician-scientists will at some point feel overwhelmed by the demands and personal sacrifices and opt for one or the other career. Even though they may choose drop out, the small pool of physician-scientists will likely be replenished by a fresh batch of younger colleagues, attracted by the prospect of concomitantly working in and bridging these two worlds.
Instead of lamenting the purported demise of physician-scientists, we should also think about alternate ways to improve the dialogue and synergy between cutting-edge science and clinical medicine. A physician can practice science-based medicine without having to actively work as a scientist in a science laboratory. A scientist can be inspired or informed by clinical needs of patients without having to become a practicing physician. Creating routine formalized exchange opportunities such fellowships or sabbaticals which allow scientists and clinicians to spend defined periods of time in each other’s work environments may be much more feasible approach to help bridge the gap and engender mutual understanding or respect.