February 12, 1999

Disease the Victor in the Decline of Physician-Scientists
"The Thrill of My Life"
Is There No Going Back?
A Call to Action

Disease the Victor in the Decline of Physician-Scientists

The point of light entering my eye moved about in response to the steady hand of our family doctor. My free eye scanned his facial features at close range: his nose leading, at length, to a piercing blue eye, a prominent brow, a receding hairline.

The year was 1957. I was lying on the couch in our living room in great distress. My mother, a registered nurse at the local hospital, knew from her training at St. Mary's Hospital in Rochester that this was no ordinary circumstance of a sick kid. She had been well trained. She was part of the nursing team that had attended William Mayo during his final illness in 1939. She knew.

So Dr. Drexler was summoned to the scene. His manner, as always, was both gentle and businesslike. Not at all the physician robot we seem to hear so much about, but no Patch Adams either. He did not plant a red rubber bulb on his handsome nose to humor me. Besides, I could not be humored.

"Well now, Billy," he said. "Let's see if we can find out what the problem is."

With that, he proceeded to explore the area of my abdomen that was causing me exquisite pain. Then he reached into his black bag and removed the medical technology that would furnish evidence for his hunch. A finger cot.

My response to his probing served as an unambiguous signal to him that I needed to be admitted, and fast. A few hours later, the surgeon removed an angry appendix. Less than 20 years earlier appendectomy carried a one-in-five mortality rate, but modern medicine showed its muscle on my behalf. My recovery was routine. I proudly displayed my scar to my brothers, just as President Johnson displayed his before the press some years later. And I got a bow and arrow set out of the deal from my folks.

George W. Drexler came from a small Minnesota town and worked all his professional life in another. The town he came from was near Alexandria. Like many Catholic boys in that area, he went to college at St. John's University in Collegeville, the same school I attended a decade after he diagnosed me.

Like many Minnesota boys who dreamed of being doctors, he attended the University of Minnesota Medical School, graduating in 1939. His roommate, my mother once told me, was a kid from St. Paul named Eugene McCarthy. McCarthy, then a law school student, confirmed that fact to me personally at a reading and signing event for his book An American Bestiary [Lone Oak Press, 2000]. I came to know the doctor in the mid-1950s, just before my appendix decided to turn on me.

I have a vivid memory of standing in line for a polio shot at school. In addition to the workup to my appendectomy, Dr. Drexler is associated in my mind with needles, which I greatly feared. My mother told me the shot was necessary. Otherwise I might get polio like Tom, a boy a couple grades ahead of me, the boy whose leg brace I used when I played Tiny Tim in "The Christmas Carol."

Today, the black bag and the house call fade into distant memory--for those who have any memory of them at all.

But what about the polio vaccine?

The vaccine was a godsend. Most people today don't realize what a godsend it was and what it took for the Salk vaccine and its successor, the oral vaccine developed by Albert Sabin, to come into being and the extraordinary powers they bequeathed on dedicated family physicians like George Drexler.

Today's novel therapies and vaccines, many of them products of the revolution in molecular biology, are in jeopardy of not ever reaching local clinics and local populations. Not because of supply or distribution problems, but because the population of people who can shepherd them from the laboratory to the clinic, who can vouch for their safety and efficacy--the physician-scientists--that population is in sharp decline all over the country.

It is hard to imagine that something as miraculous as the Salk vaccine would not be available today because of a bad cog in the wheel. But the sweeping changes in medicine over the past two decades help us to consider what was previously unimaginable. In the case of new treatments and vaccines, they help us to consider the consequence of doing nothing about the disappearing physician-scientists.

"The Thrill of My Life"

Inoculation of school children with the Salk vaccine in "field trials" began in 1954, with nearly two million participating. It was approved for use throughout the U.S. the next year. As local physicians like George Drexler loaded up their syringes with his vaccine, Jonas Salk was busy in the lab looking for ways to improve it.

Someone once asked him why he did research instead of becoming a practicing physician. "Why did Mozart compose music?" was his reply. Watching his experimental vaccine boost antibodies to a level that killed the poliomyelitis virus, and thus commence the demise of infantile paralysis as the public health monster it was, gave him "the thrill of my life." Salk experienced his greatest thrill looking into a microscope.

Such sentiment is not politically correct for physicians these days, not even for academic physicians. The movie "Patch Adams" is a good case in point. Patch, in the person of actor Robin Williams, a medical student, says something about what separates the doctor from the scientist. Scientists are loners. They like to work alone. They like to look into microscopes. Doctors like company in their work, the company of people, their patients.

It is almost as if Salk's vaccine, the children and families it spared, the fact that he distributed the formula freely without patenting it, has to do with Salk as a scientist and humanitarian, not as a physician, not as a healer.

In the decades before the Salk vaccine, scientific medicine really took hold with the general public, especially with the development of sulfa drugs and antibiotics. "The rituals of scientific, diagnostic medicine spelt out the message that care was being dispensed, and hence strengthened the bond between physician and patient," writes Roy Porter in The Greatest Benefit to Mankind: A Medical History of Humanity  (1997). But the culture changed, and so did medical practice, and so did the public's quality-of-life expectations.

I have been a patient with acute appendicitis in the hands of a caring family doctor and an editor with a curiosity about science in the employment of a leading physician-scientist who was indeed a "loner." It is my firm belief that we are a lot better off with physician-scientists in medicine, including some loners.

To be sure, their world is much different from that of the family doctor or the specialist. But they are a critical part of the broad continuum of medical care just the same. Without them, the discovery and dissemination of new knowledge is jeopardized, and the continuum is truncated.

The search for new knowledge is what drives the physician-scientist. As Jonas Salk was developing his polio vaccine in the early 1950s, the distinguished physician-essayist Lewis Thomas was chair of pediatrics and medicine at the University of Minnesota Medical School and its brand new Heart Hospital. He liked everything about Minnesota, "even the snow," but he was most absorbed by the laboratory scene.

"The laboratory drew in some of the best young bacteriologists and immunologists from around the country: Robert Good, Chandler Stetson, Richard Smith, Floyd Denny, Lewis Wannamaker, Richard von Korff, all interested in rheumatic fever one way or another and all with research projects of their own," Thomas wrote in his book The Youngest Science: Notes of a Medicine Watcher  (1983).

Then the kicker, the mark of a physician-scientist: "It was the greatest fun..." Discovery is fun.

Is There No Going Back?

Without the physician-scientist, "the bridge between bench and bedside will weaken, perhaps even collapse," writes Princeton University's Leo Rosenberg in "Physician-Scientists--Endangered and Essential" (Science, Jan. 15, 1999).

Rosenberg's warning is not knew. I remember reading an article on the subject many years ago in The American Scholar, a journal I have received for a quarter century now, a gift subscription from my uncle. The article was "The End of the Physician-Scientist?" (1984) by Gordon N. Gill of the University of California in San Diego.

Gill blamed the decline of physician-scientist on three factors:

• Economics. "The economics alone explains why most postdoctoral programs were filled with Ph.D.'s and why M.D.'s in research became an endangered species."

• The rapid rise of recombinant DNA technology that largely "bypassed the medical world" because of the lack of M.D.'s in fellowship training to take advantage of it.

• The shifting role model of the physician. With the advent of socially conscious healthcare delivery, "the role model to emulate became more and more the family practitioner, not the academic scientist--that is, the deliverer of health care, not the dispassionate scholar."

He concluded that the trend would continue and that the time was passing when those in academic medicine "rightly or wrongly believed themselves in touch, in the mainstream of originality and creativity, when they were excited about what they were doing and religiously devoted to investigation, a time when this excitement was communicated to medical students, to the talented younger people; a time when one looked to colleagues for the next advance, the next theory, the next hypothesis, the next breakthrough."

It is ironic, Gill wrote, that a separation occurred "when physicians became scientists and when the world of basic scientists became clinically relevant." Yet, in the view he expressed then, there is no going back.

As in 1984 when I first read Gill's article, today I count myself fortunate to work among physician-scientists. I had a conversation with one a couple of days ago. He straddles the bench and the bedside in his work--basic science and clinical science, on the edge of both. His work is highly specialized, so specialized that when I asked him if he is a physician-scientist, he equivocated for an instant. He does see patients--if they want to know more about what exactly is going on in the lab with their cells, more than their primary physician can explain.

His research area is part of a broader field that currently is the focus of great interest by the news media, with good reason. Because of the success of the program, which he attributes to people as much as technology, his views and those of his colleagues are sought by leading academic medical centers and clinics around the country.

I asked him why he chose the path he did back in the 1980s. He didn't say he was looking for "the thrill of my life." He said he knew what he was cut out for, and even though his chosen profession has its drawbacks, like anything else, he thought research was something he could do well.

But I've been around these parts long enough to know that it's more than having a hunch about what you think you're cut out for. To succeed in this arena, you have to have passion for discovery. And you have to be able to "feel it" when real discovery comes your way, if it does at all, and usually it doesn't. And you have to want to share what you've found. One way to measure the quality of the work is by "the intensity of astonishment," in the words of Lewis Thomas.

Admittedly, the research tools are better than ever, but the challenge is also more daunting. A patient's cells and genes don't jump to do your bidding just because you have, let's say, a big lab with lots of people and impressive instruments and a mile-long curriculum vitae  and your head is spinning from the dynamite presentation you gave at Grand Rounds. It doesn't work that way. You can induce cells to yield their secrets by knowing a lot about them, having good instincts, working like a dog, and being lucky.

More than anything else, what needs to happen to turn things around for physician-scientists, says my contact, is for medical students contemplating a similar path to be supported more than they have been, enough to nudge talent "on the fence" into the research arena.

Such nudging is underway at the University of Minnesota and at other academic medical centers, the National Institutes of Health (NIH) and the private Howard Hughes Medical Institute. But the cultural factors aligned against research careers are formidable, even as this layman is in awe of what's about to be offered in the way of new knowledge about health, disease, treatment, and disease prevention from the likes of the Human Genome Project and, locally, from the new University program in molecular and cellular therapy and other programs in the Academic Health Center.

Still, it will take more than awe to ensure that the physician-scientist doesn't end up being a uniquely 20th century phenomenon, a curious sidelight of medicine in transition.

A Call to Action

Leon Rosenberg defines physician-scientists as "M.D.'s who devote all or a majority of their professional effort to seeking new knowledge about health and disease through research." Thus they include physicians doing "basic, disease-oriented, patient-oriented, population-oriented, and prevention-oriented investigations."

The NIH and professional associations have sounded the alarm about the decline in the number of physicians doing clinical research or "patient-oriented investigation," and new programs have been launched to make clinical research more attractive. But Rosenberg writes that the entire species of physician-scientists is endangered.

The evidence rests on these trends:

• The percentage of physician-scientists seeking and obtaining NIH project grant support has been declining steadily compared to Ph.D's.

• The number of first-time M.D. applicants for NIH research project grants has decline precipitously, down 31% from 1994 to1997.

• The total number of NIH-supported M.D. postdoctoral trainees has declined by half since 1992.

• Only 10% of medical school graduates in 1996 expressed a strong interest in a research career compared to 14% in 1989.

Supporting Rosenberg's call to action, the 17-member Federation of American Societies for Experimental Biology (FASEB) and the American Society of Clinical Investigation (ASCI) recently announced they are joining forces to address the critical shortage.

Nobel laureates Joseph Goldstein and Michael Brown of the University of Texas Southwestern Medical Center believe that the physician-scientist is being redefined. Writing in the Journal of Clinical Investigation  (June 1997), they suggest that the ever-broader research enterprise means physician-scientists, in their pursuit of fundamental knowledge, must become comfortable with a "narrower, more focused role" that can be expanded through collaboration with specialists. They may also have to focus on subsets of organs and diseases. They won't be able to continue in a comprehensive fashion.

Yet the physician-scientists and the M.D./Ph.D. programs that furnish so many of them "are central to the future of research medicine."

Research medicine is part of the new medicine, and the "new medicine works," Lewis Thomas wrote in The Youngest Science . He was contrasting his time with that of his physician-father and the doctor-patient relationship of that day which often took the form of a conversation, a conversation that has largely disappeared, much to his regret.

Abbreviated doctor-patient conversation is one of the "costs to be faced." But there is no going back, "nor, when you think about it, is there really any reason for wanting to go back," Thomas wrote, noting that "conversation" often was all his father had to offer.

"If I develop the signs or symptoms of malignant hypertension, or cancer of the colon, or subacute bacterial endocarditis, I want as much comfort and friendship as I can find at hand, but mostly I want to be treated quickly and effectively so as to survive, if that is possible."

The new medicine needs to comfort and to treat as effectively as knowledge permits. How effectively it treats will depend a great deal on physician-scientists in their role of infusing the latest knowledge into the practice. They are uniquely positioned to do something about what Thomas referred to as the "highly visible difference between the pace of basic science and the application of knowledge to human problems." (The Lives of a Cell, 1974)

As patients, we have high expectations today, and we should have. We have a vested interest in making sure the latest therapies, which are largely made possible through our tax dollars, are available to us when we need them. Thus we have a big stake in the future of the physician-scientist.

An angry appendix held all the power when the University of Minnesota Medical School was established in 1888. Surgeon William J. Mayo was just beginning to remove inflamed appendices at his clinic in Rochester after visiting Harvard's Reginald Fitz, the leading pathologist on appendicitis. Perry Millard in Minneapolis and his fellow medical school deans around the country seized on the new knowledge of appendectomy and infused it into the medical curriculum. The procedure became commonplace in a fairly short time.

There was that day in 1957, lying on the couch, being examined by George Drexler. I didn't know that a ruptured appendix, peritonitis, and death had been a familiar sequence throughout human history. Nor did I know that appendectomy had become routine thanks to advances in diagnosis, surgery, bacteriology and post-surgical care.

I didn't know about these facts, but they wouldn't have occurred to me anyway. I was being consumed by the most exquisite pain I've ever known.

    --William Hoffman    hoffm003@tc.umn.edu