The Contributions of Physician-Scientists Within Divisions of Infectious Diseases

Abstract

Physician-scientists, no matter their particular disease or research focus, within divisions of infectious diseases serve a number of key roles. Foremost, they promote scholarship and excellence in research endeavors with the potential for impact not only within their division or university but globally. These individuals also make important contributions to the training experiences of infectious diseases fellows and internal medicine residents, helping to foster an understanding of how evidence-based (or not) our patient care delivery actually is. Ongoing discussions between those focused on the clinical aspects of infectious diseases and those predominantly pursuing research questions enrich the scholarly environment for both physician groups and provides the foundation for translating the science to improved care for patients with infectious diseases.

The size, scope, and composition of infectious diseases divisions vary widely. Factors that influence the structure and goals of an infectious diseases division include, for example, the size of the hospital or medical system being served, the range of patients using the hospital or medical system, the illnesses most commonly presenting to the physicians of the division, the geographic location of the division, whether or not the infectious diseases division is affiliated with a university, and the scope of the mission of any university-affiliated infectious diseases division, among others. The character and expertise of each division similarly vary, shaped by a myriad of factors such as those above but amply complemented by the training and life experiences—clinical, professional, personal, and otherwise—of the physicians, other professionals, and support staff that comprise each division. Thus, at least in my experience, infectious diseases divisions each have a character and spirit that make them unique.

Infectious diseases divisions engaging physician-scientists are most often associated with larger hospitals or medical systems that most frequently, but not always, have a further affiliation with a university or research institute. Each of us is molded by our direct experiences and I am no exception. Herein, I share my thoughts on the contribution of physician-scientists to an infectious diseases division. My viewpoint has emerged from the very rich experiences of my training at The New York Hospital–Memorial Sloan-Kettering Institute and the University of Virginia and my nearly 30 years as a physician-scientist member of the Division of Infectious Diseases at the Johns Hopkins University School of Medicine where, in parallel, I served as a clinician at the Johns Hopkins Hospital.

HOW SHOULD A PHYSICIAN-SCIENTIST BE DEFINED?

Although broader definitions of a physician-scientist are increasingly embraced, at the initiation of and for much of my career, use of the term “physician-scientist” most often inferred a physician with a strong interest in laboratory research—one “foot” in the laboratory and one “foot” in the clinic. This type of laboratory-based research wherein questions pertinent to the prevention, pathogenesis, or therapy of infectious diseases are pursued in the laboratory has been typically supported by investigator-initiated grants, such as classic National Institutes of Health R01 grants. How a physician-scientist should be defined today, however, is a complex and nuanced topic that has, in my estimation, changed over the past 2 decades. The evolution of the use of the term “physician-scientist” is arguably most evident in the arena of “clinical investigation.” Clinical investigation as a field now employs increasingly rigorous training paths that have become essentially mandatory for physician investigators focused on population health, epidemiology, and the increasingly complex methods utilized to analyze large human datasets and to control for factors that impact or confound the results so as to limit misleading or incorrect conclusions. Similar to the “classic” laboratory-based physician-scientist path, these clinical investigators conduct rigorous clinical investigations garnering extramural grant support.

As the analytical rigor and breadth of scientific endeavors have evolved and expanded—and, specifically, in my role supporting the scientific training and experiences of infectious diseases fellows at Johns Hopkins—I use the term “physician-scientist” for physicians for whom the pursuit of research—new scholarly knowledge—constitutes the majority of their effort. To provide clarity, for example, in a letter of recommendation, I qualify this term by stating “laboratory-based” (ie, the classic laboratory scientist), “translational” (for those whose work in the laboratory predominantly pursues disease mechanisms or uses patient samples in the pursuit of understanding disease, drug, or vaccine mechanisms), or “clinical” (for those whose work is based on, eg, epidemiology, investigator-initiated clinical trials, healthcare delivery, or patient-based questions asked through use of large databases). For my colleagues whose primary effort is devoted to clinical care but who, in parallel, seek to describe and quantify their clinical observations, often through prospective or retrospective case series or study, I have used the term “clinical or clinician investigator.” I have reserved the term “clinician-educator” for those whose clear focus is seeking to quantify and improve the training of the next generation of physicians. I readily acknowledge that my “classification” of how so many contribute to the advancement of our knowledge in infectious diseases is likely imperfect. I further suspect that, with time, the roles and areas developed by physician-scientists will further evolve, creating as-yet unimagined spheres of scientific inquiry.

WHY DID I BECOME A PHYSICIAN-SCIENTIST AND WHAT KIND OF PHYSICIAN-SCIENTIST AM I?

My career path has been defined by, in net, curiosity and problem-solving. As a product of a semirural setting, a high school (at that time) without advanced classes, and a family, particularly my father, who viewed female independence and self-sufficiency as the goal, I was beset with curiosity about the world farther away and a desire for more knowledge. I felt the draw to math and science as the means to understand the “why” of natural events such as the migration of butterflies or the rainbow in the puddle. My curiosity and love of learning came to fruition as a resident at The New York Hospital, Cornell Medical Center (now Weill Cornell Medicine). Here I became intrigued by both the gastrointestinal tract and infectious diseases, mostly as a result of the influence of those attendings in each field with whom I had the privilege of working on the care of their patients. At the time, the integration of the 2 did not occur to me and “career discussions” and mentoring were underdeveloped, so input to combine these elements was lacking.

However, 2 unanticipated, yet crucial events, intervened that guided my career plans.

First was the emergence of the human immunodeficiency virus (HIV) epidemic. My introduction to this infection and the illnesses it can spur began in August 1979, as the resident on the infectious diseases consultation service at The New York Hospital with Dr Henry Masur as my attending. We saw a 32-year-old patient in our intensive care unit who eventually was diagnosed with Pneumocystis carinii (Pneumocystis jirovecii) pneumonia and ultimately was included in the seminal Masur et al paper in the New England Journal of Medicine titled “An outbreak of community-acquired Pneumocystis carinii pneumonia” [1]. At that time, Dr Masur studied P. carinii in the laboratory and was quite puzzled by the diagnosis in this patient. Dr Masur greatly influenced me during this rotation through his clear enjoyment of infectious diseases, inquisitiveness, and determined pursuit of disease understanding. This single rotation was an exceptionally formative experience where I began to learn how clinical insights and laboratory investigations could be melded into a career driven to understand disease pathogenesis.

Second was the initiation of the Cornell Medical Team in late 1979, in collaboration with the International Rescue Committee, a project initially led by Dr Ted Li, Courtney Pastorfield, and others. The development of the Cornell Medical Team allowed internal medicine residents, initially from The New York Hospital and, subsequently, other hospitals in the New York City area, to care for Cambodian, Laotian, and Vietnamese individuals in the Khao I Dang refugee camp on the eastern border of Thailand, near Aranyaprathet. In this 18-km² camp of approximately 150000 refugees and 2 airplane hanger style–hospitals with 1000 beds, we saw many infectious diseases and were supervised by superb infectious diseases physicians from New York City hospitals including Drs Donald Armstrong, Frank Lowy, Arthur Brown, and Jonathan Gold, among others. In Khao I Dang, 3 themes emerged for me that guided my career development: (1) The principles of “low tech” bedside medicine were reinforced for me and supplanted any interest I had in procedure-associated medical subspecialties; (2) I learned about a plethora of infectious diseases, common and regional (eg, malaria, dengue, outbreaks in adults of common childhood illnesses such as measles and mumps among others), and this intense clinical exposure and opportunity to care for many individuals with infectious diseases thrilled me; and (3) the nascent idea of a career combining clinical medicine and laboratory science grew for me. The idea of pursuing a research career was notably fostered by one young Cambodian child with advanced rheumatic heart disease. This child’s tenuous clinical predicament spurred long discussions between diverse physicians in the field with very different viewpoints about how to address the child’s health needs—allow the child to die because that was commensurate with the available resources and usual care for a refugee child, or seek a waiver from the Thai government for valve replacement in a Bangkok hospital. (Seeking the healthcare waiver from the Thai government prevailed and succeeded, although I do not know if, over time, the child did well.) This particular event convinced me that trying to contribute through a research career was the path I would pursue with the hope that cost-effective changes in the field were possible, eliminating such dire discussions.

Upon return from Khao I Dang, I applied for research-oriented infectious diseases fellowships. However, prior to being a resident on The New York Hospital infectious diseases service with Dr Masur and prior to working in Khao I Dang and at the time of my indecision between the fields of gastroenterology and infectious diseases, I had applied to and been accepted into a new general internal medicine fellowship at The New York Hospital led by Dr Mary Charlson. Dr Charlson introduced me to the science of epidemiology and the importance of study design and structure to test hypotheses and answer questions. While I only completed 1 year of this fellowship before transitioning to infectious diseases, this experience was my first formal introduction to research and the lessons learned were invaluable over time.

My training in infectious diseases spanned 4 exceptional years, the first as a clinical infectious diseases fellow at Memorial Hospital–Sloan Kettering Institute working under Dr Donald Armstrong and coincidentally the year that the HIV epidemic bloomed in New York City, providing a clinical experience that can only be described in inadequate superlatives—startling, superb, mystifying, enthralling, and terrifying. From there, I joined the University of Virginia infectious diseases fellowship program led by Dr Gerald Mandell. In this program, I had the privilege of working with and being mentored by Dr Richard Guerrant, a giant in the field of diarrheal illnesses and an insightful, determined, and persistent voice for improved healthcare for the world’s children. Here I learned about the ravages of diarrheal illnesses in low-resource countries and was taught how to conduct laboratory science including how to compile and analyze data and to write to communicate scientific results.

And so, I became a translational physician-scientist, fascinated to this day by the ever-so-clever bacteria, symbionts, and pathogens alike. My disease is diarrhea but, in the process of following the leads provided by our data that developed over years, I was led to colon cancer. In this, my “new” field, we are testing the notion first prominently promulgated in the late 1960s [2, 3] that bacteria contribute to colon cancer pathogenesis, potentially by either promoting the initiation (requires inducing or contributing to DNA mutation[s] in the colon epithelial cells) and/or its progression (growth and metastasis). The fact that I, as an infectious diseases clinician and physician-scientist, would transition to a focus on colon cancer speaks volumes to where scientific pursuit may lead the investigator and to the promise that cross-disciplinary pursuits may contribute to creating new approaches to prevention and therapy of disease.

WHAT ROLES DO PHYSICIAN-SCIENTISTS PLAY IN INFECTIOUS DISEASES DIVISIONS?

While I can only speak from my role in the Division of Infectious Diseases at Johns Hopkins for the last 30 years, I suspect my thoughts apply reasonably well to similar infectious diseases divisions that combine clinical work and differing types of research whether laboratory-based, translational, and/or clinical. I would suggest that physician-scientists contribute not only to their infectious diseases divisions but more broadly to their universities in 4 major ways.

First, we serve as a nucleus for new ideas, extending what is known to ask the unknown, most often with the central goal to advance disease understanding and, ultimately, patient care. Seeking to help patients drives many physician-scientists. The fundamental work of physician-scientists leads not only to new insights but to new questions, new projects, and even more exciting new ideas—ideas unimagined before the work was done. This, indeed, is what propels research forward and makes it relatively simple to provide ideas and novel directions that assist in the development of new research-based careers for our infectious diseases fellows.

Second, as we pursue our scholarly objectives and present our results, I see our clinical experts absorb and ponder how to help. I find it powerful to present our work to our infectious diseases clinical colleagues whose questions and insights inform how best to direct new questions and serve as a source of new ideas. In my experiences, these exchanges foster teamwork and collaboration, both within and outside the field of infectious diseases. Furthermore, these interactions bring vitality and esprit de corps to faculty life within our division and beyond, enhancing the academic environment and quest for knowledge.

Third, physician-scientists within an infectious diseases division are critical to the education of infectious diseases fellows. Many, if not most, infectious diseases fellows enter training with limited research backgrounds. An essential aspect of training the next generation of infectious diseases fellows is the importance of teaching them the skills of critical literature appraisal; the scientific basis of our clinical recommendations as infectious diseases experts; and, perhaps most importantly, teaching infectious diseases fellows to understand and acknowledge to themselves, patients, and their colleagues what we do not know and that which we need to know. Understanding the sum of the known and unknown enables the infectious diseases specialist to provide the very best in evidence-based and compassionate care to patients.

Last, as infectious diseases attendings within the hospital wards, physician-scientists contribute broadly to resident education and career development by conveying our commitment to asking questions directed at understanding disease or healthcare processes and helping residents dissect the quality of the data used to direct patient care. These discussions not infrequently lead to the realization that we still take many steps in patient care unsecured by well-designed studies. Overall, I believe those with “one foot in the laboratory/research, one foot in the clinic” help contribute to more disciplined and structured consideration of patient care and needs. In fact, I think it is not unreasonable to posit that exposure of all residents and fellows to physician-scientists would enhance their education, if merely by exposing them to a new field of thought or research.

CONCLUSIONS

When the size and circumstances of an infectious diseases division permit, physician-scientists have the capacity to make an indelible difference to knowledge, education, and the impact of their division, hospital, and/or university through their pursuit of questions enabling a deeper understanding of infectious diseases. The true impact of the science pursued by infectious diseases physician-scientists is, however, global. In the global context, infectious diseases specialists seek to understand those infectious diseases that are unique to a region and to improve the care and burden of those very common infectious diseases, such as diarrhea and respiratory illnesses, that continue to cause excess morbidity and mortality throughout the world. Continued development of infectious diseases physician-scientists will serve to enable scientifically based clinical care, therapies, and prevention strategies that bring the best of science to the bedside.

Notes

Acknowledgments. In addition to those mentioned within this discussion, I also thank Drs Jean Pape, Barry Hartman, Tom Jones, Mark Donowitz, John Bartlett, and Julianne Sando, each of whom served as examples of excellence that greatly influenced the course of my career.

Financial support. This work was supported by the Department of Medicine, Johns Hopkins University School of Medicine.

Supplement sponsorship. This work is part of a supplement sponsored by the Ragon Institute of MGH, MIT, and the Harvard University Center for AIDS Research P30 AI060354.

Potential conflicts of interest. Author certifies no potential conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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