Chapter 28:  The Physician-Scientist Training Program and Other Activities and Some Thoughts on Retirement

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Chapter 28: The Physician-Scientist Training Program and Other Activities and Some Thoughts on Retirement

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In this chapter, Dr. Freireich talks about the Physician-Scientist Training Program at MD Anderson and shares his thoughts about retirement.

Identifier

FreireicEJ_04_20010813_C28

Publication Date

8-13-2001

Publisher

The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

Overview; Education; Character, Values, Beliefs, Talents; Professional Values, Ethics, Purpose; Leadership; The Professional at Work; Obstacles, Challenges; Institutional Politics; Controversy; Understanding the Institution; MD Anderson Culture; Working Environment; Institutional Mission and Values; The Researcher; Critical Perspectives on MD Anderson; MD Anderson History; On Texas and Texans

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Chapter 28: The Physician-Scientist Training Program and Other Activities and Some Thoughts on Retirement A: Overview;

CodesB: Education; D: On Education; C: Education at MD Anderson; A: Character, Values, Beliefs, Talents; A: Professional Values, Ethics, Purpose;A: Personal Background; C: Leadership; D: On Leadership; C: Professional Practice; C: The Professional at Work; B: Obstacles, Challenges; B: Institutional Politics; B: Controversy; C: Understanding the Institution; B: MD Anderson Culture;B: Working Environment; B: Institutional Mission and Values; A: The Researcher; B: Critical Perspectives on MD Anderson; B: MD Anderson History; B: MD Anderson Snapshot; D: On Texas and Texans;

Lesley Brunet, MA

But your program, the Physician-Scientist Training Program, is a big program.

Emil J Freireich, MD

It's fantastic. This is the best time of my life, because what I really care about is people. I think that the opportunity to teach young people is really the highest calling. The highest calling for any man is to be a physician. Some people think it's the ministry and things like that. But all theological systems are based in humanity, and the cornerstone of humanity is medicine, to relieve suffering. That's the highest calling. The second highest calling is teaching. The founder of medicine, Hippocrates, pointed out that the most important part of medicine is teaching; that is, you have to accumulate knowledge, and you have to transmit it. I've had a chance to be a physician for 50 years, and now I've got a chance to be a teacher. I'm really enjoying it. It's a great thing. Dr. Mendelsohn has given me 70 percent of my time to teach, and I'm doing that. I run the physician-scientist program. It's a grant-supported activity by the Cancer Institute. It's designed to provide, in 2 years, 1 hour a week, some of the basic principles of clinical research. I also run the Oncology Core Curriculum, which was Andy von Eschenbach's idea when he was our first executive vice president. I'm sorry he's not still. The idea there is that everybody that comes to MD Anderson should leave with a core of basic science knowledge about oncology, regardless of their discipline. We have our basic science people cover the major areas of tumor biology. That's 1 hour on Monday. Then I use our institutional grand rounds to expose our faculty to ourselves. We have 900 faculty members. I try hard to get every faculty member to present his major research/patient care/educational interest in 20 minutes before an audience of his peers, and that's been enormously successful.

So those are 3 activities. Then I participate fully in the leukemia program, because that's where my scientific and clinical roots are. So up until this year, I have attended on one of our leukemia inpatient services 2 months a year. I have outpatient clinic 2 days a week, and I see new patients and follow my old patients. I also participate fully in all the Leukemia Department's teaching activities, which are quite extensive. We have about 6 hours a week of formal teaching for the fellows who rotate through, and for the faculty, to do our research. So I'm pretty busy.

Lesley Brunet, MA

It sounds like it.

Emil J Freireich, MD

But I'm having a great time. I'm compulsive about being on time; I'm compulsive on doing what I promise to do; and I expect others to behave the same way, which they rarely do, but sometimes they do. It's a real pleasure for me to be in a circumstance where I have very little responsibility. I still have responsibility for a limited number of patients, but I have an outstanding physician's assistant who helps me, and I still have responsibility for the teaching programs. But I have the intellectual freedom now to do pretty much what I want, the kind of thing we're doing, which I love. I'm going to do for oncology what Max Wintrobe did for hematology. Dr. Wintrobe, who was the founder of American hematology, wrote Hematology: The Blossoming of a Science, which is still being published. When he retired and moved to California, he wrote this book about the history of hematology in America.

Lesley Brunet, MA

So that's what you're going to do?

Emil J Freireich, MD

Well, if I get fired. See, I love what I'm doing now. I have 2 idols: Sidney Farber and Joseph Kirsner. Sidney Farber, to a large extent, was responsible for oncology as a discipline. Dr. Farber was a pathologist at Harvard, and he discovered methotrexate, inducing remission in children.

Emil J Freireich, MD

The tragedy of the world is that he died without ever getting the Nobel Prize. Methotrexate started the whole field of molecular biology. It was the first antimetabolite, and it was intellectually conceived as an antimetabolite, because Dr. Farber thought that folic acid would be important for the treatment of leukemia[LS4] and he found out it made leukemia worse. He went to these people and said, "I need something that will inhibit folic acid." They synthesized antimetabolites. But what antimetabolites accomplished was dissection of the entire molecular biology of creating the macromolecules, because now you could make an antimetabolite to every metabolite you identified. That's why we have cloned the entire human genome. Dr. Farber died without getting the Nobel Prize. It was the most fundamental discovery in the history of medicine, in my opinion. Dr. Farber was not a quiet, retiring type. He was a very assertive, proud figure. To a very large degree, the Clinical Center at the National Institutes of Health was his doing. He worked with Mary Lasker and the Lasker Foundation. He went to Congress. He got the money, and they built the building. When I made my first discovery—a trivial one now, but then it was important—it related to the height of the white count in leukemia and the occurrence of central nervous system hemorrhage. Dr. Farber was on our external advisory board, and I remember that with tremendous trepidation we presented our great finding. Dr. Farber got up, and he was a very elegant person. He said, "That's what I love about the National Cancer Institute. It's so wonderful to give these young people an opportunity to work and be creative and to create hypotheses. Of course, this is all wrong, because we have proven that the white count has no prognostic value." He came regularly to NIH, and I went regularly to the Children's Cancer Research Foundation. He was very important. And when I decided to move, he helped me decide where to go. Dr. Farber is my idol because he worked at his job, at his office, every day, and he died at his desk, writing a paper. They found him slumped over, pen in hand, the paper half finished.

Lesley Brunet, MA

Not a bad way to go.

Emil J Freireich, MD

That's what's going to happen to me. I'm going to die working. My other idol is Joe Kirsner , because I have a daughter who has inflammatory bowel disease. She was diagnosed at the age of 18. Inflammatory bowel disease is, like all chronic illness, a lifetime illness. You never get rid of it. She came within millimeters of dying of this disease. Through a friend of a patient that I'd cared for here, Ernest Deal, we were able to get a private jet, and we actually took her to Chicago, to Joe Kirsner. Joe Kirsner is to inflammatory bowel disease what Freireich is to leukemia. He was the first full-time inflammatory bowel disease person in the world. I was the first full-time leukemia doctor in the world. Joe Kirsner created a miracle. He turned my daughter around. He educated her. She still returns to the University of Chicago once a year to see Dr. Kirsner's student. His name is Stephen Hanauer. Every time she goes, she has to have an adult with her because they use conscious sedation. You don't stay in the hospital. So I have to go up with her.

Lesley Brunet, MA

This is your daughter, but she's an adult.

Emil J Freireich, MD

She's 42.

Lesley Brunet, MA

She has to bring another adult along?

Emil J Freireich, MD

Yes, because she's going to be sedated, and they don't want to put her in the hospital, so she has to have someone with her to drive her and go to a hotel and stay with her to be sure she doesn't die. So while she's getting her colonoscopy, I go visit Dr. Kirsner. Dr. Kirsner is about 92. I take my daughter, and I go to his office. He's still in the same office. He's still working. Every time I go, he gives me some references. He gives me some publications on the latest in inflammatory bowel disease. He's lost his wife. He's got macular degeneration, so he's having difficulty seeing, but he's at work every day, writing a book. Every year I go visit Joe Kirsner, and he makes me feel young. He's a terrific guy, and he's still in his office. He's got 2 people in the outer office who love him. The people in GI adore him. They do anything he recommends. He goes to the clinic every once in a while to see a patient, but he's a senior citizen. He's an emeritus professor, but he's full-time. He's there every day. Still has personality, and he's still publishing. He still meets with the young people. He still makes rounds. He does it at 92.

Lesley Brunet, MA

That's pretty good. I don't know that I want to do that at 92.

Emil J Freireich, MD

I would want to do it. It's terrific. Things are changing. We may be doing that at 100.

Lesley Brunet, MA

I'd like some hobbies.

Emil J Freireich, MD

The idea of retiring is such a tremendous waste of talent. When you take people who have reached the level of achievement that justifies retirement[LS5] you have to benefit from their knowledge and their expertise. It's really tragic that Dr. Loo's in Washington. He should be here teaching young people. The Chinese respect the elderly. I think we have to learn that. People have wisdom and experience. Retiring, playing golf and tennis, who benefits from that?

Lesley Brunet, MA

Some people retire and do volunteer work.

Emil J Freireich, MD

It's a terrible thing to retire. I don't want to retire. There are many stories that inspire me of people who, after they finish one career, move into another career. I think a lot of people retire, get a motor home, and they travel around to see the sights. I'm going to do that. I'm going with my wife to New Brunswick for a week. But I'll go crazy in a week. I'll call the office every 3 days. There's only so much sightseeing and relaxing I can do, and that's it. I swim 20 minutes; that's it. Thirty minutes, maybe.

Lesley Brunet, MA

That's it. You're relaxed. That's all you need.

Emil J Freireich, MD

It's boring after that. Working is wonderful. It's wonderful to do things that you think will last forever and will benefit other people. There is no higher calling. The work you're doing—writing, creating knowledge, organizing the world—is terrific. It's a great place we live.

Lesley Brunet, MA

It is.

Emil J Freireich, MD

It's a great time we live in.

Lesley Brunet, MA

I'm enjoying this.

Emil J Freireich, MD

I am on vacation today. I'm not going to go to my meeting at 12:00, so I don't have to stop at 11:30. I can go on forever. When I get done with you, I'm going to go home and fight with my wife. I just decided this year that I was going to take vacation. I've never done it before. It's the first time.

Lesley Brunet, MA

A vacation?

Emil J Freireich, MD

Yes. I've never just stayed home.

Lesley Brunet, MA

I can understand that.

Emil J Freireich, MD

All of our vacations have been associated with professional travel. If I go to Paris to a meeting, we take a week. We've never just taken a vacation, but we're going to do it next week.

Lesley Brunet, MA

I think it's time.

Emil J Freireich, MD

I'm taking off August.

Lesley Brunet, MA

We're almost halfway through, and you're still here.

Emil J Freireich, MD

But I'm on vacation. I'm not going to any of the meetings. I'm not seeing any patients. I'm just relaxing.

Lesley Brunet, MA

When did you first become involved [LS6]with the physician-scientists?

Emil J Freireich, MD

It started with this grant. I've always been training physician-scientists. That's the list I'm talking about. That's really an interesting story. In 1976, a long time ago, I gave the Karnofsky Lecture. It's published just recently. It wasn't published initially, because it was too controversial. I called attention to the fact that physician-scientists were being threatened by 2 factors: One was regulation, randomized trials controlled by the government, and the other was lack of funding from the NCI.

Lesley Brunet, MA

But this was happening in other disciplines as well, wasn't it?

Emil J Freireich, MD

Oh, yes. This was clinical research in general.

Lesley Brunet, MA

What do you mean by saying it was threatened by randomized trials?

Emil J Freireich, MD

The randomized trial is a device which is very powerful. It allows you to eliminate bias, but the most important part of randomized trial is that it allows total control of the research process. That's what DeVita used to make life miserable for us, because the randomized trial requires that you make a plan, and then you stop thinking. You just follow the protocol. That's not good. I began to have disputes with people over the randomized trials. I'd say, "Well, wait a minute. We do a randomized trial in good conscience, and one group looks a little better than the other group, wouldn't you rather get the treatment that's looking better than the bad one? Why should I continue to randomize people?"

Lesley Brunet, MA

Isn't the basic idea that you had to do this for a certain amount of time?

Emil J Freireich, MD

You had to do it until the magic number was released. After that speech, I became a pariah. I was "against the randomized trial." I'm not against it. I'm in favor of it. I explained that carefully in that article. The trend in funding from the NIH for clinicians kept going down. Twenty years ago, Jim Wyngaarden, who was an NIH director, wrote an article. He said they're an endangered species. Tom Frei and I wrote an article, and they were an endangered species. The National Research Council had a panel. They studied it and said it was an endangered species. NIH had a panel; they studied it. It was an endangered species. In 1997, a dramatic thing happened to clinical research. I have to explain the organization of clinical research. I told you about the Association of American Physicians that was founded around the turn of the century. This was all the professors who chaired departments and were accomplished physician-scientists. When science came into medicine, the younger physicians took up science, and before they got to be AAP members, they needed somewhere to present their stuff. So a young guy named Henry Christian, who was an AAP member, founded a thing called the American Society for Clinical Investigation. That was about 1910 or so, and it still exists. It was also honorific. It was for the associate-professor-level people who were doing good research, who had accomplished something in their lifetime. They elected so many members a year. It was a big honor, and it still is. At the present time, there are only 2 members of this at MD Anderson, Dr. Hong and I, and there are only 4 or 5 of these guys in ASCI. Henry Christian then realized that there was another category of young assistant professors who hadn't quite made associate professor that were doing excellent research, and they needed a forum, but it was non-honorific. So he formed a society called the American Federation for Clinical Research. This was about 1940. This was the political organization of medicine when I came into it. These people were called the "Young Squirts," ASCI were called the "Young Turks," and AAP were the "Old Turks." When you came into academic medicine, you began to do research as a fellow, and you presented your papers to the AFCR. Membership was open to everybody. They had a national meeting. My first paper was given here. If you did good work here, you were elected honorifically to ASCI. You could give papers at the ASCI. If you were good at the ASCI, you were elected to the AAP. That was the hierarchy. Medicine became specialized, and there were all kinds of specialty societies—American Society of Clinical Oncology, American Society for Endocrinology, American Society for Heart—and all these societies were booming, but the tri-societies were declining. They were declining because these Young Squirts found they had a better forum in their specialty society than they did in the general medical society. So a dramatic thing happened. The Young Squirts' board of directors, all 40-year-old guys, decided that, for their survival, they had to change their name to the American Federation for Medical Research. They had a journal that consisted of abstracts, which was called Clinical Research, and they decided at the same time to change their journal from Clinical Research to Journal of Investigative Medicine. Now, why did they do that? They did that because it had gotten to the point where a physician doing research on patients could not get funding. So the only way the departments of medicine could maintain their academic status was that physicians had to go into the lab and do PhD research in order to get a grant. If they got funded as a PhD, they didn't care about their clinical research. They only cared about their lab research. They had to compete with PhD's to get funded. So the Young Squirts consisted of guys who only worked in the lab. They didn't like clinical work. They didn't like this clinical stuff. When that happened, a physician named Gordon Williams, a professor of Harvard in endocrinology, was chair of an NIH committee that investigated how clinicians fared in the study sections. They reviewed 2 full grant cycles, and they showed objectively that physicians had a lower probability of success than the laboratory scientists. So Gordon Williams wrote a letter to the editor of this journal, and he said, "I'm very upset about changing the name 'Clinical' out of Clinical Research. This is a symptom of something very bad happening with medicine. Maybe it's time to start a new society." When I saw that letter, I immediately wrote a letter to Gordon Williams, and I said, "You are dead right. I've been working on this for 20 years. It's time for those of us who are the last survivors of the patient-oriented research community to found a new society." We did just that in 1998. We started with 7 people, including Gordon Williams, myself, Ed Ahrens, who had written a Crisis in Clinical Research, and Jules Hirsch at Rockefeller University. There were 7 of us. We met, and we said, "It's time to start a new society." We're now in the fourth year. We have a new society. It's called the Association for Patient-Oriented Research. We struggled a long time about the name. We didn't want to use the words "clinical research," and I'll tell you why.

The reason we don't use the word "clinical" anymore is because the NIH had commissioned a study section to find out if they were allocating their funds properly to clinical research. The chairman of this committee was David Nathan, who was the director of the Dana-Farber Cancer Center, and they ended up doing a study. The Gordon Williams study was commissioned by the Division of Research Grants. This was commissioned by NIH. They found that the clinical research was getting just as money as laboratory research. Well, how did they do that? They did it by defining clinical research as anything involving human tissue. So every lab scientist working on HL60, any cell line, was called "clinical research." Anyone who worked on a sample from the clinic was called "clinical research." And so they proved that clinical research, all encompassing, was getting plenty of money. But there was one thing missing: the doctors. There were MD's working in lab, but there were no scientists working in the clinic. So we abandoned the word "clinical" because David Nathan's committee had taken it away from us. "Clinical" now meant everything. So we invented this word, "patient-oriented research." To do research, you require 2 ingredients, an MD—PhD can't do it; doesn't have a license—and a patient, someone who's sick. It could be a volunteer, but he's got to be alive. They both have to be alive. And we used the word "association" instead of "society," as we wanted to be egalitarian. We didn't want anything honorific. This is a place where patient-oriented physicians can come together, and we can campaign. Our first meeting was in '99. We've had 3 meetings. The Society is struggling, but it's coming along. The outcome of our struggles has been that this word is catching on. In Science, just 2 weeks ago, there was an editorial written by the scientific directors of the major funding organizations, calling attention to the fact that we need to support young physicians who want to do research.This word is catching on. The first thing that happened was the NIH floated what's called an RFP, Request for Proposal, and it was for physician-scientist training. I wrote an application, and Dr. Leonard Zwelling, who was in the Office of Protocol Research, supported it. Dr. Stephen Tomasovic [oral history interview], in the Office of Education, supported it. Then I got a call from Tomasovic that the medical school is also preparing an application, and Baylor's doing an application.

Lesley Brunet, MA

Baylor's been doing it for a while, haven't they?

Emil J Freireich, MD

No. We went in the first round. We were in the first group. There were 20 awarded the first round. They said, "Freireich, we'll never get 3, so let's join forces, and we'll get together with the medical school," which we did. Then Dr. Tyson was made PI, for a number of complicated things, and I'm the co-PI. We started this program, and it's going very well. Did I tell you about my sabbatical in Washington, when I did my study?

Lesley Brunet, MA

0:25:16 .1Yes.

Emil J Freireich, MD

The outcome of that were these K series. So the next thing is the K12 program. The K12 had an RFA called Training in Patient-Oriented Research. The first Request for Proposals came out in '99. Robert Bast was head of Medicine at the time, and he applied for one. Then in '00, Dr. Margaret Kripke asked me to be educator, and I called Dr. Tomasovic and said, "Let's look at all the grants available to support my program." We found this POR thing. He said, "Wow, Dr. Bast has just written one last year, and I think it's going to get funded, so we're competing." I met with Dr. Bast, and we worked out a thing where our grants would presumably not overlap. His is for faculty development. Mine would be for trainees. In 2 weeks, after I got appointed, I got this grant in for the deadline, and we got a 3.5 priority, which is about as bad as you can get.

Lesley Brunet, MA

Out of a total score of?

Emil J Freireich, MD

Well, it's 1 to 5. This is terrible. But we got a critique. We put it together in 2 weeks, and this year, we went in again. We met the deadline and sent it in 6 weeks ago. This time we did a good job. I fully expect to get funded. If we do get funded, that's going to fund 7 full-time clinical fellows in patient-oriented research. If it doesn't get funded, I'm going to fund it anyway. I'm working with the drug companies to raise money. I have one nibble. I'm going to create scholars, Bristol-Myers Scholar in Oncology Research. All they have to do is give me $100,000 a year for 5 years, and we'll train a fellow, like the Markle Scholars. So that's one of my big ambitions. I want to have a patient-oriented scholar program.

Bast [oral history interview] is very cooperative. We work together. He has the Faculty Development Program, and it's going very well. Dr. Mendelsohn has a physician-scientist program. When we have our big ball downtown, the money is going to go to the physician-scientists. I think they appoint 2 a year and they keep them going for 3 years. There's more and more interest in patient-oriented research, and that's good.

Lesley Brunet, MA

Yes, that is good.

Emil J Freireich, MD

We need it.

(end of interview session four)

[LS1]Insert "He"[LS2]Let's move this sentence to after "Here's what's wrong." It seems to go there chronologically unless I'm misunderstanding the order.[LS3]Insert "who"[LS4]comma[LS5]Comma[LS6]Insert "with" Freireich: 23 July 2001

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Chapter 28:  The Physician-Scientist Training Program and Other Activities and Some Thoughts on Retirement

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