Chapter 10: Advocating for Patient-Oriented Research and Patients

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Chapter 10: Advocating for Patient-Oriented Research and Patients

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Dr. Freireich begins this chapter by sketching the educational opportunities that MD Anderson offers. He then talks about his continued commitment to education and his pride in one of his trainees, Dr. Hagop Kantarjian, who now heads the Department of Leukemia. Dr. Freireich then further discusses the bias he perceives operating when it comes to awarding grants and awards to physician-scientists. He sketches the history of science in medicine, beginning with the founding of the Association of American Physicians and leading to his role in founding the Society of Patient-Oriented Research in 1998. He sketches the challenges the struggling organization is facing. He stresses that MD Anderson is set up to allow physicians to focus on their specialty, which means their minds are always immersed in their research area as well.

Publication Date

10-6-2011

Publisher

The Historical Resources Center, The Research Medical Library, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Professional Service beyond MD Anderson; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; The Researcher; The Clinician; Business of Research; Activities Outside Institution

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Disciplines

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

Transcript

Emil J Freireich, MD:

I think that once you come to MD Anderson, you get the Core Curriculum. You’re now an academic graduate medical education specialist. If you do research during your training, which you should do, and you get grants and you cure disease, you should have the tools of science that are not taught to physicians. Physicians learn medicine rote. It’s not an academic exercise. When you get internal medicine, they tell you how to do things. They don’t tell you why you’re doing things. So physicians who want to be scientists have to get science training. They have to take our courses. We have courses in clinical research. We have a course in translational research. We have physician-scientists who teach the students and whose labs they work in. So that’s going to happen, and then we’ll have a complete graduate medical education program. We’ll be able to train outstanding specialists or practitioners. We’ll be able to train academic scientists who do their practice science-driven. We’re going to train physician-scientists whose practice is controlled.

Every doctor on our faculty here practices like NIH. They have their own thing, and they know what to do. Dr. Wood does renal surgery. He’s the best in the world, but that’s all he does—renal surgery. He’s a scientist. So the physician-scientists have to control their practice, they have to focus their research, they have to understand disease. So they have to have those tools, and they get that through the Physician-Scientist Training Program. So you get the core curriculum. Then you do your research. Then you get your PhD degree. Now you’re on the faculty. Now you’re a professor.

Tacey Ann Rosolowski, PhD:

The three legs—the three legs of the stool.

Emil J Freireich, MD:

And it’s going to begin here at MD Anderson. That’s what keeps me going. Every year, I get a note from the PRS Retirement Board, which says, “Freireich, you can retire at sixty percent of your salary at thirty years. And your salary goes up, because your optional retirement program kicks in. So if you retire, you’re salary will go up.” So I go home, and I tell my wife, “This is serious business. If I keep working, I’m losing money.” She says, “You have to do what you want to do.” So I’m now in my forty-sixth year.

Eventually they’re going to fire me because I’m useless, but I really enjoy this phase of my career where my focus is on graduate medical education. I still fully participate in the leukemia research program. The Department of Leukemia is run by one of my students, Dr. [Hagop] Kantarjian, who is an absolute genius. He’s like any great professor. You know, you train students who are better then you are. He’s better than I ever was. He is really brilliant, competent, energetic, a wonderful person. The Leukemia Department is the best in the world, so I’m very proud to just hang in there. I do a little research on white cells and stuff, but I hang in there. I attend all the teaching sessions. I interact with all of our fellows, because the fellows who come here in medical oncology, they have to decide if they’re going to be nephrologists or hematologists or leukemia. We have to attract the best and the brightest from the medical oncology program into the leukemia program. This year has been a very good year. We attracted two really super guys. I play a role in that because I participate in the teaching programs and I try to stimulate the research and I—so I participate in all the departmental activities.

So we have five hours of departmental activities a week. I participate fully in all that. Then I still have—I keep a few patients that— I don’t take new patients. I don’t attend on the hospital service, because I have a policy that if you’re in the hospital, you have to see your doctor seven days a week. I don’t work seven days a week.

I had a fatal heart attack in 1987. I was saved by being on the TIMI trial at Methodist, and then I had a bypass by a brilliant surgeon. I’ve just been very lucky. I’m way outside of the ninety-five percent confidence intervals for survival. But fortunately, my brain still works, so I keep working.

Tacey Ann Rosolowski, PhD:

And you’ve been travelling too.

Emil J Freireich, MD:

Well, I’m going to do less and less of that. Traveling is getting so painful. I went to Dubrovnik, my wife and I. It took us two days to recover. It’s thirty hours on a plane. You can’t sleep, eat. Who needs it? The days of face-to-face meeting are over. It’s too easy to communicate electronically. I can talk to anyone in the world in ten nanoseconds. It’s nice to have collegiality face-to-face, but the way the world is, in my new world, the work comes to MD Anderson. I don’t have to go there. I don’t go to Japan anymore. If they want it, they can come here. I decided after this trip to Dubrovnik that I’m not going anywhere. I can travel domestically. I go to Chicago, but I’m not going to go around the world. It’s just—it’s not worth the effort. It’s not worth the time. I spent eight days going to a conference. I learned a little bit, but I could have read the abstracts in one night. And everybody knows me, and I know everybody, so I’m better off thinking.

Tacey Ann Rosolowski, PhD:

Can I ask you some questions about those—?

Emil J Freireich, MD:

So I don’t like traveling. Dr. [Michael] Keating [Oral History Interview] is the opposite. He likes to travel. He’s gone all the time. Dr. Keating is a person who depends on human contact for him to think. I’m a person who thinks—pencil and paper and Internet. Go ahead, your questions.

Tacey Ann Rosolowski, PhD:

I wanted to ask you about some of those national and global organizations.

Emil J Freireich, MD:

Oh, I want to tell you about [Lawrence] Einhorn. So the way that happened is—

Tacey Ann Rosolowski, PhD:

So this is the Association for Patient-Oriented Research?

Emil J Freireich, MD:

Yes. More and more—I told you about all the geniuses at the NIH. I actually liked them. They’re all nice guys, but they just don’t know anything about research. They’re lab guys. Fidler is a pet peeve of mine because he gets so much attention, and LeMaistre had a thing for him. They gave him a medal and now to win the Nobel Prize, the president of the AACR, and he’s famous. It’s all good research, but it’s just lab research. It has nothing to do with cancer. That’s what I call phenomenology. You want to study goldfish physiology? You get a Nobel Prize for studying immunity in goldfish. That’s wonderful. As a society, we can afford that. But it hasn’t got anything to do with leukemia.

So 600,000 Americans are going to die of cancer in the United States of America. Why is that? Because we’re not working on cancer. We can cure cancer; we just have to do it, but Fidler is not going to do it; physician-scientists are going to do it.

So the geniuses—the money, which began—the grant program began as clinical research. Eventually, the basic scientists said, “Hey, there’s money.” The peer review committees that review grants are unanimously eighty to 100% laboratory scientists. There is not a single study section at the Cancer Institute where the majority are physician-scientists—not one. So all the money flows to Fidler, clinicians.

Okay, so if you’re working in a university and you want to be chairman of the department of medicine and you have to do research and you have to publish, it means you have to get money. The only way you can get a grant is do lab research. So the smart guys at the medical school say, “I’ll do a post doc with Fidler, shoot stuff in mice, write a grant, and I’ll get money. Then I can get some fellows, I can write papers, I can get elected to the National Academy of Sciences.” See, I’m not in the National Academy of Sciences—Fidler is and Mendelsohn is. No doctor ever gets elected. Only Larry Einhorn—he’s the only one. He nominated me for the National Academy of Sciences, and I was rejected, passed over by some guy working in a lab.

So the young academics realized that the only way they can get promoted to assistant professor and associate professor is do lab research, so they did lab research. You have to go where the money is. The reason there is a Cancer Institute is that Congress put money there. Otherwise, no one would work on cancer.

Well, I told you that science in the United States, in medicine, began with the Association of American Physicians. These were professors who trained in Europe and came back and they learned European science and they learned physiology and so on, so they formed a scientific organization. All the professors, they published all the papers. They trained all the doctors. But the medical schools had very little science and research. That was just done by the professors. So if you want to become a professor in the United States, you could either go to Europe or you could study with a professor, and if you studied with a professor, you learned to do what he does and you write papers and you do experiments with mice and test tubes. The first thing you know, you might or might not get a job. But you need a society where you can become presentable. So in 1914 or 1920—I don’t remember the exact date—these young associate professors formed another society—The American Society for Clinical Investigation. To get into the Association of American Physicians, you had to be a proven leader/professor, so they were called the Old Turks. To get into the Society for Clinical Investigation, you had to be a Young Turk. You had to be an associate professor or wanted to be a professor who is doing lab research, publishing, and getting ahead in academia.

When I was working at Boston University, I got elected as a Young Turk when I was—whatever year that was—’65. I was forty. You have to get to be a Young Turk before you’re forty-five, because if you can’t produce before forty-five, you’re never going to be an Old Turk. So how do you get to be a Young Turk? Well, you have to do research, and if you’re doing research and you have to have a place to present it and you’d like to go to the meeting—and the Young Turks and the Old Turks met together in Atlantic City. They formed a thing called the American Federation for Clinical Research, the Young Squirts. And the Squirts formed their society about 1930, and we went along happily that way until the late ‘50s, and the three societies met together back to back. So it started with the Squirts, and the assistant professors presented their papers. The Turks and the Old Turks could hear their papers and could tell if they were good, and they criticized them and helped them get ahead. Then the next day, we go to the Young Turks, and they presented their papers to the Old Turks to prove that they can get ahead. Then there’s the AAP, where all the professors talk about how great they are, and they actually have an honorary luncheon and so on. And all of this is honorific.

Now, to get into the Squirts, you only need to write one paper, so there were lots of Squirts. To get into the Young Turks, you have to make it under forty, you have to—only ten a year or something get in, so it’s an honor if you’re a Turk. But to get into the Old Turks, that’s really an honor. You have one out of forty get in, and that’s a lifetime badge.

So I climbed the academic ladder the usual way. I was a Young Turk at Boston University. When I went to NIH and I wrote my papers up about white cells—good stuff about mechanism of anemia—laboratory stuff—nobody ever benefitted from it—I got to be a Young Turk. Then I started publishing on leukemia, and when I came here, Rulon Rawson, who was our dean, recommended me, and I got to be an Old Turk. So I have all these credentials.

So the Squirts realized that to be a Young Turk they had to publish. In order to publish, they had to get grants. In order to get grants, they had to do lab research. So the societies—the Squirts—were the first to become a basic science society. They talked about clinical things, but basically they did Fidler stuff—mice and test tubes and chemicals. Gradually, the Young Turks became a basic science group. Gradually, the Old Turks became a basic science group. I went to every Old Turk meeting from the time I got elected in ’65, and every year the speaker became more and more lab oriented. The last one I went to, about five years ago, the guy who is now the NIH director, the famous—cloned all the genes—he was guest speaker at the Old Turks. He didn’t even have an MD.

So these societies became basic science societies. Well, if you want to move up the academic ladder and become an assistant professor or associate professor, this is the route you have to go. Well, the Young Turks decided that the way to get grants was to work in with the federated societies. These are the basic science societies—the science for physiology, for biochemistry, for pharmacology—all the basic sciences together in what’s called the federated societies. So the Squirts left the clinical meetings and moved to the federated societies because that’s where they had to present their papers in order to get grants. They had to do lab work.

Tacey Ann Rosolowski, PhD:

That whole clinical focus has just disappeared.

Emil J Freireich, MD:

This is a catastrophe for the US. This is even worse than the FDA. It’s the same problem. You see, things always occur when there are crises. If there’s no crisis, the natural trend is to go back to stability, and stability is no innovation. The way you can be stable is everybody does laboratory research, no upset. The money is distributed. It’s all peers. The patients die of cancer.

So the AFCR left. Now, there are a handful of Neanderthal physician-scientists who didn’t like that, because they didn’t want their Young Squirts training in their departments to go to the federated societies. So the guy I mentioned, Gordon Williams, was the one who wrote an editorial in the Young Squirts’ newsletter, and he said, “If the Squirts have left clinical research, we need to form a society for the Young Squirts who do clinical research.” I read that editorial, and I said, wow, here’s my man. So I dashed off a letter to Gordon Williams, and I said, “I am totally in support of this. We ought to start it immediately.” He said, “Wait a minute. I got this idea from a guy named Bud Robertson, who works at Vanderbilt.”

So we were all Old Turks, and we said what we’re going to do is we’re going to meet at the next Old Turk meeting—[Dr. L.E. “Bud”] Robertson, Gordon Williams, and Freireich. We’re going to invite people we know who are totally committed to this cause. So we invited—my recollection is—four other people, maybe five. One of them was Ed Ahrens, who had written the book—a very famous book on—I can’t find it. He wrote a book which documented what I just said, but not just talk. He went to all the NIH review committees, laid out all the peer reviewers, laid out all the grants that were awarded, looked at all the subjects, and he wrote a book with all that data that demonstrated that the flow of money was progressively away from clinical research to basic research, and it was impacting health. We’re not getting any clinical research.

So Ed Ahrens came and a guy named Jules Hirsch, who worked at Rockefeller University, a very famous guy in body composition. Then we had the lady who ran the grants program for the research centers, and so on. We had about seven people. We decided to form a society. We’re the founding members of that society. We called it the Association for Patient-Oriented Research.

Now, we tried to get back with the Young Turks and Old Turks, but they didn’t want us. They were already laboratory guys. So we have to start this whole progression over again. We have to get a clinical Young Squirt, a Young Turk, and an Old Turk Society of Patient-Oriented Research. So we started the society in what year?

Tacey Ann Rosolowski, PhD:

In 1998.

Emil J Freireich, MD:

In 1998, and Bud Robertson was the first president, and I was the eighth president. It’s struggling. It’s not going to make it.

Tacey Ann Rosolowski, PhD:

Oh, really? Why?

Emil J Freireich, MD:

Why? Because they made the mistake of hiring a doctor to be the director of the cancer institution. It was a big mistake. You don’t allow doctors—and that’s when all this clinical stuff began. I’m blocking on his name right now. He was a radiologist from Hopkins. He became the director of the Cancer Institute. He made the diagnosis immediately that there was no funding for clinical research, so he created the Clinical Translational Grant Program. He got all the directors together. He embarrassed them into realizing that there was no patient-oriented research, there was no ongoing clinical research, and he convinced them all to set aside some money in a pot, under the director, to give grants to people who would do what they call translation research. You don’t want to call it clinical research because they’ve got to do laboratory. But they are going to take all this Fidler stuff and apply it to patients. That’s the paradigm. If we discover everything in a lab and we give it to some dumb doctor, he’ll know how to cure cancer—translational research.

Unfortunately, he was a radiologist. He was not a doctor, but he was a radiologist, and he still believed in that paradigm. He didn’t recognize the fact that the inverse is the case; the translation occurs from the patient to the laboratory because if you’re not working on clinically relevant problems in the laboratory, you’re working on goldfish. That’s fine. You can cure goldfish. And we can have more healthier goldfish, but we’re not going to have healthier people.

So the Translational Research Program was funded, and it was called Clinical Translational Science. All the academic institutions that were hurting because they couldn’t get any money for clinical research became translational research centers, and all the people at APOR applied for grants, and they all got it. The guy who was the chair elect of APOR decided to form a society—the Clinical Translational Research Society. In the first round of the awards, the Health Science Center got—that shows you—you know—Tyson. Tyson became the thing. And Kurzrock’s program, our K-30 program, got funded. Now Tyson is back in charge, so you know where that’s going to go, straight down the pits. That was the end of funding for our clinical trial program.

Tacey Ann Rosolowski, PhD:

The existing paradigm is really strong.

Emil J Freireich, MD:

So the CTSA lasted one round, and then it went away. The guy who started all this, he’s gone—I forgot where he went—and they got a basic scientist back in. We’re back on track. The people who were in APOR have gone to this CTSA thing to get money. We met with the CTSA at our annual meeting to try—the main purpose is advocacy. We have to convince— We’re never going to convince the National Institute of Health that clinical research is important. The only ones we can convince is Congress. Those are people who are sick, and their parents are dying of cancer, and they want progress. And when the Nobel Laureate goes to Congress, they say, “What progress have you made?” He says, “Oh, we’ve made great progress with translation.” “How much money are you spending on clone research?” “Zero.”

So eventually we have to—we have an advocacy organization, which includes these guys and APOR and the AFCR. They’re coming back, the Young Squirts. But there’s not enough money. APOR has no money. We tried to make money from industry, but industry worries about conflict of interest. They can’t mess around. So we have no money. CTSA program is fading down. The money has been reduced. The Young Turks are still getting money from the federated societies—the basic sciences. So we don’t have the money. We have a lobbyist, but what could have worked did not, so we need another strategy. Leaders of academic medicine have to get to Congress, because it all starts with money. If Congress says—it’s like MD Anderson. There would be no MD Anderson if the legislature didn’t pass a bill to have a cancer hospital. Roswell Park is the same thing—the legislature—because the legislature represents the people. The NIH represents the scientists. As they used to say, you lick your own ass. You don’t go outside your circle.

So APOR exists, but it’s not functioning well. People aren’t joining. We don’t have any money. But the idea is right. So we’re going to have to get to Congress some way. For right now, as we said in the first session, this country is—we’re only worried about safety. We don’t care if 600,000 Americans are going to die this year from cancer. They’re just sick.

Tacey Ann Rosolowski, PhD:

It sounds like you have to wait out—

Emil J Freireich, MD:

What we’re worried about is the economy, Greece, the stock market, safety, no drilling, no energy, clean air, clean food, no drugs. So we can’t make any progress with the legislature, because the legislature— We had a bill in the legislature four years ago to get around the FDA squelching new agent development. It was called the Patient Rights Bill or something, and I was an advocate. We went to court. We won in regional court a couple of times. The general idea was that if a patient and his doctor want to undertake a treatment, the FDA can’t stop it. Why should they? But the bill failed, not for lack of support, but for lack of priority. There were just so many things pressing on these people. Now it’s can we even run the government. The guys elected to Congress have got to cut the budget. You can’t talk about money for clinical research. They’re trying to fight for money for NIH even. Can you imagine? Can you imagine reducing the budget for basic research? Fidler? My God! The guy who is director of the NIH goes to Congress and says, “We’ll become a backwards society if we don’t shoot cells in the tails of mice. Just cure people? That’s terrible.”

Tacey Ann Rosolowski, PhD:

Dr. Freireich, we’re almost at 11:30, so shall we—?

Emil J Freireich, MD:

I’ve worn you out. I’ve still got a few topics I want to cover, but you’ve done very well.

Tacey Ann Rosolowski, PhD:

Absolutely. We’ve done very well. Why don’t we stop for today, and we can make another appointment and continue. The time is 11:25.

Chapter 10: Advocating for Patient-Oriented Research and Patients

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