Chapter 02: Integrating Research and Clinical Practice

Title

Chapter 02: Integrating Research and Clinical Practice

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Dr. Bast explains how his desire to integrate research into his clinical practice evolved in medical school, internship and residency. He attended Harvard Medical School (MD 1971) for six years because he spent two years conducting pathology research, integrating his clinical and research practices. Dr. Bast explains how working with patients and seeing the minute-by-minute progress of disease enhanced his research. Next Dr. Bast explains his focus on cancer research, noting that he was influenced by Bill MacFarlane's early interest in immunology and cancer. He focused entirely on cancer when he took a research internship at the National Cancer Institute (1972 - 1975) and gained experience with microbacterial approaches. He explains that he studied the successful effects of Bacillus Calmette-Guerin on tumor control and metastasis in guinea pigs. He believed that there could be analogous results in humans.

Identifier

BastRC_01_20140707_C02

Publication Date

7-7-2014

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Professional Path; The Researcher; The Clinician; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Influences from People and Life Experiences; Patients; Discovery and Success; Definitions, Explanations, Translations

Transcript

Tacey A. Rosolowski, PhD:

Well, tell me about the next step, after Wesleyan.

Robert Bast, MD:

After Wesleyan, I had gone to Harvard Medical School which I thoroughly enjoyed. After completing the first two pre-clinical years, I had the opportunity to spend two years in the Pathology Department at MGH [Massachusetts General Hospital] before completing medical school. Ben [Benjamin] Castleman [MD] was the head of Pathology at that time, and he was one of the truly great pathologists. Training in pathology helped me to not only think in three dimensions, but also to understand that anatomy and pathophysiology of disease. Very often, if you’re trained only as an internist, and you don’t necessarily visualize the organs and tissues that are affected by disease.

Tacey A. Rosolowski, PhD:

Right.

Robert Bast, MD:

And then, I returned to finish up my clinical years at Harvard.

Tacey A. Rosolowski, PhD:

So, how did that work? You were in med school for how long? And then took time—

Robert Bast, MD:

Well, it was two years, and then two years and two years. So—

Tacey A. Rosolowski, PhD:

Okay.

Robert Bast, MD:

—I finished medical school in six years.

Tacey A. Rosolowski, PhD:

I see. So that two years out, it wasn’t an official part of your program? You chose to stop for a time?

Robert Bast, MD:

Well, no, it was an official part of the program. I wrote an honors thesis—

Tacey A. Rosolowski, PhD:

Oh, I see. Okay. Interesting.

Robert Bast, MD:

—out of that. So, I was still technically in medical school.

Tacey A. Rosolowski, PhD:

Right. So, you were basically—I mean, just tell me, I’m interpreting that this was basically your way of making the medical—putting a research stamp on medical school? Was that really what it was, or—

Robert Bast, MD:

The two years were great preparation for practicing medicine and for research. I always both really enjoyed clinical medicine and really enjoyed research.

Tacey A. Rosolowski, PhD:

Mm-hmm?

Robert Bast, MD:

And I think that this was a way to actually get in greater depth, and to provide preparation in research, between the two years I had spent at MGH working with Hal Dvorak and the three years that I subsequently spent at NIH. I had about five years of lab research experience.

Tacey A. Rosolowski, PhD:

Oh.

Robert Bast, MD:

I know there’s no exact formula for this, but whether you earn a formal PhD or work in the laboratory as an MD, you need to gain enough research experience to actually become funded and prepare for a career in research, it generally takes about five extra years of research activity.

Tacey A. Rosolowski, PhD:

Mm-hmm?

Robert Bast, MD:

After graduating from Harvard Medical School, I had then survived an internship, at Johns Hopkins [University].

Tacey A. Rosolowski, PhD:

Yeah, I noticed this—

Robert Bast, MD:

Those were the days when you spent two nights on and one night off.

Tacey A. Rosolowski, PhD:

Oh, so that’s the survival part. That’s brutal!

Robert Bast, MD:

That’s the survival part.

Tacey A. Rosolowski, PhD:

Oh, wow.

Robert Bast, MD:

Johns Hopkins was, again, in retrospect, a great experience, but there must be an even better way to become a physician! One of the positives about two nights on and one night off is that you spend long hours with patients, and you really watch from minute to minute how a disease can rapidly progress. Not only do you learn to integrate all of the details of care for each patient, but also, you get a sixth sense for when somebody’s really sick. That sort of sixth sense has served well for decades after internship.

Tacey A. Rosolowski, PhD:

Mm-hmm.

Robert Bast, MD:

Having cared for patients at Harvard with Dana Farber [Cancer Institute], the Brigham and Women’s, Johns Hopkins, Duke [University] and here, one of the common denominators of all four places, although there certainly are differences as well, is that there’s a fierce dedication to exceptional patient care. Certainly at Johns Hopkins, it was almost fanatic.

Tacey A. Rosolowski, PhD:

Really?

Robert Bast, MD:

Which I think is a very good kind of fanaticism.

Tacey A. Rosolowski, PhD:

Hmm. Now, obviously you were doing some—it sounded like you were working with oncology patients. And when did the oncology piece enter your professional life?

Robert Bast, MD:

Well, it’s tough to say, although my mother had developed breast cancer when I was ten or eleven, and fortunately was cured by surgery. I had also worked with Bill MacFarlane, a hematologist-oncologist at the VA [Veterans Administration] Hospital, during college. Most of his patients had leukemia, rather than solid cancers. So my first interaction with cancer patients would have been during summer jobs in the early 1960’s.

Tacey A. Rosolowski, PhD:

Very early.

Robert Bast, MD:

—with leukemia patients early on.

Tacey A. Rosolowski, PhD:

Wow.

Robert Bast, MD:

Being interested in immunology initially, I was very much interested in the possibility of using immunotherapy to control cancers more effectively.

Tacey A. Rosolowski, PhD:

When did that idea start to occur to you, do you think?

Robert Bast, MD:

That would have been, again, in high school and college.

Tacey A. Rosolowski, PhD:

Really, in early, early times. Wow, that’s amazing. So, you were very focused. I mean, it just worked that you retract pretty—

Robert Bast, MD:

Yeah, it’s, you know, it’s very fortunate I’m very focused.

Tacey A. Rosolowski, PhD:

Yeah. (laughter)

Robert Bast, MD:

You know, those are opportunities that wouldn’t be available if you were living in a different part of the country.

Tacey A. Rosolowski, PhD:

Absolutely. And it sounded like you—

Robert Bast, MD:

Or in a rural area.

Tacey A. Rosolowski, PhD:

And you were just put in the way of really key people who helped you consolidate this path.

Robert Bast, MD:

Yes, exceptional mentors who really were dedicated to helping younger people, too, which is, again, really special.

Tacey A. Rosolowski, PhD:

Yeah.

Robert Bast, MD:

I mean, that’s something I’ve tried to do in return over the years.

Tacey A. Rosolowski, PhD:

Right. That pipeline, as people call it.

Robert Bast, MD:

Yes.

Tacey A. Rosolowski, PhD:

Yeah. Is there anything else you want to say about your formal medical training, the residency on out?

Robert Bast, MD:

After internship, I spent three years at the National Cancer Institute (NCI) working with Herb Rapp [PhD] and Bert Zbar [MD] who were interested in guinea pig models for immunotherapy. Here’s where my early experience with mycobacteria at the VAH proved particularly valuable. Herb and Bert were using a tuberculosis vaccine, an attenuated strain of bovine tuberculosis, called Bacillus Calmette-Guerin [BCG]. They injected BCG directly into the transplants of liver cancers growing on the flanks of guinea pigs. Not only the transplanted cancer regressed when exposed to the intense inflammatory granulomatous response to the BCG, but also lymph node metastases regressed. Following BCG-induced tumor regression, animals were resistant to subsequent re-challenge with transplants of the same cancer, but not to other cancers, so they were specifically immune to their cancer. After I joined their group, we tried to use other bugs like Listeria monocytogenes with similar results in mice. At that time, there was a lot of clinical research going on with BCG worldwide injecting living BCG vaccine directly into metastases from cutaneous cancers like melanoma. Some investigators scratched BCG into the skin, to see if that would control cancer body-wide.

Tacey A. Rosolowski, PhD:

Mm-hmm?

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Chapter 02: Integrating Research and Clinical Practice

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