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Medical research

Them and us no longer

Scientists and medical doctors view research through different lenses — but the gulf in outlook between the two tribes isn't what it used to be. Meredith Wadman reports.

Genetics graduate student Rima Adler reached the limits of her collegiality one evening last May, when she needlessly missed a concert by the Baltimore Symphony Orchestra.

Credit: NIH MEDICAL ARTS

Late that afternoon, she had stayed in the lab to help a physician colleague, and ended up spending three hours explaining the basics of the polymerase chain reaction and how it could help the young physician's analysis of their results.

Adler ended up stuck in the lab until 9.30 at night, forgetting about her concert ticket. So she wasn't too thrilled the next day, when she heard the same colleague asking someone else in her lab at the National Institutes of Health (NIH) in Bethesda, Maryland, the same question. “I thought: what the hell am I wasting my time for?” Adler recalls. She thinks the colleague “didn't want to learn new things”. It was a classic case, she says, of a physician “wanting to just get an answer” instead of taking time to properly understand a problem.

Conflict between PhDs and MDs has been as perennial in biomedical research labs as head lice are in kindergarten — and can be just as unpleasant. “There is this stereotypical idea among medical students that those people are getting PhDs because they couldn't get into med school,” says Javed Siddiqi, a California-based neurosurgeon who spent two years in a research lab before himself going to medical school. Meanwhile, he says, PhD students see themselves as intellectuals, “broadening the frontiers of science” while medics, as he puts it, are “memorizing anatomy”.

The culture clash arises when freshly trained doctors are unleashed on laboratories full of bench scientists. Having been deferred to by patients and taught to treat and discharge people in three days — or even three hours — they encounter a strange environment where asking questions is as important as obtaining answers, quick fixes are rare, and jeans and trainers trump ties and stockings. And lurking always in the background is the fact that the MDs are paid higher salaries.

“The cliché — which must have some truth in it — is that the medics want to come into the lab and get everything to work very quickly, without any special struggle, and then write some fantastic paper and make their career in five minutes,” says Paul Klenerman, a virologist with an MD and PhD at the University of Oxford, UK. “They generally get a bit of a shock when they realize quite how much effort is involved and how much can go wrong.”

But Peiman Hematti, a physician with extensive bench training who studies stem cells at the medical school of the University of Wisconsin-Madison, says the problem has diminished over the years. He recalls a conversation he had ten years ago when he was a young MD looking to get training as a postdoc: a friend cautioned him in the direst terms about the inhospitable environment he was sure to find if he joined a lab headed by a scientist rather than a physician.

Conflicts happen

In fact, Hematti's experience suggests that the stereotypes are losing their power. Conflicts “can happen in any lab”, he says. He doesn't think they occur because physicians expect scientists to clean up their messy lab benches for them, or because PhDs look down their noses at MDs. Today “it's more a personality thing; I don't think it matters whether there's an MD or a PhD at the end of your name.”

During a postdoctoral fellowship, for example, Hematti enjoyed what he terms a “very fruitful” collaboration with Boris Calmels, a French scientist whose strengths in molecular biology combined with Hematti's clinical background to produce notable papers1,2 on the integration of lentiviral and retroviral vectors into host genomes. “The result was much better than if we had worked separately,” he says.

Calmels, now at the Centre for Cell and Gene Therapy at the Paoli-Calmettes Institute in Marseille, France, agrees. “When he had basic questions, usually I had the answer,” he recalls. “And when I was looking for specific clinical knowledge, he was the person to ask.”

A number of forces have combined to blunt the once-common tensions between scientists and physicians in the lab. For a start, clinical medicine is less hierarchical than it used to be, and produces doctors less likely to enter the lab with a “Scalpel, nurse!” attitude. And in the United States, at least, sharp growth in biomedical-research funding, combined with growing demands for the translation of research into cures, is blurring the line between bench and bedside.

Birth of a divide

In this environment, cooperation has become imperative. Isolated efforts by physicians or bench scientists “just don't work”, says Rick Morgan, a geneticist who oversees neurosurgeons' postdoc work at the National Cancer Institute in Bethesda, Maryland.

Others argue that tensions have never been as great as laboratory gossip would suggest — and were always far outweighed by the achievements of MD–PhD partnerships. These stretch back to Linus Pauling and Harvey Itano's classic 1949 discovery that sickle-cell anaemia is caused by a structural problem with the haemoglobin protein found in red blood cells. “The mix of MDs and PhDs in my lab enriched everybody's experience,” says Sam Silverstein, a physician in the department of physiology and cellular biophysics at Columbia University in New York.

Calmels, however, suspects that the problem is more acute in nations such as his own, where the two groups are educated separately from the moment they leave school. Moreover, in France, training rules may force physicians seeking academic appointments to complete a year of bench research. “They're not really interested in working at the bench,” Calmels says. “Most of the time, there are two different cultures.”

All aboard: crowded weekly lectures at the National Institutes of Health uncover the mysteries of medicine for scientists. Credit: M. TEMCHINE

One hundred years ago, this division would have seemed odd. Biochemistry was then the nexus of medical research, but there was no such thing as a PhD in biochemistry: aspiring biochemists went to medical school on their way to the bench. This explains why the biomedical luminaries of the first half of the twentieth century, from Otto Meyerhof to Hans Krebs, started out as medical doctors. And although they spent the rest of their lives in research, their experience in clinical medicine provided an important bridge between the two.

“People are realizing that their specialty is not an island; they are going to have to talk to somebody else. Javed Siddiqi”

But after the end of the Second World War and a sudden influx of public funds, medical schools for the first time established academic departments with PhD-granting powers. Ironically, this meant that PhD students were suddenly being trained on the premises of major medical schools and centres — but with virtually no exposure to patients, doctors or pathology. Thus the great divide was born.

“For many years, it was the prevailing view among scientists that somehow medicine was a bit dirty, because people made a lot of money and it wasn't based on hard science,” notes Irwin Arias, a physician and cell biologist who oversees a popular NIH lecture series that teaches clinical medicine to scientists. “That created this tension. There was ‘us’ and there was ‘them’. The physician was the one who dealt with the patients.”

It wasn't until the early 1990s that the public push to bring research to the clinic gained momentum, and a slow rapprochement of the two sides began. “The wheel has turned,” says Arias. “More and more there's the realization that you can't separate basic science from human health. Those who try to do it, even as scientists, often get butchered” by grant reviewers, he says.

Meanwhile, those paying for research are moving to address the issue directly. This week, the Howard Hughes Medical Institute (HHMI) is unveiling awardees in a new $10-million grant programme aimed at directing PhD students into clinically related thesis projects co-mentored by a physician and a scientist. Thirteen awards are being made following 82 applications. “It's an idea whose time may have come,” says William Galey, director of graduate education programmes at the HHMI.

And at the NIH main campus, a weekly lecture series schooling scientists in medical topics from tuberculosis to Parkinson's disease is drawing enthusiastic reviews. The ‘Demystifying Medicine’ series attracted 80 or so scientists to an NIH auditorium when it was launched five years ago; this year more than 900 have registered for it, and thousands all over the world download videos of the lectures.

“Nowadays, PhDs are intensely interested in learning more about disease — what it looks like, what it feels like,” says Arias, the course designer. “And it turns out that it's a lot easier to demystify medicine for PhD scientists than it is to make last year's chief resident into a bench scientist.”

That transition may be the shape of the future, as the era of the physician–scientist draws to a close. Today, “you have to be superhuman to do both well,” says neurosurgeon Siddiqi. So getting the best science to the bedside is going to demand collaboration. “Neither the MD nor the PhD is going to be doing the whole thing. More and more, people are realizing that their specialty is not an island; they are going to have to talk to somebody else.”

References

  1. 1

    Hematti, P. et al. PLoS Biol. doi:10.1371/journal.pbio.0020423 (2004).

  2. 2

    Calmels, B. et al. Blood 106, 2530–2533 (2005).

    CAS  Article  Google Scholar 

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  1. Meredith Wadman is a freelance writer based in Washington DC.

    • Meredith Wadman
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Wadman, M. Them and us no longer. Nature 439, 779–780 (2006). https://doi.org/10.1038/439779a

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