Trapped in the Lab

“Patients Have Been Too Patient with Basic Research” by Ralph M. Steinman with Maia Szalavitz, in Cerebrum (Fall 2002), Dana Press, 900 15th St., N.W., Washington, D.C. 20005.

Biomedical researchers, working in laboratories with rats and mice and tissue cultures, have made great strides in the theoretical understanding of human diseases—but benefits to the people suffering from those diseases have not kept pace. The reason? Not enough physician-scientists, who both treat patients and use them in research, contend Steinman, a professor of immunology at Rockefeller University, and Szalavitz, a science writer.

“Historically, medical research was conducted by physicians, but the molecular and cell biology revolution changed that dramatically by the early 1960s,” the authors observe. “Since then, even basic research on particular diseases has required specialized skills that most doctors never develop.” And most specialized researchers, working at the cellular and molecular levels, are far removed from the bedsides of patients.

Of the 700,000 physicians in the United States today, only 14,000 are scientists working to apply lab discoveries to human disease. Their numbers have declined since 1980, for manifold reasons. It can take 12 to 14 years to become both a physician and a research scientist—far longer than it takes to become just one or the other. The time spent in research training after medical school makes it harder for physicians to pay off their student loans (typically more than $100,000). Research on humans is more complicated and takes longer than research on animals and lab cultures, and is less likely to yield positive, publishable results. And managed care—by forcing physician-scientists to treat more patients and by cutting funding to teaching hospitals for patients in clinical trials—prompts many physician-scientists to drop their lab work.

But the payoff from the combination of treatment and clinical research, in ideas generated and tested, and ultimately in benefits to patients, can be great, say the authors. In his own work with colleagues, Steinman has shown that a type of immune cell called a dendritic cell not only directs the immune system to attack enemies, but can switch off immune cells poised to attack the body’s own tissues—a discovery made only when a study was done of humans who had a deadly form of blood cancer. Thanks to pressure from pediatric oncologists, some 60 percent of children with cancer now are enrolled in clinical trials combining research and care, compared with only one percent of adults with cancer—and today at least 75 percent of the young victims are cured, compared with only five percent four decades ago.

Some steps have been taken to create more physician-scientists, without success so far. “As with the big research initiatives against AIDS and breast cancer, the public will have to demand that this research be done,” write Steinman and Szalavitz. “From the patient’s perspective, nothing is more urgent.”