Mentors for the New Millennium
Advice to a Young Cardiologist
“Congratulations! Today is your day, You’re off to great places, You’re off and away … You have brains in your head, You have feet in your shoes, You can steer yourself, Any direction you choose …” —Dr. Seuss1
Along time ago in a galaxy far, far away, there was a solitary young cardiologist standing at the crossroads of his medical career. As a starry-eyed college undergraduate, he had dreamed of combining the life of a scientist with the practice of medicine. This academic calling would intertwine the intellectual fruits of curiosity-driven science and the emotional satisfaction of making a lasting difference in the lives of patients. Although he had a gift for science in his coursework and was fascinated by new medical discoveries and therapies for heart diseases, he had little practical laboratory experience. The nagging questions of self-doubt, the difficulties of obtaining grants from the National Institutes of Health, and the war stories of younger faculty seemed to point to the default pathway of clinical cardiology in the nonacademic setting. However, the road to private practice was also littered with casualties, thus creating the current dilemma of choosing a career path. Unfortunately, the dark side of managed care had changed the balance in academic medicine, and there were too few academic role models to allow for an informed decision. Although he had “brains in his head” and “feet in his shoes,” he did not know which “direction” to choose. In short, he needed a mentor.
Perhaps it is time for young cardiologists to look outside of cardiology for mentors in the next millennium. Toward this goal, this current perspective garners the collective wisdom of several important men who acted as mentors: Lewis Thomas, Abraham Lincoln, and Yogi Berra.
Seizing Clinical Opportunity
“Halfway technology represents the kinds of things that must be done after the fact, in efforts to compensate for the incapacitating effects of certain diseases whose course one is unable to do very much about. By its nature, it is at the same time highly sophisticated and profoundly primitive… It is characteristic of this kind of technology that it costs an enormous amount of money and requires a continuing expansion of hospital facilities… It is when physicians are bogged down by their incomplete technologies, by the innumerable things they are obliged to do in medicine, when they lack a clear understanding of disease mechanisms, that the deficiencies of the health-care system are most conspicuous… The only thing that can move medicine away from this level of technology is new information, and the only imaginable source of this information is research. The real high technology of medicine comes as the result of a genuine understanding of disease mechanisms and when it becomes available, it is relatively inexpensive, relatively simple, and relatively easy to deliver.” —Lewis Thomas2
Clinical cardiology is largely based on halfway technology. Heart transplantation, angioplasty, coronary artery bypass, left ventricular assist devices, implantable defibrillators, and a host of nonbiologically targeted therapeutic agents form the cornerstones of modern cardiovascular therapy. Although efficacious, these approaches are cost-intensive and are not aimed at the underlying mechanisms that initiate and promote the disease process itself. Undoubtedly, the total cost will increasingly become the penultimate denominator that will limit the extent of cardiovascular care available to the general population. The only way forward is to move from halfway technology to a new wave of modern, biologically targeted therapy that is based on a true understanding of the complex molecular and cellular pathways that lead to human heart diseases. Fortunately, we are entering the Golden Age of molecular medicine.
Moving beyond halfway technology for heart disease has been empowered by the impending completion of the human genome database, the availability of DNA microarrays to monitor changes in the expression of thousands of genes in parallel from small tissue samples, custom oligonucleotide chips that allow for screening human populations for single nucleotide sequence variations that confer disease risk, the ability to genetically engineer cardiac-specific and inducible mutations in animal models to uncover new disease-related genes, and recent advances in the development of hybrid “smart vectors” for gene delivery and therapy. Cohesive teams of physicians and scientists have been formed at leading medical centers to identify the pathways for complex heart diseases, and strategic alliances are forming between academia and large pharmaceutical companies to develop agents that will interrupt or reverse the nodal points in the pathway for the disease of interest. Opportunities now exist for young cardiologists to train in some of the best molecular biology laboratories in the world, which recognize the value of clinical insight in exploring the role of favored genes and technology in human cardiovascular disease. New funding programs from the National Institutes of Health and the American Heart Association have been designed to support the training of cardiology fellows in this new wave of translational science, and the percentage of funding of RO1 awards is at the highest level in over a decade. For the entry-level physician-scientist, the technical barriers have never been lower and the scientific opportunities have never been higher.
Joining the Team
“When you come to the fork in the road, take it.” -–Yogi Berra3
Many of our current leaders in academic medicine were unsure of their career path when they reached the “fork in the road.” Often, a mentor played a role in the decision; this mentor acted as a sort of Good Samaritan on the road to academic medicine. Regardless of the choice, one thing is quite clear. The only way to learn whether one has the “research gene” is to “just do it.”
“You can observe a lot by watching.” —Yogi Berra3
Of course, having the research gene is necessary but not sufficient. The gene must be induced by the right environment. Good mentors can still be found at a roadside stand near you. Sometimes the best mentors are no longer players themselves, which allows them to be unbiased in pointing one in the direction of the best laboratory for her needs and interests. It is no longer necessary to confine the choice of laboratories to the hospital where one receives clinical training. In many cases, the best places to train clinically may be different from the best places to train scientifically. The most precious assets in the scientific process are its people. The size, funding, building, and location of a laboratory are important, but secondary, issues. In many cases, the most valuable training comes via observing the work of others outside one’s immediate field of interest. Accordingly, the overall strength of the surrounding scientific environment and the opportunities for interaction with other highly qualified scientists at every level (graduate student, fellow, and faculty) are critical elements. Sometimes, one can learn even when sitting in the dugout.
“90% of the game is half mental.” —Yogi Berra3
Serendipity can work for or against one. There is no sure thing in science. If a thing is sure, then it is probably not worth studying because the outcome is somewhat predictable. Often, technical barriers exist that prevent the breakthrough experiment from being conducted. Accordingly, an investment in developing high-risk, innovative approaches, tools, and reagents can be warranted. Needless to say, the risk is reduced when the laboratory one joins is either already on the cutting edge of the particular field of interest or has already shown a knack for the intriguing, surprising experimental result. If the game is “half mental,” then the approach must include alternative strategies to increase the chances of success. Sometimes one must “swing for the bleachers.”
“Nobody goes there anymore. It’s too crowded.” —Yogi Berra3
Medical science often moves forward via distinct movements. A single exciting discovery can influence many fields simultaneously. In this manner, molecules, pathways, and principles that have been worked out in other organ systems can subsequently become topical in the cardiovascular field. Although this sort of lateral information is always valuable, it can be viewed as derivative, and it often does not break new ground. In many cases, the most opportunity lies at the intersection between scientific fields, eg, computational science and biology, genetics and integrative in vivo physiology, chemistry and molecular biology, etc. Opportunity is created by having the vision, judgment, creativity, and technical skill to find valuable, feasible, and synergistic opportunities that have been overlooked by others. In some cases, these represent logical steps forward, and in others, they represent quantum leaps. In short, innovation is the defining quality of the highest science, and it will likely become an even more valuable commodity in the future. One of the major challenges for the next generation of leading physician-scientists will be to move beyond the molecular biology and genetics of simple in vitro cell-based systems into the complex in vivo setting of human biology and disease. Avoid the crowd, and one will have an opportunity for major discovery. Maybe the crowd will start following you.
“It ain’t over until it’s over.” —Yogi Berra3
The three most important words in science are focus, focus, and focus. Science is a multifaceted endeavor, complete with pre- and post-game shows, home and away games, commentators, prediction analysts, scorekeepers, journalists, play-by-play announcers, and cheerleaders. Meetings, conferences, societies, grant and manuscript reviews, fund-raising, and grantsmanship are also clearly a part of the scientific process. However, in many ways, these can serve as distractions for young clinician-scientists, who may get a mistaken view that science is based on a spoken, as opposed to a written, medium. The score in science is based on original articles in the most stringently peer-reviewed journals. There can be singles, doubles, triples, and homers, but the quality of the work itself is of more importance in the long run than the particular top-tier journal of choice. In short, it “ain’t over” until the data are published and their veracity can be reproduced by others. Keep your eye on the ball.
Finding Your Way
“The dogmas of the quiet past are inadequate for the stormy present. The occasion is piled high with difficulty and we must rise with the occasion. As our case is new, so we must think anew and act anew. We must disenthrall ourselves and then we shall save our country…” —Abraham Lincoln4
For academic medicine, these are the worst of times and the best of times. Unfortunately, a civil war is brewing between academic and nonacademic medical centers, and declining reimbursements are creating red ink at virtually every major academic medical center in the country. Ironically, this has created a demand for cost-effective, biologically targeted therapeutic strategies. As always, curiosity-driven science will lead the way in this new wave of therapy for patients with heart disease. As Yogi Berra once said, “It’s déjà vu all over again.”3 We are in desperate need of physician-scientists who are both clinically and scientifically well trained. This new generation will, hopefully, be able to combine clinical insight, physiological understanding, and state-of-the-art molecular, genetic, and genomic technology. The result should be “nouvelle medicine” that replaces our halfway technology.
For a young cardiologist interested in unraveling complex heart diseases, there has never been a more exciting time to enter the scientific arena. Although there will likely be fewer academic medical centers, the ones that survive will likely be stronger and have a clear mandate for breeding the next generation of leading physician-scientists. In the end, each person must find his or her own way. The good news is that science can take you there. Godspeed, young cardiologist. May the Force be with you.
- Copyright © 2000 by American Heart Association
Geisel T. Oh, the Places You’ll Go. New York, NY: Random House;1990.
Thomas L. The technology of medicine. In: The Lives of a Cell. New York, NY: Viking Press; 1974:31–36.
Berra Y. The Yogi Book. New York, NY: Workman Publishing Company; 1999.
Sandburg C. Abraham Lincoln. New York, NY: Scribner; 1940.