MARK: Good afternoon.
Welcome on behalf of the Pritzker School of Medicine ,
the Biological Sciences division,
and the MacLean center for clinical and Medical Ethics.
I'm delighted to welcome you to the 28th annual Lowell T.
Coggeshall Memorial Lecture.
The Lowell T. Coggeshall lectures
have generally focused on medical education,
and started in 1989 to honor Dr. Coggeshall who
had begun his academic career as a faculty member
here at the University in the 1930s.
During World War II, Dr. Coggeshall
ran the malaria program for the US government,
and he returned to the university in 1946
to become Chair of Medicine and Dean
of the Division of Biological Sciences.
From 1946 to 1960 during his years as Dean,
Dr. Coggeshall was known warmly nationally as the Dean
of Deans of American Medicine.
Almost single-handedly, he built the AAMC
into the powerful medical school organization
that it remains today.
Previous speakers in the Coggeshall lecture series
read like a who's who of American Medicine
and of University of Chicago Medicine,
speakers have included--
you see early on--
Bob Petersdorf, Al Tarlov, Bob Ebert, Al Feinstein,
Jordan Cohen, Dan Tosteson, Arthur Rubenstein
was the only person to give the lecture twice,
Joe Kirsner, Bruce Beutler--
a graduate of Pritzker who won the Nobel Prize--
Mike Parmacek, Holly Humphrey who's with us today,
and Sam Hellman is a wonderful addition
to this roster behind me.
It's now my pleasure to introduce our speaker
today, Dr. Sam Hellman.
Dr. Hellman is the A.N. Pritzker Distinguished Service Professor
Emeritus in the Department of Radiation and Cellular
Oncology, and previously served as Dean
of the Division of Biological Sciences at the Pritzker
School of Medicine before coming to Chicago.
Dr. Hellman was physician in chief at Memorial Sloan
Kettering hospital in New York, and before that, he
had served as the founding chair of the Department of Radiation
Therapy at the Harvard Medical School.
Throughout his career, Dr. Hellman
has been active in both clinical and laboratory investigation
especially related to breast cancer, prostate cancer,
and lymphoma.
He's also written extensively on the ethics of clinical research
and managed care, and on the doctor-patient relationship.
Dr. Hellman has served as president
of both the American Society for Radiation Oncology
and the American Society of Clinical Oncology.
Sam is the author of more than 300 scientific articles,
and is co-author with Vincent DaVita
and Steven Rosenberg of the standard textbook in cancer
called Cancer Principles and Practice of Oncology which
is now in its seventh edition.
Recently, Dr. Hellman published a new book called Learning
while Caring Reflections on a Half-Century
of Cancer Practice, Research, Education, and Ethics.
His new book is a collection of Dr. Hellman's essays
and articles exploring the issues generated
by the modern revolution in medicine,
and by changes in health policy over the past 50 years.
Today, Dr. Hellman's lecture is titled Learning while Caring.
Please join me in giving a warm welcome to Dr. Sam Hellman.
HELLMAN: Thank you very much.
We're going to do it very quickly.
So let's just look at nine at a time.
We'll be out of here in 10 minutes.
Thank you very much.
Well, thank you for that generous introduction Mark,
and it's wonderful to be here.
I have very, very fond feelings about Chicago the city
and the University of Chicago.
So thanks for inviting me out.
I take any reason to come and this is a wonderful one.
Mark, as mentioned this title, Learning
while Caring being the title of first an essay, then
a book, and now this talk, but each are somewhat different.
Learning while caring is what we do as a medical faculty
and it's what we do as physicians outside
of medical faculty, and it's important to recognize
this distinction.
We learn with our patients.
We treat patients as physicians at the same time,
and that's the heart of my discussion.
Let me see if I can get this to go.
So because I'm used to teaching, I'll
give you the summary at the beginning--
at least the table of contents.
I'm going to talk first about a little bit
of a primer of the nature of learning inductively
as a scientist and as a physician scientist.
Then a little part on the birth of academic medicine
in America.
It's very easy to determine exactly when it really started,
and how it started and it's important,
I think, to understand what we do.
I'm sorry.
Then a little bit of what Mark was talking about,
which is the dual responsibilities of physicians.
Those to serve society and those to serve
the individual patient, and when they have the possibility
of becoming in conflict.
And a little bit on patient rights and then
my final message.
Now these other players and that's insight,
it's an academic talk so there's going to be a test.
And you can see it now, and the answers will come at the end.
So we'll start with medical learning.
I like to distinguish, and I'm sure all of us do,
that we are one of the learned professions, but very much so--
and even more so-- we are a learning profession.
As we all know, lots of the things
we got taught in medical school are not true.
We didn't know which ones were going to be true
and which ones weren't, and we constantly change on it.
Knowledge, despite the notion that
randomized clinical trials are the
be all and end all of learning, it's in fact not true.
For any of us who practice medicine, we learn.
And I put knowledge and justified belief
because just to remind you that knowledge is uncertain
when you get it inductively.
So justified belief may be, in fact, a more correct way
of thinking about it.
It comes from randomized trials and meta analysis of those.
It comes from professional meetings.
It comes from our teachers, and it
comes from our clinical experience, and the accumulated
clinical experience of the profession.
And all are necessary.
Now this is just my pet peeve slide
because I think the notion of quantifying or categorizing
knowledge has gone crazy.
This is an example from the United States Government Agency
for Health Care Policy and Research--
Not for patient care.
Not for taking care of individual patients.
For policy and research.
And NICE is a nice acronym, but the British started this,
and you can read what they categorize
as the way in which knowledge should be assessed,
and I'd said enough about it.
In fact, clinical learning is based
on what Michael Polanyi says is tacit knowledge.
Tacit knowledge is the ability to integrate unconsciously
a series of pieces of information or data
and everyone--
lots of people came in today that I said hello to.
How did I recognize them?
What was the process?
It wasn't a conscious process.
I saw Eric--
Everett.
Freudian.
I saw Everett and I recognized him, but how did I do that?
Tacitly, unconsciously, I looked at his face.
I was prepared to see him here, and I make a decision
and when I do it from a distance,
I am less secure about it.
But as he comes closer, I become more secure.
That's one essential part of learning
and Michael Polanyi wrote a book about it
and it's quite interesting.
And it's, of course, what is a part of what
we call clinical experience?
Wisdom.
For whatever field you're in, you have an experience base
and it applies to it.
Second is Bayesian thinking.
You have preconceived notions of what
they should be or shouldn't be.
Anna, you may remember Jim Savage.
Do you remember him?
A statistician at Yale when you were there.
Well, he made the best comment I've ever
heard him explaining this.
He said, if someone tells you that they could flip a coin
and have it come up heads 19 out of 20 times,
you'd say there's something wrong with the coin.
If a musicologist told you that he could recognize a Mozart
score and 19 out of 20 times, you'd
say how did he miss that one?
And that's what Bayesian thinking is all about.
When you see an unexpected finding that
goes against everything you think is true,
you need a lot more evidence before you accept it.
On the other hand, if it's very much in what
you're used to the data needed is much less.
And just the final point about knowledge is that we learn
and we talk about textbooks which tell us
about one tumor or a cardiac problem or another,
but we apply it to individuals.
And so the knowledge is useful as a framework,
but the decision making is completely individual.
Just a couple of quick points on this.
These are explaining to you what I think these words mean.
Theory, an internally consistent explanation
of a series of obligations.
A hypothesis is a testable consequence of a theory,
but a confirmed hypothesis doesn't prove a theory at all.
It helps, but it doesn't prove it.
And the other is what I've just been
saying that there is no dichotomy, knowledge
or ignorance.
It's a gradient.
You go from almost complete ignorance as you're young
and then you start to learn and have some levels
and these levels are just--
I gave you four different things at the bottom.
There's accepted knowledge.
Standard.
Everybody seems to believe that it's confirmed many times.
There's evidence.
There's belief that you think things should be certain way.
And then there is the individual particular action that you do,
and you sometimes act on accepted knowledge,
only sometimes on evidence, and sometimes just on belief.
Try to give an example of medical learning,
and what you don't learn.
As many of you probably know, a major advance in cancer care
was the development of adjuvant chemotherapy.
Chemotherapy given to patients who
had seemingly localized breast cancer
because it was believed from previous experience
that a significant number of them
would develop metastases later even when
their primary tumor was removed or controlled by radiation,
and there are theories for how that cancer spread.
Well the first theory is that the operation itself
spread cancer cells, either by some immune suppression,
by the anesthesia, by the manipulation of the tumor
and removing it physically causing cells to spread.
That's one theory, and the other theory
is that the tumor had spread aculpably before you saw it,
and that was the cause.
And that localized disease was really much less common
than you thought.
You just didn't have the tools to find it.
So the hypothesis that was chosen to test
was to see whether adjuvant chemotherapy could reduce
breast cancer metastasis.
So I'm going to show you the three major studies,
and try to help determine what they meant.
The first one I think historically in starting
was a Scandinavian trial based on the premise
that surgery promulgated the metastasis.
So you'll see when I show you to the design what
they did for that one.
Then the two most famous ones in this country, one
is by Bernard Fisher, and he started his first trial
with that surgical spread notion,
but quickly changed to believe it really
should be considered a systemic disease whether or not
you detect the tumors.
And finally, Gianni Bonadonna down in Milan
did a study which was an American study.
It was developed at the National Cancer Institute
to follow the rules that were done
with multi-drug chemotherapy for Hodgkin's disease
and they just took that same approach and here's
the difference.
Nissen-Meyer, an alkylating agent cancer toxin
cyclophosphamide very soon after surgery
within 24 hours given for six days and that's all.
Bernie Fisher gave a similar alkylating agent for two years,
and Gianni Bonadonna, three drugs.
I say very similar to the Hodgkin's trial,
he first tried 12 months, and then
tried six months-- showed six month was as good as 12 months,
but both long, one short.
All trials were positive.
Not too different in extent.
What theory was supported?
Both theories were supported.
This could be consistent with both theories,
and if these trials were negative--
one or all of them--
what would you have learned?
You wouldn't have learned that adjuvant chemotherapy was
no good.
You're just learning that that particular drug
given that particular way wasn't good.
So you have to be see what it is you learn
versus what the hypothesis that you're testing is,
and as a matter of fact--
wait a minute--
Fisher did his first trial with Thiotepa, another alkylating
agent, and it was negative, and nobody talks about that trial.
And Fisher decided the drug was just not active enough,
and so he chose another drug.
Here's the interesting study.
This is the Bonadonna study.
You can see a big effect.
That's months on the bottom so 120, that's 10 year survivals--
curve is relatively flat, significant improvement
between the treated patients and their controls,
but does it tell us anything about the theory?
Not in this form.
But Bonadonna and his colleagues were very smart,
and what they did is they plotted the hazard
rate, the likelihood of having demonstrated metastasis
as a function of time, and you could
see the dotted line is the untreated patients
and the solid line is the treated patients,
and it looks like almost all the effect is somewhere around two
years with a range.
And they postulate something must have happened
to cause the metastasis at a specific time,
and it took two years for that metastasis
to be clinically demonstrated, and that something was likely
the surgical procedure.
Now that's just an explanation.
I haven't learned that, but I believe
this supports the first theory.
And that's what we've learned from this.
One, that the hypothesis is confirmed
for certain drugs in certain ways, and two,
that you see this.
And it's interesting in this case
especially because it was Nissen-Meyer who only gave it
for six days where this might have
been what you would expect.
This is given for six months or twelve months.
Well, I gave you that.
Just to summarize that part of this talk.
Popper, Karl Popper a great philosopher of science
said that--
well, you can read it.
You don't need me to tell you, but the last thing
he said there was, no matter how many instances of white swans
observed, that doesn't justify the inference
that all swans are white.
But, of course, the more you see of white swans,
the more suspicious you are when you see a black swan,
and you worry, well, was there some oily water or something
that discolored the swan?
But it doesn't prove it.
And Ernst Mayr, probably the progenitor of modern biology,
said, what Popper said is true.
It's conditional, but repeated consistency supports.
It adds to your security in the knowledge,
and I think that's what we do all the time,
and if you see some funny thing happen, you doubt it.
You work to make sure that you can confirm it strongly.
I'm going to switch now to the emergence of academic medicine,
and I said you can tell exactly when this began.
It began, American academic medicine, with a report
by Abraham Flexner for the Carnegie Foundation.
Asked to do this by the AMA because we
had all kinds of medical schools, proprietary schools,
schools that took people with no particular background,
and gave him six months or a year of medical training.
A lot of it was really being a preceptor with a student,
and the Flexner's report said you should
do what Johns Hopkins just did.
And Hopkins in 1889 built a medical school,
but first built a hospital and then built a university
to help this perform, and that has expanded and as they say,
the rest is history.
And four of the essential points on this
are that the medical schools have
laboratories and faculty doing research and involved
in patient care.
They must be full time-- a cadre-- not all of them
but there must be a significant full time group.
They needed a full undergraduate experience,
and it was organized as two years basic science
and two years clinical medicine and that held in America
until way into toward the end of the 20th century, where
we started to fool with problem based learning and learning
in blocks as opposed to the other
but it's all from the Flexner report and all from Hopkins.
And these are the founding four of Hopkins.
The most important of whom--
you'll like this Kenneth-- it was the Dean.
And well, she was first chosen, and he went
about hiring the remainder.
Osler is the most famous name on that list,
and deservingly so, he was the first Chair of Medicine,
and the others were also very important.
From there, the Rockefeller Institute.
Not by complete accident, the President
of the Rockefeller Institute for Medical Research
was Simon Flexner, the brother of Abraham Flexner,
and he took this to heart, and they built beds--
actual beds-- in the place and expanded it,
and it's now a university, The Rockefeller University
The Harvard Medical School did two things.
The first thing they did was to build the Peter Bent Brigham
Hospital right adjacent to the medical school
so they could achieve what Hopkins had done.
Billing's Hospital here, I think this--
is this room in Billing's, Mark?
This room is in Billing's, right?
Yes, so we are in that building built to meet
these particular requirements.
It took later, but it was based on this and then a gift
to Harvard and the Boston City Hospital
was to make such a unit at the Boston City Hospital,
and that became the Thorndike Lab at the Boston City
Hospital, and that was Harvard run from 1924 so
until 1974, when Boston politics took over
and Harvard and Tufts left the Boston City Hospital.
It became BU's hospital but they're very important.
Now the first of your cast of characters
is Francis Weld Peabody.
You'll notice those are two Boston Brahmin names.
Well, Peabody, he came from the establishment.
His father was the Deacon of the Congregational
Church in Cambridge.
He was a quintessential Harvard person, very bright,
trained at the Brigham, sent to Hopkins
to get some further training, and to the Rockefeller
back to the Brigham.
During all this time, Presidents Judson and Burton in succession
tried to get Francis to come to the University of Chicago,
and help start the civil adventure,
but he took the Thorndike and as a good many of you--
if you look at that first quotation
under The Care of the Patient--
this was a paper written by Francis Weld Peabody and he
says, one of the essential qualities of a clinician
is the interest in humanity--
and this is the quote that everybody uses--
for the secret of the care of the patient
is in caring for the patient.
Emphasizing that, and the second point that he makes
is the one I was making before.
The difference between learning in general,
and treating an individual patient in particular.
Well, Francis was very articulate.
These writings are his kinds of things.
I looked into him a little bit, and it's very interesting.
He developed GIST, a gastrointestinal stromal tumor,
unrecognized as such in those days.
It was medistat into his liver and he
died before he reached his 46 year birthday.
So the article was written while he had the tumor
and knew that it was inoperable.
So I think it adds a certain fullness
to what Francis is saying because he's
on both sides of this thing.
He was the doctor and now he's the patient,
and writing about this.
And there's a little irony--
irony may not be the right word--
but this is one tumor where the idea of precision medicine
has been particularly effective, and today, we
do so much better with this tumor
than we ever did in those days.
And I use it because clinical medicine blossomed
at Thorndike, and I use one example,
and the example is completely prejudiced.
My first boss was Hermann Blumgart,
and Hermann Blumgart was a research associate right
after medical training with Francis.
I know him so well I call him Francis now.
And what he did was just 30 years
after this discovery of radium, he
took radium-c, which is a very short lived decay
product of radium, and injected it into anti-cubital vein
in one arm, and developed what was a cloud chamber which
you could put over the other arm and determine
how long it took for the radioactive material
to go there.
This became a cardiac transit time.
It was, I think, the first novel way
to study cardiac function, and as I point out,
cardiovascular council.
That's their award to the best research,
and so very much was wanted was there.
Now, Francis emphasized this care of the patient and caring
for the patient, and this is just a quote from Warfield
Longcope-- the first one--
who says that the relationship develops not only knowledge
but sympathy, and he calls it the essence of medicine.
Blumgart, my boss, says, well, not so much.
He says it's very important but you need some detachment
from the patient.
You can't just empathize with the patient.
You have to have some objectivity,
and he called them those two terms.
And this is further Blumgart who wrote in the '60s
an essay which was in the New England Journal which
is very interesting.
It's about Francis.
What Francis said and how Blumgart felt about it
and you can read it.
So we understand the vehicle, academic medicine.
We understand something about how you gain knowledge, and now
let's talk about the patient and the doctor, and how
that fits into this and the--
so we're going to talk about patient rights,
and also about medicine's responsibilities
to the larger society, and how those two
come together or conflict.
I'm sure you can make a list of doctor's responsibilities
to the patient.
This is my list.
But I think it's worth thinking about it a couple of things
there that I think are particularly important is
that it's loyalty and fidelity to the patient that
should be paramount.
Then that comes up first in everything from Hippocrates on.
We should be respectful of the patients' rights dignity
and most importantly, their autonomy.
Patients must be involved.
You can't-- you have to involve them in this,
but they have to get your guidance and advice,
and the rest you can read.
A little word about vulnerability.
If you've ever been a patient, no matter who you are,
you are not in an equal relationship.
You are vulnerable.
You've got this bad thing happen,
and you found the doctor and you want that doctor to guide you.
Not to do it without your blessings or agreement,
but you are not equals.
Now, the societal stuff.
Public health, disease prevention,
very important for medicine.
Public education I believe is even more important now
than ever before.
I just put down there for those of you molecularly inclined
the gene editing, the CRISPR technology.
The discussion about how to gene edit and when to gene edit
is not a medical decision.
It's not a scientific decision.
It's a decision of an informed public,
and the person that informed public or that public
wants to get the information from is largely their doctor,
and that's our responsibility to get to this.
Just to make this an academic exercise, Asclepius,
the Roman god of medicine--
followed the Greeks, so the name but with an I-U-S,
it's Roman not the Greek, but it's the same--
had five daughters.
I mentioned his two daughters to you,
and their names Panacea and Hygeia.
Those are the two goddesses of medicine.
Panacea means what we use it for,
a drug to cure all the ills.
They want cure.
They want something that can do it.
And Hygeia is communal benefit.
Let me just point out to you that the philosophic basis
of Panacea is very much right space-- patient rights,
formal relationship, and individual--
communal benefit is utilitarian.
How you get the best.
Best example is vaccination.
Another example is quarantine.
You hurt some people by restricting them in order
to preserve the common good.
You can't do that if you're taking
care of an individual patient.
It's just a different role.
It's not an unimportant role and it's not a wrong role,
but it's a different role.
And, of course, clinical medical research, and I've
talked to you a little bit about that.
It's interesting to me if you look--
and Mark is much more able at talking about this--
but if you look at how we came to these things.
It all started after the Second World War
where the Nazi doctors were tried at Nuremberg
for crimes against humanity.
For crimes that just were complete in opposition
to the oath of a physician, and then the Helsinki declaration
a little later formalized it.
And then this next person that I mentioned to you, Henry Knowles
Beecher wrote this article.
And this article in the New England Journal,
he took 22 studies from the literature,
from very good institutions and very good people,
and questioned the ethics of them.
And I showed you just a few things,
but the worst maybe for me was the intentional
giving a live hepatitis virus to mentally impaired children
to prove how the transmission of the virus occurred.
Now look at the dates.
It's 1966.
So from '47 to '66.
Krugman.
Saul Krugman at NYU won the [? Marco ?] prize, and later
the Lasker award the American Nobel Prize
for the hepatitis study.
And Beecher wasn't so pure either.
This, I learned just this last year inadvertently
but very interestingly, Henry Knowles Beecher
wasn't named Henry Knowles Beecher when he was born.
He was Harry Unangst, or Unangst, or Unangst.
But when he decided to go enroll at Harvard Medical School
after completing his undergraduate training
at the University of Kansas, he changed his name.
And it's no accident that Knowles and Beecher are
two other Boston Brahman names.
His mother was a Beecher, but at least the people
I read do not know whether in fact she was of the Beecher's,
but that's him.
He was the Chair of Anesthesia at MGH--
one of the leading pioneers in anesthesia--
but he did a lot of experiments that
would easily fit into his article,
and I just mentioned a few.
Well, they're both interesting.
He did a randomized trial of using
arterial bypass and a control group that were operated on,
but the bypass wasn't done and he never asked the patients
for consent, and the patients never
knew because he was worried there'll be a placebo effect.
And he also was looking during the Cold War--
The Cold War really did a lot for expediency
rather than individual rights--
and so he studied LSD in medical students,
in unsuspecting volunteers.
Anyway, for some reason, he changed his mind
about informed consent and then wrote the book.
But none of this made much of an impact on people
until the Tuskegee study which came out in 1972.
It started in 1932 of leaving patients
with syphilis untreated to study the natural history
of the disease.
During that time, of course, penicillin became available,
and there were other less satisfactory treatments
before that.
And people got very upset and there's
a series of other things I won't bother you
with except the last one which is when
the first real questioning of untreated controls
came up from the statisticians.
This was on the AIDS epidemic.
The first drug for AIDS was to be started in the trial,
and half the patients got the drug and half the patients
got a placebo drug.
Pills look exactly the same and the public--
ACT UP if any of you are old enough to remember ACT UP,
the advocates for AIDS care-- screamed and hollered
about this.
But the most telling thing that happened
was that addicts on the street who were once
one major group that was affected by the disease pooled
their drugs.
They pooled them together because they
didn't think it was right that only half of them
would get treated.
So they pulled the drugs and took them out
so everybody got a little bit.
That didn't help the trial any, but it kind of points out
how difficult this is.
And it is the problem with the doctor acting
as a double agent trying to get information that will
serve patients in the future.
And as well as treat patients currently.
And Tony Fauci, the great leader of Allergy and Infectious
Disease at the National Cancer Institute--
I mean at the National Institutes of Health said,
and this is exactly what I think they believe
which is it's not to deliver treatment
for individual patients.
It's to help future patients, but you as the doctor
are taking care of those individual patients.
And buyer at all is an article in the New England Journal
too from ten statisticians saying
we can't do randomized trials in AIDS patients.
So this gives you a sense of this dichotomy,
and there are other examples of the dichotomy.
And you can see these quickly I'm running.
Problems with randomized trials are listed up above,
but there are other things such as rationing.
The opportunity if you work for the National Health
Service in Britain and have to ration your drugs
at the same time, You're trying to take
care of individual patients.
It's a straightforward, very difficult circumstance,
and it's true in America as well,
and we have to separate these two actions.
You can't have the caring physician
be the one doing the trial.
And now I'm going to go quickly through two
of my favorite people.
This is Thomas Hodgkin from whom Hodgkin's disease was named,
and he did both Panacea and Hygeia.
He lived from 1898 to--
I'm sorry, 1798 to 1866.
He practiced individual patient care.
He then ran the museum, and did the first
as far as I understand detailed clinical pathologic
correlations at Guy's hospital, and obviously, he
described Hodgkin's lymphoma.
And the story of that is a very interesting one.
But he also determined that lymph nodes with disease
in them associated with cancer patients
had the same disease in the lymph nodes
that they had in the cancer.
All before a microscope.
All before the microscope, then when
the microscope became available to him,
he noticed the bi-concave nature of red cells,
and striation in muscle.
So he was doing both I mean clearly doing
medicine's things, but he also campaigned
to get rid of lead pipes and cover them in tin.
He said fiber was good and cream and butter
were bad, and tried to get Britain to pay attention.
This is in the mid 1830s and 1840s.
Those of you who watched the Victoria series
on public television, young Victoria when she--
the attempted assassination was made of her and her husband,
Prince Albert, Hodgkin spoke and for the first time said,
there are people who do not know right from wrong,
and that's a form of insanity.
And that defense won.
The attempted killer, he went to Bedlam,
and remember that's the famous insane institution in Britain
and died there.
And that was it.
So the first time.
And for until he died, he went to the parts
of the British empire where he felt
there was a moral obligation to make sure that people were
getting certain levels of care.
And went with his friend Moses Montefiore--
again another story--
but points out his social conscience,
his way of doing things for the good of society
as well as individual patients.
And one that's not an M.D. is Marie Curie.
Madame Curie was thought when she discovered penicillin
that it would be a panacea.
It was put in all health potions and advertised greatly.
And in the early 1970s, my wife and I
were at the international breast cancer meetings in Florence,
and we got a room in not in Florence but Montecatini, which
was a spa, and in the room was this offering
of therapeutic enemas from the spa and emphasizing they
had high concentrations of radium.
This is 1974 or something.
So it wasn't panacea to some, but she did much more
than that.
She raised funds for using radium
to treat cancers, primarily female cancers.
She was a feminist and an ardent feminist,
and cervix cancer was cured with radium and endometrial cancer
as well.
And she recognized that.
But more than that.
When the First World War came on,
she said they need some x-ray machines to pick out
people who had broken limbs.
People who had shrapnel in them, and so she and her daughter--
who also won a Nobel Prize, I'll point out--
Irene, developed this cart--
motorized cart with x-ray machine in it.
They took the x-rays that made the diagnosis,
and took care of it.
She did both.
You can do both but you got to do them separately.
I'm running out of time and I have to give you the results.
I'm sure you got them all but that's obviously Madame Curie.
Five Nobel prizes in that family.
Just think about that.
And not the Peace Prize, but I mean science prizes.
Pierre and Marie won the first one together
for the discovery of an isolation of radium.
Pierre had died, and she won the second one in chemistry
for the chemistry of radium, and so that's three.
And her daughter Irene and her husband Frederick Julio Curie
won the prize in the mid '30s for showing
that you could bombard atoms and make them decay,
and that's the first example of artificial radioactivity.
5.
She's definitely a genius.
That's Francis Weld Peabody.
He's our hero because heroes when the most heroic die young,
and Francis did.
And he was the embodiment to me of modern academic medicine.
Not so much with Henry Knowles Beecher
He's much more checkered than I thought.
One of the books that described the emergence of medical ethics
by Rothman compared Beecher to Rachel Carson.
I think he probably overdid it.
And the Renaissance person is Thomas Hodgkin.
He knew and did many things, and was an internationally known
figure.
I could go on again about him, and that's my special guest.
That's my boss who did the radium-c transit
time, Hermann Blumgart.
And his boss was Francis Peabody.
So you can read this if you want for a minute,
it's from Blumgart and from that article.
So it's easy to know the patient,
and sometimes very difficult to know who the doctor is.
My message is we're a learned and learning profession.
Medical knowledge is uncertain.
Best advice to an aspiring physician is don't be too sure.
We have the primary obligation to the individual patient.
Both the public health and the medical
should be served but not concomitantly
in my belief by the same doctor with the same patient,
and my last one is there's much to learn
about studying your predecessors and it's also fun.
Thank you very much.
MARK: Dr Hellman's talk is open for comments and questions.
AUDIENCE: You have been critical of the randomized trials,
and yet, drugs do have side effects.
We don't know when and how they work.
So how has your position evolved?
HELLMAN: Not the way you would like it.
But I'm going to give you two answers, the answer is no.
I do think that if you're doing a trial,
you're actively involved in the trial,
then the patient must have primacy,
and if you're doing a study like Tony Fauci does,
that's perfectly OK with me.
He's not taking care of those patients.
And the person who takes care of those patients
has to be convinced that he or she doesn't
know which one's better.
Doesn't have a hunch which one's better.
If it was their mother, father, sister, brother, child,
they would be perfectly comfortable putting them
in a trial, and worse that if in doing their trial,
they find out that they see one group is doing better,
they've got to figure out which group that is
and give the other patients the same treatment which
is the end of the trial.
It ruins the trial.
So it's hard to do to start with but possible.
I can't in my judgment do it where
you gain information which would cause you to actually treat
people who you don't think are getting the right thing,
and finally you can't do a corroboratory free trial.
It's ethically impossible to me to do a corroboratory trial.
And then the second answer to your question
is with personalized medicine, at least in oncology, we're
going to get very small groups of people,
and it's going to be very hard to do statistics on them.
And so we're developing as you know
as well as I do other ways to deal with this.
AUDIENCE: Sam, back in the days, I
think you remember the use of ficus chemotherapy for breast
cancer.
Were you opposed to the randomized trials
of that approach?
HELLMAN: Well, I don't remember when it was in
my career at. '79 was when I first wrote about this.
So I'm trying to remember, but I think I probably was.
Yes, I was opposed to them for the same reason.
Now I mean I know the argument-- the pragmatic argument--
but there are other ways to deal with it.
There are some perhaps less good,
but they're very easy to repeat and there's no ethical problem.
You can have match pair analysis.
You can match groups from different places.
You could repeat it ad infinitum,
and that gives you a lot of support.
So I don't think the argument that if we
don't have randomized trials we'll get no advances.
That's not true.
It's not true.
And, in fact, things like penicillin--
which had big effects--
you didn't need randomized trials.
There was no point in that, right?
So I mean it's a more complicated point.
I'm not arguing that they couldn't-- that they're not
useful.
I'm just saying they're not ethically
valid for the individual doctor who is at the same time taking
care of those patients.
But I forgive you.
MARK: Holly.
AUDIENCE: Sam, thank you very much.
I'm wondering given your long history in academic medicine
if you have any specific advice for
the entering medical student in 2017 to best learn by caring?
HELLMAN: Well, the first thing I would tell them--
but I wouldn't like to see them as an entering medical student,
I'd like to see them as an entering college student.
Because I think one of the most misunderstood,
and it's especially bad today with the emphasis on STEM
education, that people are programmed
too early into the sciences, and not enough into the humanities.
And I mean I look at my career.
Randomized trials was very important to me.
I went to Memorial Hospital, and I suddenly saw this epidemic
of AIDS come where an eighth of the patients in our hospital--
a cancer hospital--
had AIDS, and the doctors were frightened
to death of treating them.
The nurses were frightened.
What are we going to do?
What's about touching people?
And it was all this hysteria, and it required, I believe,
the values that you get from a liberal education
to figure a way through it.
And that was true for the doctors, the nurses,
the other professional people, as well as the people
at random cleaning machines.
They especially vulnerable for it.
And the board.
And the board.
So I would say get a liberal education.
Meet your minimum requirements for science.
Trust the science you'll get in medical school.
I had just a last note, I know I'm over.
I had a medical student many years ago
in Boston who was one of three daughters of a very
eminent biologist.
Not a PhD in biology.
He's really the person that made us able to clone cells
in culture--
mammalian cells in culture.
I said to her, I knew that all three girls
were in medical school or physicians.
I said, Jennifer, how come all of you chose to be doctors?
She said, well, we listened to our father.
He said that you should get a good general education
and the best general education is to be a doctor,
and that's the education I want to give them.
MARK: I think it's a good pointer.
Thank you.
For more infomation >> Drake - Fake Love x Mario ft P.Diddy - I Don't Wanna Know | Success Obuh Mashup - Duration: 0:43. 
For more infomation >> T'as pas la nuit ! - Duration: 2:51. 
For more infomation >> Jeff Sessions' Numbers On Minneapolis Crime Don't Match Up - Duration: 2:39. 
For more infomation >> This will make sure you won't lose signal in Boston tunnels - Duration: 1:30. 
For more infomation >> Decision on Futuristic Inf@ntry Comb@t Vehicle worth $7 5 bn by July end - Duration: 2:42. 
Không có nhận xét nào:
Đăng nhận xét