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The clinician vs. the investigator: Or, town and gown in cardiology
Ed itoria Is
The Clinician vs. the Investigator: Or, Town and Gown in Cardiology RICHARD Pasadena,
J. BING, MD, FACC California
Cardiology, more than any other branch of internal medicine, has become two-headed, with the two heads like those of Janus, looking in opposite directions, One head belongs to the practicing cardiologist, the other to the investigator interested in clinical and fundamental aspects of cardiology. Rarely does one find the two heads combined into one head with features of harmonious beauty. The cardiologist in practice may have a private office with privileges in a hospital, or he may be a fulltime practicing physician within a hospital, diligently using the tools of modern diagnostic cardiology, such as coronary arteriography, left and right heart catheterization and lipid profile of his patients. He is also frequently connected with the treatment; he is responsible for training of both nurses and house staff. The other head belongs to the cardiologist who, also familiar with these tools of modern diagnosis, uses them for investigational purposes. He directs his emphasis toward a study of the relation of a disease to a group of diseases, with special interest in the natural development of the disease, either as a clinical entity or at the fundamental level. In the latter case, he becomes more and more removed from considerations of the individual patient. The fact is that a schism is developing between the two branches of cardiology; the language of one has become unintelligible to the other. The investigator might speak of the relaxing factor in heart muscle, the clinician of Mobitz block; there is little common origin between the two languages and, therefore, little understanding. There is yet another difference between these two branches of cardiology, one not peculiar to our field but common to all branches of medicine. It is the ciifFrom the Huntington Memorial Hospital, Pasadena, Calif. and the University of Southern California. Address for reprints: Richard J. Bing, MD, Huntington Memorial Hospital, 100 Congress St., Pasadena, Calif. 91105.
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ference between the structures of medical practice and academic medicine. The former is blessed with the gifts of freedom and independence. An individual in the practice of medicine does not have to be subservient to anyone and is dependent only on his ability to treat his patients well. The academician, on the other hand, may move further away from considerations of the individual patient and come to rely more on those in charge of academic administration, sometimes to his undoing; by force or circumstances he may become utterly dependent on them. In exchange of course, he can devote most of his time to research and work in an environment that furnishes him his tools. Can the two facets of cardiology be combined through education, common training or common exposure? This joining of forces is not only possible but essential; it should not be so difficult because there is much common ground on which the two can meet. Consider, for example, the coronary circulation. The advent of coronary arteriography combined with the determination of coronary blood flow has enriched the physician and the physiologist alike. In combination, much can be gained from these studies, particularly if they include biochemical investigations of the effect of changes of coronary flow or cardiac metabolism. There is much common ground here and it is always a matter of regret to me to see beautiful clinical facilities without investigational programs or splendid research laboratories with no relation to clinical problems. We must strive to awaken in a purely clinical setting the spirit of research, and in the laboratory we must kindle the interest that can come only from the sick. It is not essential for the practicing cardiologist to use sophisticated physiologic or biochemical methods in his investigation. Original work based on observation of the sick is still needed, but unless we combine the two branches of cardiology, the field will be diminished and progress come to a halt.
The Amerkan Journal of CARDIOLOGY
The Clinician vs. the Investigator: Or, Town and Gown in Cardiology RICHARD Pasadena,
J. BING, MD, FACC California
Cardiology, more than any other branch of internal medicine, has become two-headed, with the two heads like those of Janus, looking in opposite directions, One head belongs to the practicing cardiologist, the other to the investigator interested in clinical and fundamental aspects of cardiology. Rarely does one find the two heads combined into one head with features of harmonious beauty. The cardiologist in practice may have a private office with privileges in a hospital, or he may be a fulltime practicing physician within a hospital, diligently using the tools of modern diagnostic cardiology, such as coronary arteriography, left and right heart catheterization and lipid profile of his patients. He is also frequently connected with the treatment; he is responsible for training of both nurses and house staff. The other head belongs to the cardiologist who, also familiar with these tools of modern diagnosis, uses them for investigational purposes. He directs his emphasis toward a study of the relation of a disease to a group of diseases, with special interest in the natural development of the disease, either as a clinical entity or at the fundamental level. In the latter case, he becomes more and more removed from considerations of the individual patient. The fact is that a schism is developing between the two branches of cardiology; the language of one has become unintelligible to the other. The investigator might speak of the relaxing factor in heart muscle, the clinician of Mobitz block; there is little common origin between the two languages and, therefore, little understanding. There is yet another difference between these two branches of cardiology, one not peculiar to our field but common to all branches of medicine. It is the ciifFrom the Huntington Memorial Hospital, Pasadena, Calif. and the University of Southern California. Address for reprints: Richard J. Bing, MD, Huntington Memorial Hospital, 100 Congress St., Pasadena, Calif. 91105.
78
ference between the structures of medical practice and academic medicine. The former is blessed with the gifts of freedom and independence. An individual in the practice of medicine does not have to be subservient to anyone and is dependent only on his ability to treat his patients well. The academician, on the other hand, may move further away from considerations of the individual patient and come to rely more on those in charge of academic administration, sometimes to his undoing; by force or circumstances he may become utterly dependent on them. In exchange of course, he can devote most of his time to research and work in an environment that furnishes him his tools. Can the two facets of cardiology be combined through education, common training or common exposure? This joining of forces is not only possible but essential; it should not be so difficult because there is much common ground on which the two can meet. Consider, for example, the coronary circulation. The advent of coronary arteriography combined with the determination of coronary blood flow has enriched the physician and the physiologist alike. In combination, much can be gained from these studies, particularly if they include biochemical investigations of the effect of changes of coronary flow or cardiac metabolism. There is much common ground here and it is always a matter of regret to me to see beautiful clinical facilities without investigational programs or splendid research laboratories with no relation to clinical problems. We must strive to awaken in a purely clinical setting the spirit of research, and in the laboratory we must kindle the interest that can come only from the sick. It is not essential for the practicing cardiologist to use sophisticated physiologic or biochemical methods in his investigation. Original work based on observation of the sick is still needed, but unless we combine the two branches of cardiology, the field will be diminished and progress come to a halt.
The Amerkan Journal of CARDIOLOGY