When I began training in dermatology in the 1970s, I was impressed with the rapidly increasing depth and breadth of cutaneous research and eager to participate in what I imagined would soon be a revolution in the diagnosis and management of skin disease. I was fortunate to train in a department in which recent progress in human photobiology was being translated rapidly into an effective new therapy for psoriasis, mycosis fungoides, and other T cell–mediated dermatoses (
Wandering and wondering: a dermatologist’s experience with hospital based multidisciplinary translational research.
). I even had the good fortune to spend one year of my residency as the photobiology fellow, participating in clinical research and developing new therapies that became immediately available to patients (
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). The experience was highly gratifying and motivated me to obtain laboratory-based training following my residency to prepare for a career bridging basic discoveries at the cellular and molecular level with improvements in patient care. Limited only by my imagination and work capacity, I embarked on just such a career.
My story could not happen today. The inability of dermatology residents to immerse themselves in translational research at the most formative time in their careers is a great loss, not only to aspiring physician–scientists and clinical investigators but also, and more importantly, to dermatology as a discipline and to our many patients whose diagnostic and therapeutic needs remain unmet.
With the best of intentions, our government, certifying agencies, and academic institutions have imposed numerous hurdles on the preparation for and conduct of translational research. Cumulatively these regulations and requirements deter all but a handful of exceptionally determined individuals from attempting to translate discoveries from bench to bedside.
Consider the typical dermatology trainee who may have participated in laboratory-based research as a medical student, in some cases in the context of an MD–PhD program, suggesting a strong intent to mature into a physician–scientist. Upon entry into a dermatology residency program, he or she is likely to be informed that devoting any substantial time during the three-year residency to research—whether clinical or laboratory-based—is virtually impossible. In addition to the extensive and detailed certification requirements of the American Board of Dermatology, hospitals require a full complement of residents in patient care roles. Dermatology departments also rely on this clinical manpower to meet their patient-care obligations. As teaching hospitals and dermatology departments become ever more reliant on high patient volumes to make ends meet financially, the time and money required to encourage resident participation in research disappear.
Should the resident be willing to work nights and weekends on a clinical research project (knowing that laboratory-based or animal research is usually even less compatible with the obligations of dermatology residency), it soon becomes apparent that delays are to be expected. First, the trainee must take a formal course to qualify as a clinical investigator and thereafter must maintain certification, usually with monthly reading assignments and quizzes. Submission of the project proposal to the institutional review board and the inevitable revisions require months—in my own experience up to a year (a long time in the context of a three-year residency program). Once the project is approved and under way, meticulous and time-consuming HIPAA (Health Insurance Portability and Accountability Act)-compliant data storage is required. Of course, it is impossible to argue against the intent of these safeguards or the necessity of covering institutional costs by maximizing residents’ patient-care roles. However, it appears that little attention has been paid to cost–benefit ratios or to the lost opportunity that results from discouraging trainees from participating in research early in their careers. I believe the cost is huge—both to the trainees, who will forfeit many years of professional challenges and accompanying rewards, and to the patients who will never benefit from their potential discoveries.
To trainees, such impediments must seem the inevitable way of the world, integral to conducting safe, ethical research. They may deduce that meaningful participation in research is incompatible with obtaining a solid foundation in the practice of dermatology, at least during a three-year residency. But none of these requirements existed 30 years ago! Research-oriented residents, many of whom are today’s department chairs and accomplished career-long investigators, as well as highly regarded clinicians, routinely spent a year or more of their three-year dermatology residency at the bench, seeing patients under faculty supervision for perhaps only half a day per week during that time. Their research, including human-subjects research, was discussed in an ongoing manner with appropriate faculty supervisors but did not require lengthy applications or approval by committees unfamiliar with the disease being studied or the specific techniques employed. In the “old days,” mistakes may have been made and study designs may occasionally have been flawed, but I suspect such errors still occur today. Importantly, however, in the absence of extensive regulation, a critical number of physician–scientists and clinical investigators-to-be emerged from their residencies fully committed to translational research, their enthusiasm and curiosity intact.
Over the past 30 years, a second phenomenon has discouraged translational research, although happily it is now being addressed constructively. I refer to the core belief by many academics that product development is ethically and intellectually inferior to “basic” research. Related beliefs include the ideas that involving physicians in bringing their intended treatments or diagnostic procedures to the clinic creates an insurmountable conflict of interest (
); that money is the major incentive for physicians or anyone else becoming involved in such projects; and that encouraging pharmaceutical or biotechnology companies to participate in research meetings reduces meeting quality, introduces bias, and detracts from physicians’ learning. The consequence of such beliefs was for many years a dysfunctional separation between leading physician–scientists and clinical investigators and those best able to harness their discoveries for improving human health.
The 1984 Bayh–Dole Act was enacted in response to Congress’s realization that surprisingly little US government–funded research resulted in new disease treatments or better public health. This legislation directed academic institutions to promote commercialization of discoveries made by their federally funded investigators. Motivated by the potentially lucrative provision of this act that institutions—the owners of any intellectual property created by their faculty—could generate income from this process, academic medical centers gradually developed “technology transfer offices” to assist investigators with patent-protecting and then licensing their discoveries to companies wishing to commercialize them. Although often inefficient and underfunded, these offices did provide assistance to already savvy investigators. More recently, these offices have also attempted to educate students and faculty in relevant matters. In tandem with a more progressive view of the product-development process by the professoriate, such efforts are slowly bearing fruit.
As will be described in a series of invited editorials to be published in JID throughout 2015, several dermatologic investigators have successfully participated in the creation of new drugs and devices based on their own laboratory work or are working to facilitate the translation process through creation of new structures or paradigms. As well, the Society for Investigative Dermatology (SID) and many other dermatologic research organizations have begun to reach out to industry representatives and venture capitalists. The SID now solicits their membership, invites them to annual research meetings, welcomes sponsored symposia, and has even initiated “speed dating” sessions to promote dialog between individual investigators and those who might commercialize their work. All these efforts have great potential to accelerate progress in translational research.
Translational research is a vague term used by different individuals and groups to mean different things (
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). To me, the critical elements include conceptualizing an improvement in patient care, identifying a potential means of achieving that improvement through one’s own research or recognizing that means in the work of another, demonstrating proof of principle, and then assembling the team that will be required for commercialization. It is an ambitious undertaking, easily derailed. It cannot thrive in an environment that is overly distrustful or disparaging of any of the required components. Translational research is best taken up as early as possible in one’s career because there is much to learn and many experts who need to be in the professional network of a successful translational researcher.
Not every dermatologist or cutaneous biologist wishes to participate in translational research or, indeed, research of any kind. I am comfortable in suggesting, however, that everyone in the larger dermatology community must be supportive of this effort. This includes those responsible for setting the parameters of dermatology training, those supervising residents, those referring patients for research projects, and those funding research proposals. At the institutional level, I urge consideration of the risk–benefit ratio when evaluating protocols that entail truly minimal risk to human subjects (e.g., a punch biopsy or completing a questionnaire). Benefits of rapid, hassle-free approval include not only conducting the research in a timely manner but also teaching young investigators that such research can involve them in a deeply gratifying process and yield interesting results after a tolerable investment of time. I predict that even a modestly enlightened application of federal institutional review board regulations at teaching hospitals would notably promote clinical and translational research among investigators at all levels of seniority.
However, the primary rationale for selecting “Progress in Translational Research” as the JID’s 2015 theme is not to emphasize current barriers. For many reasons, these barriers are unlikely to be mitigated in today’s medical environment. Rather, it is to celebrate the impressive progress being made despite the obstacles described above. Such progress is manifest in every issue of the Journal and in day-to-day patient care. May this progress continue and accelerate.
Edward Jenner Performing the First Vaccination in 1796 (ca. 1895, Gaston Mélingue). In this issue, we introduce the JID theme for 2015, “Progress in Translational Research” (see the Editorial on page 1), with the story of Edward Jenner's demonstration that cutaneous inoculation with purulent material from a patient's cowpox lesion—a procedure he termed “vaccination,” from the Latin vacca for “cow”—confers immunity to the similar but far more deadly disease variola, or smallpox. Beginning in the Middle Ages, wave after wave of smallpox epidemics decimated the population of Europe and later the New World. It had been noted that patients who survived smallpox were subsequently immune to the disease. By the early 1700s, Europeans became aware of a practice in Turkey and other parts of the world of intentionally inoculating healthy people with purulent material from a smallpox lesion (“variolation”). This led in most, but not all, cases to a mild transient disease with little scarring, followed by long-term immunity. Because the fatality rate was about 2–3%— no more than one-tenth that of naturally acquired smallpox—many physicians and their patients opted for this procedure. At this time, it was also recognized by cowherds, although not by learned physicians, that contracting cowpox, a mild disease common in cows, seemed to protect workers from smallpox. Jenner, working as a physician/surgeon in rural England, made the intellectual leap that purulence from a cowpox lesion might be substituted for purulence from a smallpox lesion to provide immunity to smallpox with virtually no risk. In 1796, he used the purulent drainage from a cowpox lesion on a dairymaid's hand to “vaccinate” the arm of a healthy 8-year-old boy, James Phipps, who developed a mild fever and axillary adenopathy but was soon completely well. Two months later, Jenner “variolated” the boy, who developed no smallpox lesions or symptoms. Jenner carefully wrote up his observations and interpretation and submitted the paper to the prestigious Royal Academy—which rejected it. The following year he self-published a booklet setting forth his hypothesis and supporting data based on young Phipps and several other vaccinated patients. Acceptance of Jenner's approach was not immediate, but he persevered and provided inoculant to numerous physicians, who replicated his observations. Within 40 years, vaccination became the standard of care in Europe and the United States, leading to virtual eradication of the deadliest disease of the time. There are several lessons in this story. (i) Jenner was observant and open-minded. (ii) Based on the available information, he made a reasonable deduction about the potential benefit of vaccination and then performed and documented proof-of-principle experiments. (iii) It is highly unlikely that any institutional review board would have approved his experiments. (iv) His learned peers initially rejected his hypothesis and supporting data. (v) Without any knowledge of virology or cutaneous immunology, Jenner almost single-handedly eliminated the world's deadliest and most disfiguring disease. In the 1700s, the “bench” in bench-to-bedside translational research was underdeveloped, but the approach of harnessing astute observations for patient care, epitomized by Edward Jenner, remains central to successful translational research.
© 2015 The Society for Investigative Dermatology, Inc. Published by Elsevier Inc.