Q: Do you think this has something to do with the government funding through their war on cancer from the '60s onward?
Conley: I think hematology is an academic specialty. And I would not personally advise a young physician to join the hematology training program in an academic medical center that was not oncologically based, unless he planned an academic career. There is a tremendous opportunity for research in hematology. And if you plan an academic career, then hematology is a rich, promised land.
Q: It seems that this split between hematology and oncology didn't extend as far as pediatric hematology, for of course, you still have to deal with leukemias.
Conley: I think that's true. I think it has been possible for pediatricians, for pediatrician hematologists to cover the waterfront more satisfactorily because of the relative rarity of pediatric neoplasms and the more uniformity of their approach.
Q: So you would see this split coming more from the growth of knowledge, so called, rather than--?
Conley: Yes. The impossibility for any one physician to have sufficient expertise across the board, to handle these things well. Now classic hematology has also undergone mitosis. So a specialist in blood coagulation, the real contributing specialist, really is not likely to know very much about treating leukemia nowadays, or running a blood bank for that matter.
Q: What about the programs in sickle cell anemia, also, is that another area that's--?
Conley: There are several types of programs in sickle cell anemia. When Nixon was President, he designated sickle cell anemia the disease of the year, and Congress was pressured to make the funds available, not only for research in sickle cell anemia but also in patient care programs, the establishment of sickle cell centers and clinics which were primarily related to patient care.
Q: Did research money, however, flow to--?
Conley: There was research money, but hemoglobin research was progressing apace, without that. Nixon in his speech when he announced this said that we, I don't remember his words, had been shamefully negligent in supporting research on sickle cell anemia. In fact, at that point this was one of the most exciting research areas there was. And things were moving along very rapidly. Investigators, who were studying abnormal hemoglobins, were being generously funded, because that was a very promising, productive area of research.
Q: But you don't mean to move research monies away from--?
Conley: There is no question that the availability of funding for sickle research brought people into the sickle cell research area who hadn't given sickle cell anemia a thought before. So x-ray crystallographers, who hadn't thought a thing about sickle cell hemoglobin, or didn't even know about it, suddenly were very interested in studying the crystal structure of polymerized hemoglobin S and so forth.
Q: Was there any sense that hematologists lost out in the race for funds?
Conley: Oh no, I don't think so. I think that for hematologic research, across the board, there has been no shortage of outstanding investigators. And I think that hematology has been generously funded. Now, let me put it this way. That to get funded to do hematologic research, you have to do very good research. If you're doing cancer research, it doesn't necessarily have to be that good. I think that's a fair statement. I think there's been lots of money to support cancer research of a nature that would not have been funded, research of the same character wouldn't have been funded for hematologists. Which means that you can't be funded as a hematologist to do a clinical study of pernicious anemia or that sort of thing. It's increasingly sophisticated research. But I think people who are doing good, sophisticated hematologic research are probably doing pretty well. I think that if there is any criticism, it would be the support of less good research in other areas which have a great appeal because of the popular concern about such diseases as cancer and heart disease.
Q: Could we go back to your experiences at Johns Hopkins, in light of these last comments, and talk about the genesis of the hematology program here.
Conley: I didn't have any prototype to follow and I did what came naturally. I told you that I became interested in research in coagulation as a pastime and it was great fun. And it was productive. As new things came along I tended to ask questions and either to get involved myself or to get other people involved. And so as we evolved a training program that was inevitably research oriented. I've never had a clinical training program. So that every young physician who came to work with me knew before he came that he was going to be involved in a research program and he knew what he was going to do. In other words before he joined the group, we had selected some research activity. And this worked out extremely well, as you can see from what happened to these trainees.
What impressed me was that if you had very good people, they did not have to have six weeks in the blood bank, six weeks in the coagulation laboratory, six weeks here, which is now almost required by the boards. If you have an acceptable program now, you have to do this sort of thing. This is one of the reasons why I was opposed to boards, because I didn't want to have a standardized program. We were doing very well with our program. And as I told you, Dudley Jackson who came here to do coagulation research, ended up as Chairman of a Department of Medicine. Julius Krevans not only became Chairman of a Department of Medicine, but now is Chancellor of the University of California at San Francisco. So these people did all right. Sir David Weatherall, who did superb hemoglobin research here, is Nuffield Professor of Medicine at Oxford and the Editor of the two volume Oxford Medicine.
So you see I didn't have any reason to think that there was anything defective about my program, in terms of clinical training. These people were very good people and they did very well. So I was not only not impelled to set up a rotational program, where the fellows would be assigned here there and everywhere in sub-specialties of hematology, but I fought against it, because I thought it would destroy our research program.
Q: I guess the experience of David Weatherall might be a good case in point for this--
Conley: David Weatherall is a good, is a fine example. We had similar ones. They haven't all reached his distinction, although some of them are quite distinguished. David Weatherall came here with virtually no research training. He made use of our clinical resources and the hemoglobin research program that we had set up. But he also made a close affiliation with our bio-physics laboratory, Howard Dintzis and his people.
What Howard Dintzis had done was to study the assembly of the protein molecule to show that the amino acids are added in sequence to ribosomes. Well how did he do that? He used reticulocytes. And why did he use reticulocytes? Because Irving London, years ago, was studying heme synthesis. And he found that when he added N15 labeled glycine to the blood of normal people it didn't get incorporated into heme. But when he did this to the blood of patients with sickle cell anemia it did. This led to the discovery that reticulocytes synthesize hemoglobin. So reticulocytes all of a sudden become a treasure, because now you have easily available cells that synthesize protein. And so they were used by all kinds of people who were studying the nature of protein synthesis. David Weatherall went over and learned the techniques, used their facilities and resources. This is what I like, an open ended division with collaboration, and we've done this many times. He couldn't have learned that from me, certainly, or from anyone in our division. But in a great university, this is what's good. This is again why I detest an enclosed program.
Q: He also came in originally on his initial fellowship to work with--
Conley: He joined Victor McKusick's group but he immediately discovered that if he was going to do what he wanted to do that they didn't have the resources. So he transferred in just a few months to our division. And he did collaborate with Ned Boyer who is a member of the genetics division but all of his subsequent work was done here in this division and with collaboration of Dintzis’s group. He set up some of the techniques here. He was a very hard working, very intelligent, very ingenious worker and his productivity is even now incredible to me. With the responsibilities he has, I don't know how he does it all. But he started out doing it here at a great facility.
Q: Which techniques did he bring from biophysics?
Conley: He learned out to incorporate radioactively labeled amino acids into evolving hemoglobin molecules, to feed amino acids to reticulocytes. And that led to the study of hemoglobin synthesis in thalassemia. His monograph on thalassemia was largely based on his experience here. The book was published after he went back to England, but the work was largely done here.
Q: You said there were other examples similar to Weatherall who would serve to shape this picture of hematology being this hybrid discipline and formation.
Conley: Ronald Rieder did pretty much the same thing. Ronald Rieder is now Professor of Medicine and Head of the Hematology Division at Downstate. He had had no training in hematology until he came here. He learned some things from David Weatherall but also from collaboration with others including Dintzis's group and went on to make significant discoveries. Many of these fellows have been rewarded by election to elite research societies, the American Society for Clinical Investigation, and the Association of American Physicians, which I think reflects their accomplishment.
Q: Did Oscar Ratnoff also have similar type role?
Conley: Oscar Ratnoff was in medical school with me. I knew him slightly as a medical student. Actually he was a class ahead of me, although he is a year younger than I am. He's very precocious, I guess. He lived in New York, so he did not live in the medical student dormitory, and I didn't get to know him well. But then when he joined the army, which he did after I did, he was also assigned to Randolph field, to the altitude training unit. We got to know each other very well then, and we thereafter kept in contact with each other. After the war, he came to Hopkins sometime after I had been here and joined the division that was newly headed by George Myrick, which was called the Biological Division, but really was the microbiology division.
Oscar looked with great interest on what I was doing, and although he published a paper or two from the Biological Division, he spent most of his time working with me. This was after I had done the work on surface contact and he got very interested in that. We published a number of papers together here. I think this is where he really got firmly established in coagulation research. He's a brilliant scholar and he went on to Cleveland, and has continued this work until this very day. He has a lifetime scholarship that supports him as long as he wants to work in research. He's been very fortunate that he's been able to devote his professional life to research, which he's done with extraordinary productivity. I can't count him as one of my fellows, because he was a fellow in another division, but the fact is that he spent most of his research time working with me. And we did some rather significant things together.
Q: Was there a point at which, as you began to acquire more knowledge of the hematologic field itself, that you looked for models, research, clinic relationships at other universities? Were there other prototypes for what you were doing, or did you feel confident that what was unfolding at Johns Hopkins was--?
Conley: I think our program was a little bit off beat in its unstructured nature, that we never had clinical fellows, that everybody who came's primary responsibility was to do research and anything he learned beyond that was sort of incidental. But the wealth of clinical cases was well-organized in a hematology clinic with just unbelievable patients. In a few months we would see more of everything than most people would see in a life time. Really, it was like that.
One of my interests in life from the word go, has been the study of the natural history of disease, so I never let go of a patient. I'm still seeing patients that I first saw 40 years ago. You learn a great deal by doing that. Even now I have a clinic where current residents work with me. I see new patients, but most of the patients are old patients, many of whom I've been following for years. There is no better way than that to learn about the natural history of disease.
Q: Was this; is this a concept that you feel that you have played an important role in developing? Is it a certain approach to organizing the department of hematology for example?
Conley: I don't think I've had very much influence on other training programs.
Q: You wouldn't think that Hopkins has played a role in say colonizing or organizing other younger hematology departments, as fellows leave from here and go elsewhere, and they carry forward a Hopkins model or a Hopkins approach?
Conley: Well, it's hard to generalize on that. We've had diverse people, who've done really quite different things. Oscar Ratnoff, for example, I'm sure held on to all of his coagulation type patients, as long as he's able to. But he didn't originally head a division as such across the board. David Weatherall has very broad interests. After all, he's a chairman of a department of medicine. He's interested in everything and he's made significant contributions in fields rather far removed from hematology. He's a geneticist of very great distinction. But if you ask me does he follow up his patients forever, I simply don't know. I don't know how they work.
It's much more difficult for us to do it now. For example, the marvelous hematology clinic that I formerly directed withered away when they started charging big fees for patients to come. So as soon as patients had to pay a large fee to come here to get their treatment for pernicious anemia and they found they could get it from their local doctor at a fraction of the price, they disappeared. So we don't have any patients coming here now to get their monthly injection of vitamin B-12. But for many years we did. Sam Charache, who's taken over the abnormal hemoglobins, still follows many patients with sickle cell anemia and they are still used for research, because he has an experimental treatment program. But it's more difficult than it used to be. Teaching hospitals such as this, years ago didn't have to pay the minimum wage. A lot of the people who worked here were in effect volunteers, including very educated people who came here to work for the fun of it, or worked at very low salaries because they liked the work. That's all changed now, of course. People expect to be paid and you have to pay big salaries for people who aren't necessarily as talented as some of the people we formerly had. Patients do have to pay or have to be paid for. So we can't have patients coming back primarily for our education.
Q: So the approach of upholding this philosophy of natural history of disease actually belongs to a different type of work organization, hospital structure, than could exist today?
Conley: Well, theoretically the HMOs should be able to do this extremely well, but whether they will or not is the question. I have my own detailed clinical records quite apart from the hospital records. Some of these records, I have cabinets full of them, are very thick and so every time I see a patient, the notes in succession are added and then on the front of the chart I have a flow sheet, so that I can quickly look back. When fellows or residents see one of my patients for the first time they can quickly follow the course of the patient's illness. And they find this very instructive because they see patients with important diseases who never get admitted to the hospital, patients that they wouldn't ordinarily see. In a snap shot view, they can view the life history of a patient's illness.
Q: If we could switch gears somewhat--
Conley: I'm afraid we've been doing that right along.
Q: And talk about first year associations with the National Institutes of Health (NIH) and what role this played in shaping a hematological field or discipline.
Conley: I've had continuing associations with the NIH up until the time of my retirement, when I decided I didn't want to do any of that anymore, because I had done so much of it in my life. My first association with the NIH was when I received my first research grant in 1948. And then thereafter, I was continuously funded for research in blood coagulation, and for research in sickle cell disease, and abnormal hemoglobin. I had a training grant when they became available. In 1952 I first became a member of the Hematology Study Section. I will point out to you that I came here as a fellow in 1946, and in 1947 was by appointment the Hematologist in Chief without any prior experience or training. Then in 1952, I was a member of the Hematology Study Section.
Q: What went on the Hematology Study Section?
Conley: This was where grant applications, bearing on hematology were reviewed. The Hematology Study Section was very important to me primarily because it brought me into intimate contact with the other members. The Study Section would meet and review ponderous research grant applications, usually over the course of a couple of days. We would have to spend the night in the vicinity. When I first went to the NIH, the Clinical Center and other large buildings hadn't been built. We used to meet in a hotel in Washington. So we had a rather intimate relationship with the other members of this relatively small panel. The members of the panel were largely very distinguished hematologists, whom I had a chance to meet. When I joined the Hematology Study Section, Carl Moore was the chairman. And such people as Larry Young and Max Wintrobe and Bill Castle, and many other distinguished people served on this rotating board. I think the period of appointment was four years, so in the course of four years, I got to meet many of the leaders in academic hematology. This was great for me, having started without contact with other hematologists. I got to know these people rather personally from these contacts. And I think having a panorama of research before me, as these research grant applications were presented, was very instructive. I got to know what was going on in the world.
Q: Was there a common scope as to, common vision as to how hematology should develop as a field, held by people in this--?
Conley: No, I don't think at that point that the Hematology Study Section was regarded as any kind of a policy forming group. But the Hematology Study Section critically reviewed the applications. Each member of the study section secretly graded each application with a number. These numbers were averaged and then each application was given a rank score, which was basically the average of these grading. It was very well done.
Q: But there still must have been, at least implicitly, some notion of what goes into making up a discipline of hematology.
Conley: I don't think we even considered that.
Q: Is that true?
Conley: I'm sure that was true. We proudly considered that hematology was widely ranging. I think we were pleased that these applications were so very diverse.
Q: Were there any very strong differences of opinion over funding in the early stages, 1952?
Conley: I don't think so. I think that it was in those days, relatively easy to pick out the real pearls, to pick out the really good things.
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