Teamwork and Collaboration in Clinical Research

David G. Nathan, M.D.
Dr. Nathan, a past President of ASH, is currently the Robert A. Stranahan Distinguished Professor of Pediatrics and a Professor of Medicine at Harvard Medical School. He is a member of the Division of Pediatric Hematology and Oncology at the Dana Farber Cancer Institute and the Children's Hospital in Boston.

Though the efforts of the National Institutes of Health and private foundations have improved the lot of clinical researchers, obstructions to progress persist. One of the most serious obstacles to rapid translation of basic science to productive results at the bedside is the complexity of the task and the concomitant requirement for multidisciplinary approaches. We have a degree of understanding of the pathophysiology of hematologic diseases that is overwhelming to one who was carefully informed in the first year of medical school that DNA is blue in stained slides of the spleen. Today we can know the precise location of a gene of interest and define the mutations that cause many of the profound disorders of the blood, including the neoplastic diseases. But we have trouble translating that knowledge into more effective therapy because we cannot do it alone. We need the help of vectorologists, imaging scientists, pharmacologists, clinical trialists, cell biologists with expertise in signaling, and a host of others. Yet, for the most part, we are still evaluated for promotion, prizes, grants, and other indices of success as individuals. Credit and responsibility for clinical research are still seen as one-doctor functions. Until teamwork is evaluated and respected as much as individual performance, we will continue to lurch rather than thrust forward. Slavish adherence to 19th century academic standards in the 21st century will mire us and cheat our patients of the progress they deserve. Eventually our slow pace will frustrate our funders. Then perhaps faculties and funders alike will "get the message" and establish academic research norms that favor focused teams with clear-cut goals. NIH, under its new leadership, is trying to move in that direction. To keep up, faculties will need to change the culture of promotion committees and give much more credit for teamwork, while insisting on clear-cut responsibility for quality.

In case this sounds as though I favor a commercial model for clinical research, I hasten to assure that nothing could be further from the truth. In fact, I have a very guarded view of the relationship of industry to academic medicine. Industry, if well run, rewards winners and gets rid of losers. And industrial rewards are usually financial. In fact, industry prefers to pay cash for services rendered, and industry must maintain secrecy in order to establish patents that provide the income that supports research. In academic life, we favor a search for and rapid reporting of new results no matter where they lead, and in academic clinical research, the patient is far more important than a bottom line. Furthermore, we believe that lack of success in the achievement of a goal may be perfectly acceptable if the search produces new and interesting information. We do reward ourselves financially with promotions (which translate to a modest enhancement of income), but we serve our patients and society poorly if we have a financial interest in a company that makes a drug or a reagent that we administer to our patients. That conflict of interest becomes unacceptable to our funders and various overseers and particularly to the news media if an attempt to translate new ideas ends with a complication.

Despite the risk of unwanted conflict of interest, teams of academic and industrial researchers can make enormous progress. No academic institution can develop the expertise in modern medicinal chemistry that characterizes a successful pharmaceutical company. If as academic researchers we find a promising metabolic pathway in a human disease or disease model, it makes perfect sense to ally ourselves with an enlightened pharmaceutical company to find a compound that might become a useful drug. In fact, the closer the alliance, the faster progress we will make, with our patients as the beneficiaries. But each partner in the alliance has to respect each other's standards. We have different roles and different rules. Both partners must acknowledge a bright line that defines our differences while encouraging our collaboration.

Teamwork and respect for the contributions of others is essential in clinical research. We need both of them in our dealings with ourselves and we need them even more as we deal with collaborating institutions that we do not control. We are close to a new era in which "smart drugs" will lead to effective management of blood diseases that were formerly beyond our reach. We must establish and support the vital collaborations that will bring the fruits of decades of modern biomedical research to our patients without sacrificing the standards that define us.

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