Nobel Prizes in Medicine: Are Clinicians out of Fashion?”

 

 BBC News - Nobel Prize goes to scientists behind mRNA Covid vaccines.

 

https://www.bbc.co.uk/news/health-66983060

 

The Nobel Prize in medicine or in physiology this year in 2023 again goes to two scientists rather than to a clinician. A clinician is a medical doctor with a basic bachelor’s degree in medicine. He or she may also be a medical specialist. But clinicians are not a doctorate holder unless they have a PhD in addition to their basic bachelor’s medical degree. 

 

Sometimes I wonder why medical doctors are called clinicians because they hardly do much clinical work except take medical history, prescribe the medicine, and request for laboratory tests which are done 100 % by medical scientists and laboratory technologists. Even radiologists mainly read the results of imaging and send the results back to the clinician. The term ‘clinician’ means anyone who does a lot of clinical work. A nurse who does most of the clinical work such as take the temperature and blood pressure of the patient, clean and dress up the wounds of patients, set up and monitor the IV drips, give the injections and other medication, measure their fluid intake and urine output…etc, etc. is actually a clinician. She does far more clinical work than a medical doctor who merely takes medical history, does a few clinical examinations, requests for blood, urine, haematological or radiological examinations, and prescribes the medicine.  

 

 All these are clinical work a nurse does which the medical doctor hardly does.

 

The only exceptions are the surgeons and anaesthesiologists who do a lot of clinical work on their patients. They together with the nurses are the real clinicians rather than a medical doctor who merely takes medical history, auscultate (listen) to the lungs for crepitation, rhonchi, plural rubs, etc, or listens to the heart for murmurs with a stethoscope.

 

It is what we do most that we are given a name of such an activity such as one who drives a car is a motorist, one who rides a bicycle, a cyclist, one who plays the violin or a piano a violinist, pianist, one who swims, a swimmer…and so on and on. So, in my opinion a nurse who does most of this clinical work should be called a clinician rather than a medical doctor who hardly does any of these jobs a nurse does.

 

Anyway whatever it is, a group of clinicians from the Royal Society of Medicine in London then wrote this in dismay:

 

“Nobel Prizes in Medicine: Are clinicians out of fashion?”

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164255/

 

I learned about this grievance from clinicians more than 25 years ago. They were my Fellow colleagues at the 200-year-old Royal Society of Medicine in London (RSM).

 

I was admitted as a Fellow of Royal Society of Medicine in London in 1993 just one year before my retirement. 

 

I supposed the Royal Society of Medicine admitted me as a Fellow as a consolation “honour’ just before my retirement, and as a 'gift' to me for retirement after toiling for 25 years in medical research as a Senior Medical Research Officer at the Institute for Medical Research in Malaysia.  

 

It is very sad to learn that since 1927 most of the Nobel Prizes in Medicine or in Physiology were not awarded to clinicians, but to medical scientists.  Most of the medical scientists are in research who are frontiers of new medical discoveries as they plough into the unknown looking for new knowledge in medicine.

Anything the clinician uses today whether for diagnosis or for treatment does not belong to them. For instance, X-rays was discovered by physicist W.C. Rontgen in December 1895 after seven weeks of assiduous work during which he had studied the properties of this new type of radiation able to go through screens of notable thickness. The ultrasound machine was the invention of engineer Tom Brown who gave it to Ian Donald, an obstetrician to use for the first time.  Similarly, it was Godfrey Hounsfield, a biomedical engineer who contributed enormously towards the diagnosis of neurological and other disorders by his invention of the computed axial tomography scan for which he was awarded the Nobel Prize in 1979. It was never invented by a clinician or a medical doctor. The only medical doctor who was also a physicist was Raymond Damadian, MD.  He invented the first magnetic resonance imaging and built the first magnetic resonance imaging (MRI) scanner, which revolutionized the ability to diagnose cancer and other illnesses. Unfortunately, he never got the Nobel Prize in medicine. It went to two other scientists, Paul Christian Lauterbur (May 6, 1929 – March 27, 2007) an American chemist who shared the Nobel Prize in Physiology or Medicine in 2003 with Peter Mansfield for his work which made the development of magnetic resonance imaging (MRI) possible.

Similarly, it was Willem Einthoven (1860 - 1927) was a Dutch physician and physiologist who invented the first practical electrocardiogram (ECG) in 1901. Einthoven began his studies of the ECG with the mercury capillary electrometer and improved its distortion mathematically, so that he was finally able to register a good representation of the ECG before the beginning of the twentieth century. He later further improved ECG recordings with the introduction of a string galvanometer that he designed. For this, Dr Einthoven won the Nobel Prize in Physiology or Medicine in 1924.

The same with all the drugs clinicians use. They were not discovered or invented by them. The development of pharmaceuticals is the brainchild of pharmaceutical chemists, biochemists, biotechnologists, immunologists, microbiologists, pharmacologists, physiologists, toxicologists, cellular biologists, and other biological scientists.

 After developing the drugs, they put them on various stages of animal and clinical trials before marketing them to the clinicians who merely use them on their patients after the manufacturers teach the clinicians about their pharmacology, pharmacodynamics, pharmacokinetics, indications, dosage, etc and how to use them.  These drugs were never invented by clinicians. The pharmaceutical companies merely sell them to the clinicians who in turn prescribe them to their patients.

 

 

If all these products from discoveries and inventions by other scientists, from blood tests to imaging were withdrawn from the clinician, then they will be at a loss how to diagnose and how to treat except taking medical history, writing clinical notes and listening to heart beats and doing other physical examinations. There is nothing to give, no medicine, no drugs, no treatment, nothing to give or how to treat.

Thus, "the proportion of clinicians receiving this award has been diminishing year on year. In the past 100 years of awards to medical scientists (excluding war periods where Nobel Prizes were not awarded to individuals); over 79% of Nobel Prizes in the first 30 years were awarded to clinicians. This contrasts significantly with the last 30 years, where only 26% of prizes have been awarded to clinicians between 1970 - 1979.

 

Before and after 1979, almost all the Nobel Prizes in Medicine or in Physiology were given to non-clinicians.

Normally clinicians do not make medical discoveries or contribute anything to add new knowledge in medicine. They normally do just routine work in hospitals and elsewhere.

 

The Nobel Prize in Medicine is arguably the most prestigious award in the world in healthcare.

 

Although clinicians do routine work by applying the results and products of research done by their colleagues who are medical scientists, my feeling is, at least some of them should be given the Nobel Prize because clinicians have saved millions of lives throughout the world especially in emergency medicine and in critical care, an area I know well.

 

 But then there are millions of clinicians around the world, including myself, and we cannot expect the Royal Swedish Academy of Sciences for the Nobel Prizes to award such a prestigious accolade to every clinician. 

 

Then again not all diseases are life-threatening that require instant life-saving intervention. Most diseases are not. So, to whom shall among the millions of clinicians in this world should the Nobel Prize be given? 

 

Such a precious award should only be given to anyone whose discoveries and contribution in medicine has benefited and has saved millions of lives, and not just a few rare cases such as a heart or a liver transplant that benefits only a few and only the very rich can afford it who enrich the surgeon at the same time. They do not deserve the Nobel Prize no matter what the treatment that benefited only a few. It must be something simple, cheap, and very large scale such as a vaccine or a drug that could wipe out malaria or tuberculosis that are reemerging from the surface of this earth forever. So far, no scientist can do this.  

 

But I still think some clinicians who have toiled restlessly among thousands of poor communities without asking for remuneration deserve this glamourous Prize in Medicine. Very few do this. This is my feeling even though we admit 99.99 % of new diagnostic and new therapeutic approaches these days are done and contributed by medical scientists, and not by clinicians.

 

I think one of the reasons is, modern medicine these days focuses not just on traditionally gross broad aspect of medicine, using standard type of diagnosis and treatment as we see in all hospitals and health-care centres, but scientists help the clinician to go into molecular levels of medicine such as, using nanotechnology and nanoscience to manage SARS-CoV-2 and their variants, epigenetics and stem cell therapy in the management of diseases, gene-targeted diagnostics and therapies for cancer and metabolic liver disorders.

 

Other areas of medicine that require an understanding of molecular biology are cell therapy, gene virotherapy, molecular mechanisms of immune response, molecular mechanisms in neurodegeneration, molecular medicine in cancer treatment, molecular medicine for cardiology, molecular microbes, and disease. 

 

These areas are very tough to understand. These areas are beyond the understanding and knowledge of ordinary clinicians who normally only have a basic bachelor’s degree in medicine and surgery unless they also have an additional doctorate (PhD) in that area.

 

Another possible reason why such a prestigious Nobel Prize in medicine is not given to medical doctors is because they can earn more money by charging their patients huge frees than if they go into research that earns them nothing except their names goes eternally into the annals of medicine when they are able to publish a paper where their names are cited again and again by other researchers and clinicians. This too is quite a glory and achievement. Whereas even if a clinician sees 100,000 patients in his lifetime, it is just his routine job, and he is paid for each case he sees. In what way should he be given a Nobel Prize for this? Even if a clinician treated 100,000 cases in his life, his name will not be quoted or cited, and his name will not go into the archives of medicine. Only those researchers who have published papers to contribute to new knowledge in medicine will find their names quoted in the archives of medicine. 

 

Furthermore, for a clinician to go into research he or she must have that kind of special brain to be able to think critically and analytically on their own out of the box and outside textbook knowledge. Additionally, they need to source for research funds which sometimes can be quite difficult outside their fixed salaries. They also need to find 3 -6 research collaborators outside their expertise. To get them who are willing to cooperate is hard to come by. Hence it is far more lucrative for clinicians to go into private practice and charge patients exorbitantly.

  

This may explain why most of the Nobel Prizes in medicine since pre-war go are not given to clinicians, but to western scientists who normally may not even have a medical degree although most do.

 

But what is most important is, they must have a PhD. That alone suffices. They use their basic understanding of medicine as a springboard and bounce high up into new areas in diagnostics, treatment and in preventive medicine, and give the results of their work and discoveries to the clinician to apply on patients. Such a scenario will eliminate all clinicians from getting any Nobel Prize in medicine or in physiology.  

With a PhD these scientists can think out of the box. They then plough into new areas of medicine and made significant discoveries which earned them the much sought after, highly esteemed, and glamourous Nobel Prize.

 

See my additional view here, published on Sunday, July 9, 202

 

lim ju boo