Unafraid to embark upon “The Year of Thinking Dangerously”
By Neale McDevitt
These are good days to be the Dean of the Faculty of Medicine, just ask Richard Levin. With the grand opening of the state-of-the-art Life Sciences Complex on Sept. 18, Levin finds himself at the helm of a faculty poised to make medical science history. But having practiced, taught and researched medicine for 30 years on the front lines of New York City’s Bellevue Hospital Center, the oldest public hospital in the United States, Levin knows too well that the true measure of a institution’s worth is in its people. The former Vice-Dean for Education, Faculty and Academic Affairs at New York University (NYU) School of Medicine, Levin had plenty to say about the past, present and future of medical education when he sat down recently with the McGill Reporter.
Could you give us an idea of the significance of the Life Sciences Complex to the Faculty of Medicine and to McGill?
In my introductory remarks at the inauguration, I used the word “monumental.” It is the largest construction project in the history of McGill. The concept that drove the development and construction of the LSC is not unique but it represents a major change in the way we organize biomedical science at the University.
The building was developed with an open laboratory structure – not departmentally based, but based on the five areas of concentration; cancer, complex traits, chemical biology, developmental biology, and cell information systems. This will enhance the interactions that occur between scientists. The ability to aggregate such a mass of biological scientists in a single, contiguous space organized by theme is extremely interesting. We have great expectations for the future.
What kind of impact will the LSC have on medical research in Canada?
We expect it will have a great impact, of course. The designers were brilliant and understood that it is really about the aggregation of people. It’s the promise of what they’ll be able to do together synergistically that they might not have been able to do on their own. It’s a chance encounter. It’s understanding that a technique is available in the hands of an expert 10 metres away. It’s the magic of collaboration – the notion that in this,the genomic era, there is a need not only for massive arrays of data that describe the genome of an individual but also a need of massive arrays of investigators to collect the kind of information necessary to advance the cures at a very rapid pace.
So we hope that this is one of the structures that transform life sciences in Canada to the 21st century model that we will help invent.
Why is collaboration so important in medicine today?
In order to develop answers that are tied to the molecular biology of an individual – the genome, the proteome, the metabalome – we need information registered for that individual of an extraordinary depth. We need to describe the patient’s genetic composition and potentially the genetic composition of something gone awry – a tumour that has acquired over a long period of time, maybe 30 years, a series of mutations that makes it unique. Of course the genetics of that tumour will be distinctly different from the genetics of that human.
Then we need the phenotype, the expression of the patient’s genes interacting with the environment. The patient’s phenotype and the phenotype of the tumour. Does it stay held in a cage locally? Does it metastasize? Where does it metastasize? How likely is it to metastasize after the primary tumour is arrested in its development or destroyed?
What about the environment of the patient, the history of the family? How does that environment influence the development of the condition? In order to get that kind of information, the scientists in the LSC need to be able to interact easily with their colleagues in the hospitals. We need to have tissue banks which have descriptions – the phenotypes of the patients from whom the tissue has been removed – available for the kinds of wizardry that bioinformaticians do by looking at these huge, large-scale databases.
From there they will be able to extract little glimmers of interest, something out of the ordinary that makes a suggestion that it is not Hypothesis A that is responsible for this tumour or the expression of this tumour but rather something totally unexpected. It’s not, for example, just the fact that the patient had diabetes for x-number of years; it’s that the diabetes was uncontrolled for most of that time that may turn out to be the critical factor.
So, the building needs to be seen as part of an extraordinary network that is not limited to city, to province, to Canada – but one that can interact with scientists, clinicians worldwide who might have a local aggregation of the problem of interest.
Having said that, what the building will do to and for the health sciences in Canada depends upon many other external factors.
What are some of those factors?
One of the critical factors is the level of funding for biomedical research by federal and provincial governments. When a government decides that the return on investment of biomedical research needs to be changed and it puts a halt on the growth of research funding, the direct effect is to prevent a generation of scientists from maturing.
When funding levels drop significantly, that new generation of biomedical scientists who were recruited during the last period of growth cannot be sustained. They leave the field, they leave geographically, they leave science and it’s a loss that takes 25 years to recover from.
In the way ontogeny recapitulates phylogeny, on a macro scale this building has to be seen as part of the world’s living complex of biomedical science.
I know it is hard to make such lists, but what are some of the “bells and whistles” of the new complex that are most exciting to you?
One of the really great elements is the idea that the large, highly specialized equipment, which tends to be very expensive, has not been replicated and is not sitting in individual laboratories. The owner in this case is the community and the core facilities are available to all investigators in the University complex and beyond. In doing this, you break down one of the barriers to the free asking of questions because everyone has access to these specialized items.
The building was also designed to be as green as possible and is likely to receive LEEDS status. It has a green roof, and it has built into its systems energy saving methodologies that make it greener.
The building also has the latest in automation for its secure mouse facilities; including a bio-safety level three laboratory. The systems are state-of-the-art so there is as little handling of the mice by humans as is necessary for the experimental protocol. That automation makes the biological environment more secure.
The building is so open physically, by design, that the people working there have this sense of connection with the larger world. It changes not only how they feel about being in that space but also how they interact with each other.
How has medicine, both the practice and teaching of, changed since the beginning of your career?
Since my early days at NYU and Bellevue, medicine has changed in every way conceivable except that we still believe as a philosophy that as the patient’s fiduciary, the doctor is responsible for taking care of the patient the best way they possibly can.
When I entered medical school in 1970, the useful pharmacopeias, the full list of useful medications, numbered less than 50. Today we have some 2,500.
When I started, the human classroom of the hospital was unlimited in its scope; the concept, which was actually developed by William Osler, a graduate and early faculty member of McGill who went on to found Johns Hopkins University Medical School, was that the teaching hospital was the unifying principal of great academic medicine. The patients were there as were the students, the residents, the faculty, the diagnostic armamentarium, the treatment andthe surgical facilities – it was a remarkable geographic expression of what we needed to do to make patient-centred education and care work.
But that human classroom has changed in 60 years more than any other life-changing development with the possible exception of the Internet.
When I started, patients could be admitted with no limit on their length of stay. It is very costly to have a patient stay in a hospital, and today there is pressure on length of stay. That means much of what used to exist, certainly in the diagnostic phase of a hospitalization has moved out of a hospital. It happens before a patient is admitted now. That means that the medical student’s experience of a patient’s illness – the history taking, the physical examinations, the encounters late in the evening when the patient is more relaxed, the meeting of the family and friends which give a sense of not only how this illness impacted this patient but also his family and the larger community – all this is lost to the students unless we find ways to give them back that continuity.
And the breakthroughs in research?
Research has morphed to the same degree. When I started, we hadn’t yet entered the era of rapid development of molecular biology with the cloning of genes and the development of knockout and knockin mice – none of those things were available.
The expression of the human genome waited until 2002. So we have moved from an era where hypothesis-driven research, often called classical investigation, in which a single investigator has an idea, develops a hypothesis and submits a grant to research that. This has been supplemented in an era in which you can ask questions about collections of people. What is the difference between that group which seems to be resistant to heart disease and another which dies of a heart attack at an early age? You can ask that question now not as a hypothesis but as an expedition in genetic epidemiology and do the genome of large numbers of people and discover things that then have to be developed.
Further, the advent of the large, multi-centre, randomized, clinical trial has answered questions such as; if you have Condition A being expressed by Symptoms B, C and D, what is the best approach to the therapy of that patient? Now there is a huge new library of treatments to known diseases that simply did not exist 50 years ago. So doctors have had to incorporate that information into practice along with the prime directives that go back to Hippocrates 2,500 years ago.
What are the challenges of having four years to teach medical students a mass of scientific knowledge that seems to be increasing all the time?
It is a significant challenge. When my colleagues entered medical school in that period from early after World War II to around 1975, there was an expectation of mastery of all that was the practice of medicine. You would know all the diagnoses, certainly be comfortable with all the medications available. Yes, you might specialize in surgery or internal medicine but you certainly understood everything.
That simply is no longer a reasonable expectation now. There’s a book that was published in 1975 by Derek J. de Solla Price called Science Since Babylon in which he predicts that total knowledge of science would double every ten years. It’s actually now down to seven.. That means when the average physician has completed advanced training – medical school, residency and fellowship if there is to be a fellowship – a span of at least seven years has passed. What was known upon their entry into medical school has now been doubled and in their first seven years of practice it will double again.
Does this mean we need to rethink the way we view medical education?
We must begin to think of the education of a physician as a lifelong prospect. We have to think of the continuum of a pre-medical education in which we might, for example, invent a new segment between college and medical school in which we ask our students to go out into the greater biomedical workplace – anything from the business of medicine to working in Third World countries in clinics to doing fundamental research. During that period they would engage with us in a web-based community of education in which there would be an expected level of mastery of the basic science material – the first 18 months of medical school – interacting with experts and faculty members who are also in that community.
Then perhaps the four years of medical school begins and is concentrated on the more specialized interests of every student. The majority will move on to a clinician track and those students will become practitioners. There will be clinical investigators, there will be fundamental biologists who have decided they have to go to medical school to understand which questions to ask about the diseases patients have rather than follow a PhD track.
We can then begin to answer the question of what it means to have a lifelong continuum of medical education? At the moment, early childhood education is in one institution’s hands; Cegep or college is in another’s; medical school is four years for a diploma; and residency is, yes, under our direction but the licensing agency is either the Royal College of Physicians or the Collège des médecins du Québec or both.
Who should be responsible for lifelong learning then?
I would say the University must be responsible for continuing medical education and we must get serious about the issue.
We need to define the continuum and that hasn’t happened yet. In the early 1900s, Osler said the patient must be the centre of medical education, and Abraham Flexner said medical education must be science-based, university linked. We’ve been living with that revolution for 100 years.
Yes, experiments in medical education around those two broad concepts have occurred in many locations but people are asking – McGill is asking – do we have to do something quite different now given the changes in education, patient care and research? Is medical education doing what it ought?
The faculty here has decided to do a deep inquiry during a period we have christened “The Year of Thinking Dangerously.” We’re going to take a year to do strategic planning, ask about our three major missions – education, research and patient care – and ask whether the structures that have made McGill the wonderful collection of faculty and students that it is with its storied history of invention and clinical development, are still serving us well or do we need to make some significant changes?
Why did you decide to stop practicing medicine and move into administration?
In my time at NYU, I slowly grew into medical administration, helping first as a special assistant to the Dean shortly after my post-doctoral fellowship. Kind of an ambassador without portfolio. Over the years I got more and more involved. At the end of my time at NYU, I was Vice Dean for Education, Faculty and Academic Affairs.
“There is a tide in the affairs of men…” as Shakespeare said. You have a narrow window in which you have to decide whether you will try to lead a major organization or not and my time came.
After spending your whole professional career in NY, how difficult was it to make the move to McGill and Montreal?
It was a difficult thing. My wife and I had prepared as best we could for a move of this nature later in life. Thirty-six years in New York City is a long time. But the move was more stressful than we had anticipated. Of course I’m not sure that wouldn’t be true had we moved to any new location after that much time. The bilingual nature of the city, the difference in the structure of the health care systems, the extent to which the government is involved in medical practice and medical education here are all so grandly different from what I had experienced in NY – it took a couple of years on a very steep learning curve to begin to be comfortable with all of these elements. [Laughing] And I would predict that we still have a few more years to go before we are real Montrealais.
What are McGill’s best qualities?
I think No.1 is the very high intellect of the McGill community, the McGill magic. The ability to aggregate people in the faculty and the student body from all over the world who have the capacity to think deeply about many things and in many fields and then engage in easy, open and creative conversations about those elements.
We always end by asking people about their first job.
It is somewhat embarrassing but I was a locker boy on the Jersey shore at a beach club. My job was to make sure that the renters of a long row of lockers along the beach had their every need met [Laughing]. It was a lesson in politics, organization and humility, I must say.
But the best thing about the job was, by chance, my future wife was staying at this place with her family for the summer. It was love at first sight and we’ve been together every since.