Nobel Prizes Illustrate that Doctors are Not Scientists
Posted by Henry Bauer on 2008/10/19
The prestige associated with Nobel Prizes and similar awards is often excessive and sometimes quite misplaced, for a variety of reasons. There is no need to point out that a single Prize per year in Literature cannot be decided objectively — decisive are subjective taste and judgment and regional or ethnic or national biases. That ideological or political considerations enter the award of the Prize for Peace is obvious a priori as well as from the history of the actual awards. The Prize in Economics, too, inevitably entails a certain degree of subjective judgment, as would be true in any social science. That there are awards only in Chemistry, Physics, and Physiology or Medicine means that a large amount of research in mathematical and physical science is simply not eligible.
The history of the awards in medicine and in science is also instructive about several aspects of these fields that are not widely appreciated. One of those provided the title for this post. The training of doctors is appropriate to their mission: to help suffering patients by applying the best available contemporary understanding. The training of scientists is also appropriate to their mission, but it’s a different mission: to advance understanding beyond the contemporary state, which means to discover things that reveal gaps or mistakes in contemporary understanding. That difference becomes of considerable practical significance when research in medical science is carried on by people trained as doctors.
Training for research in science begins only at the graduate level. Undergraduate science courses dogmatically instill familiarity with the present state of understanding. Only in graduate and postdoctoral work, as apprentice researchers, do neophytes begin to appreciate the fallibility of contemporary knowledge and to sense how ephemeral that knowledge is. Through actually doing research, one discovers errors in the published literature of research articles, reviews, monographs, and textbooks — sometimes quite fundamental errors. Through doing research, one learns to accept paradigms and theories only provisionally — though we tend to have that in mind more readily with the pet projects of our competitors than with our own scientific obsessions and passions. Doctors who venture into actually doing research do so without the benefit of an apprenticeship in research, and the consequences are sometimes all too obvious, as when MDs in the CDC assert in a formal publication that a correlation proves causation (pp. 194-5 in The Origin, Persistence and Failings of HIV/AIDS Theory).
So, in the HIV/AIDS context, it is far from irrelevant that those most responsible for making a dogma out of HIV/AIDS — notably Gallo and Fauci — are MDs, while prominent early skeptics were research scientists like Duesberg, Mullis, Gilbert, Root-Bernstein. As with all generalizations, of course there are exceptions: two of the most stubborn and extreme HIV/AIDS vigilantes, Moore and Wainberg, are PhDs, not MDs. But occasional exceptions don’t vitiate the explanatory utility of well-founded generalizations.
Another such generalization, also pertinent to the cases of Gallo and Fauci, is that the most capable researchers set their sights on obtaining academic positions, with the corollary that the overwhelming majority of outstanding work has come from universities rather than from industry, still less from government institutions — despite such exceptions as Nobel Prize work from Bell Telephone Labs or breakthroughs concerning trace-metal nutrients and leading work in radio astronomy from the government laboratories in the Commonwealth of Australia. One salient reason is that ambitious people seek the freedom to choose their own projects that academe offers (in principle!), whereas government-run labs are inevitably subject to a degree of bureaucratic control and hierarchic decision-making. Another practical reason is that academic researchers are in fierce competition for everything — grants, students, facilities — whereas researchers in federal laboratories experience nothing like that sort of competition. A sort of “natural selection” tends to bring the best and brightest to the fore in the intellectual free market of academe; whereas bureaucracy may supersede such “natural selection”, because researchers in government labs can’t always follow their best scientific judgment: they need to be on good terms with their bureaucratic superiors and may have to defer to their judgment. One visible consequence of these differences is that directors of government labs can accumulate staggeringly long lists of publications bearing their name even though their personal intellectual contributions may be meager.
There are quite objective indications, how different are the fields of medicine and of science: the recorded history of Nobel Prizes shows how much more often there have been mistakes in the Medicine Prize than in the Chemistry or Physics Prizes. In the latter, I have located no cases where a Nobel Prize was awarded for work that later turned out to be simply mistaken, wrong, and became generally repudiated; whereas in Medicine, there are a number of such instances or cases where the lauded discovery later turned out to be, if not entirely wrong, then seriously misleading or just not useful:
1903, Prize to Niels Finsen for light therapy as a cure for various conditions including tuberculosis.
1927, Julius Wagner-Jauregg, for treatment of mental illness by inoculation with malaria!
1949, Antonio C. de A. F. E. Moniz, for treatment of mental illness by surgery (lobotomy).
1975, to David Baltimore, Renato Dulbecco, Howard Temin “for their discoveries concerning the interaction between tumour viruses and the genetic material of the cell” — part of the red-herring search for viruses that cause human cancers, and responsible for the consequential error that reverse transcriptase activity demonstrates the presence of a retrovirus.
1976, to Carleton Gajdusek for discovering the first “slow virus”, which supposedly caused Kuru in humans and analogous brain disease in animals, for instance mad-cow disease. Since 1997 (Prize to Stanley Prusiner), it’s been believed that these diseases are not caused by viruses but by prions, a class of proteins.
1989, to Michael Bishop and Harold Varmus for the “discovery of the cellular origin of retroviral oncogenes”.
It’s also in the nature of medical matters that some of the consequences of apparent advances may later turn out to be disadvantageous, as with DDT (Prize to Paul Müller, 1948); or with studies of the role of cholesterol (Prize to Michael Brown and Joseph Goldstein, 1985) that led to the mistaken belief that lowering blood cholesterol could prevent atherosclerosis (inflammation or abrasion inside arteries, and elevated levels of the amino-acid homocysteine, are nowadays believed to be precipitating factors, not the mere presence of cholesterol).
At any rate, comparison of Nobel awards in chemistry and physics with those in medicine demonstrates that the fields differ significantly in the degree to which one can be certain about the long-term significance of an apparent advance that is lauded by its contemporary mainstream.
I believe that these generalizations provide a useful context for such controversies as those about HIV/AIDS; but a disclaimer is in order, since comments like the preceding ones can be readily misinterpreted if one is so inclined. Therefore let me re-emphasize that these, like all generalizations, are subject to exceptions. Further, I have enormous respect and endless gratitude to a considerable number of doctors who practice as physicians and surgeons and who have helped me remain active to a respectable age; as just one instance of several available ones, I was treated wonderfully well and had a splendid outcome in the first clinical trial of angioplasty at the Clinical Center of the National Institutes of Health. Nevertheless, I would prefer that those valued doctors and surgeons not engage in research in retrovirology or statistical evaluation of data.