Defining the Tension Between Physician, Researcher
authors Lucy Schultze
A physician directing care for a patient may be guided solely by what’s in that patient’s best interest. But when that same physician deals with patients in randomized clinical trials, an entirely separate set of goals is in effect.
“As a researcher, your primary obligation is to get the best possible data — which is very different from making the best possible decision for one patient at one time,” said Jonathan M. Green, MD, for whom exploring that tension has become a central focus of his career.
A professor of medicine and of pathology and immunology in the Division of Pulmonary and Critical Care Medicine at Washington University School of Medicine, Green devotes a large proportion of his time to his role as associate dean for human studies and executive chair of the Institutional Review Board (IRB) at Wash U.
Additionally, he recently began a three-year term on the Secretary’s Advisory Committee on Human Research Protections (SACHRP) within the U.S. Department of Health & Human Services. In that role, he will be among 11 committee members offering guidance, as the department rewrites the set of rules governing human trials across the nation for the first time since 1981.
“It’s a particularly exciting time to be appointed to SACHRP,” Green said. “These are the rules that will govern our work as researchers for the next 20 years.”
Green’s current focus on bioethics has evolved over the years, stemming from his own experiences as a pulmonary and critical care specialist. He continues to maintain a clinical practice in the medical ICU at Barnes-Jewish Hospital.
“In the ICU, we deal with very sick and dying patients, which involves a lot of end-of-life issues,” he said. “Ultimately, ethics is about grappling with: What is the right thing to do?”
Green became involved in the hospital ethics committee in the early 2000s, and went on to chair that group from 2005-09. That experience developed his interest in research ethics alongside clinical ethics. His interest continued to grow after he joined the IRB in 2008 and became its chair two years later.
“I’ve become more and more fascinated by the physician-investigator conflict,” he said. “In research, you still have a duty to the patient, but it’s different than if you were acting just as a physician. It becomes a protective duty, and sometimes you have to be able to take the patient out of the research study in order to do what’s best for them.”
Likewise, he said, a physician is expected to tailor care to each individual, while a researcher must treat each person according to a defined protocol to get valid results. Randomizing patients and giving placebos can also be ethically challenging from a medical perspective.
“If you went to your doctor and said, ‘I’m sick,’ and they spun a wheel of fortune and that’s how they picked your treatment, you’d think they were crazy,” Green said.
Still, he said, research has to go forward in this way.
“I’m a firm believer that we have to do these things to advance care,” he said. “But when these research subjects take on the risk, the benefit very often doesn’t go to them. It goes to other people in the future. They should be as informed as possible and receive as much protection as we can offer.”
In his own basic science lab, Green and his team study the regulation of T-cell immune responses. His interest in bench science developed during his undergraduate years at the University of Michigan in Ann Arbor, where he got a job assisting in a lab. Up to that point, he had been focused on a career as a physician but had never considered academic medicine.
“I always thought I would be a regular doctor, taking care of people,” he said. “But I found I really enjoyed the lab environment as well.”
Green also worked in a professor’s lab during his first two years at Wayne State University School of Medicine in Detroit. He went on to complete his residency at Boston City Hospital, then returned to Michigan for his pulmonary fellowship. There, he had an opportunity to work in the lab of Craig B. Thompson, MD, now president and CEO of Memorial Sloan Kettering Cancer Center in New York. Green followed Thompson to the University of Chicago for an additional two-year postdoctoral fellowship. He then joined the Wash U faculty in 1996.
Over the years, Green has made a priority of taking time away to participate in medical service missions to underserved areas around the world. Most recently, he spent six weeks in Liberia this past spring, as part of the response to the Ebola outbreak.
“Last winter, the death count was still rising and they were projecting there could be up to 100,000 deaths,” he said. “I have a skillset that’s useful in that situation. I decided to go, because I couldn’t sit back and do nothing.”
Green cleared the idea both with his family and with Wash U, and identified an opportunity to go with the nonprofit Partners in Health. Ultimately, his time in Liberia focused on working with local health providers to prepare them to respond if Ebola flares up again. He also spent a week providing care in a village so remote, it took a 10-hour drive plus a five-hour walk through the jungle to get there.
“Normally, the local providers try to set up a clinic there once a month, but since the Ebola outbreak, they hadn’t been to the village for over a year,” Green said. “The whole health system in that country was overwhelmed by the impact of Ebola. In addition to the thousands of deaths, the tiny bit of health infrastructure they had just completely fell apart.”
Green has also taken part in medical missions to Southeast Asia, East Timor and Vietnam. While such endeavors require a departure from his duties at Wash U, for Green, they have an important place in the bigger picture of his work.
“I’ve been very lucky in my life in all sorts of ways,” he said. “So it’s important for me to find ways to give back and to contribute in a meaningful way – whether that’s on an individual level with a patient in the ICU or on a bigger level in taking these trips. The unifying theme for me is to try to do work that contributes positively beyond myself to society as a whole.”
On his own time, Green enjoys outdoor activities like cycling, backpacking and traveling with his family. He and his wife, Christy Auston, a teacher at the new Hawthorn Leadership School for Girls in north St. Louis, have four children ages 12-22: Michael, Lizzie, Sarah and Owen.
Washington University School of Medicine: Jonathan M. Green, MD
Secretary’s Advisory Committee on Human Research Protections