Focus on Internal Medicine Careers: Infectious Diseases.
Jerrold Ellner, MD, FACP, Professor and Chair of Medicine at University of Medicine and Dentistry of New Jersey—New Jersey Medical School (UMDNJ—NJMS), whose amazing Infectious Disease career has taken him from tuberculosis research in Cleveland to AIDS vaccine trials in Uganda, talked with us about medical school, career options, internal medicine, and life. The interview was conducted by Tony R. Tarchichi, a third year student at UMDNJ—NJMS and the Central Atlantic Region Representative to the ACP Council of Student Members.
IMpact: Would you please give our readers a brief introduction to your career, fellowship training, and some of the things you have done?
Dr. Ellner: I was trained in basic immunology at the National Institutes of Health and was interested in how a human, or host, recognizes infectious agents, and focused on the interaction of antigen presenting cells (macrophages) with T-cells. I chose tuberculosis as a disease model. When you start to study infectious agents, like tuberculosis, you always have the issue that many people are exposed but only some get the disease. Over the years I’ve done studies, starting at the Cleveland Clinic and going to Uganda and Mexico City, where I’ve tried to understand the immunologic concomitance of tuberculosis. I started doing international research because, when you want to study a disease like tuberculosis you need to go to a place where tuberculosis is common and where a number of individuals are relatively healthy except for the prevalence of tuberculosis.
IMpact: Could you please quantify how much tuberculosis there is in the world for our readers who might not know?
Dr. Ellner: There are two million deaths from tuberculosis in the world annually. Ninety-five per cent of the cases are in developing nations, and 99% of the deaths are in developing nations. In the next ten to twenty years we’re likely to see major changes in the way we treat tuberculosis as a result of scientific advances.
IMpact: At some point in your career HIV became very prevalent. At what point did you decide that you didn’t want to completely change your research, but that you wanted to start incorporating HIV research into it?
Dr. Ellner: I was mid-career when HIV came along. I was one of the few people who was studying tuberculosis, and therefore I got more funding. I did go through a period where I had to decide if I wanted to stay in tuberculosis research or change to HIV. One of the reasons I stayed with tuberculosis was because I was an immunologist, not a virologist, and it seemed to me that I didn’t have the right to start work in HIV. I began to look at the impact of HIV on tuberculosis and vice versa.
IMpact: Some of the work you did regarding HIV was revolutionary. Could you tell us about the HIV vaccine study you did in Uganda?
Dr. Ellner: We did a very small HIV vaccine study. At the time the strain used in HIV vaccines was the North American strain, which was also known as clave B (a certain class of HIV), but we began using the strains endogenous to Uganda (clave A and D). The question was whether you could use a clave B vaccine to protect against the endogenous strains in Uganda. My role in the vaccine trial was mostly as a middle person. I developed very strong collegial collaborations with both scientists and public health officials in Uganda, so I was able to “broker” the vaccine trial there. My role became quite complicated because there were lots of ethical questions that arose, including the fact that we were testing a clave B vaccine in a country where that particular clave didn’t occur. It took three years before we could vaccinate the first person. I made it a point to be there for the whole study of 40 people. It was actually a proof of concept; we weren’t trying to find out if the vaccine was effective in preventing HIV, we were really just trying to see if any cross-reactivity occurred.
IMpact: Was there any cross-reactivity?
Dr. Ellner: Yes there was. We were working with an interesting vaccine; it was attenuated canary pox. At that time it looked to be a very promising vaccine because canary pox could infect mammalian cells but it couldn’t replicate. It could express the antigens on the surface of mammalian cells. One of the hurdles in AIDS vaccine development was to induce a CD8 response. Unfortunately, the vaccine studies (ours and others) showed that the vaccine only produced CD8 response in a small fraction of those who were immunized. This vaccine is no longer the leading candidate for large scale trials.
IMpact: Many researchers have a disease focus. Is it important for a medical student who is interested in research to figure out what disease or area they would be interested in researching?
Dr. Ellner: No, I think that the main goal should be to get yourself the best basic scientific training you can. With it, you can study a wide array of diseases, but without it, you’re very limited in terms of what you can do scientifically.
For example, take a disease like Multiple Sclerosis (MS). For fifty years investigators have tried every scientific approach, and we still don’t know a lot about its pathogenesis. As a student, or a physician, or even an MD, PhD with just your clinical training, you’re probably not going to have much of an impact, when all these great minds before you couldn’t figure it out. On the other hand, if you have really good basic science training, and if the area you train in is relevant to MS studies, then you can apply it to the disease.
IMpact: What advice would you like to give to students who want to go into internal medicine?
Dr. Ellner: Sometimes students think about their careers and base their decisions on what’s popular now. One thing we can be certain of is that medicine changes. I think the most important thing is for students to follow their own interests and take opportunities as they arise, rather than imagining that they can plan everything out in advance.
For instance, I started to work in tuberculosis because of my own scientific interests, not because of a real understanding within myself of how much of a problem tuberculosis was in the world. Then AIDS came along and changed so many things. Tuberculosis became regarded as much more of a public health problem in the US, whereas before AIDS it was not. Because of HIV, the US government had an interest in setting up collaborative projects in developing countries. So they set up a program, and one of my mentors, a Nobel Laureate in internal medicine, was very eager to get involved in training students in AIDS research. At this time both he and I were at Case Western. By chance, there were a couple of people at Case Western who had been volunteering in Uganda and my mentor then went on an initial visit to Uganda. As a Nobel Laureate (which he had won during his fellowship), he had never written a grant in his life but all doors were open to him, so he asked me to come along and help him.
This really changed my life. I wasn’t very sophisticated in what it took to develop collaborations internationally. As is usually the case, naiveté was an advantage. I got involved in a situation which was very complicated and where a skeptic would say that there’s very little chance of success, but timing is everything. Early on we got to do some studies and the program we had just grew and grew.
IMpact: So it seems like there was a lot of chance on your side?
Dr. Ellner: If you choose to go into private practice your career remains pretty much the same over time. An academic career, however, has various phases and it’s more likely that you’ll be influenced by serendipity and external events, and you might end up in places you never would have imagined while you were in medical school.
When I was a child, Africa was a forbidden continent. I never dreamed that I would visit there, let alone work there.
One of the reasons I came to work in Cleveland, however, is that there are very important problems in our inner cities. Devoting a big chunk of my life to improving health in other countries without trying to have a hand in doing something positive in my own country began to wear thin. I thought that maybe I could do something and have some positive impact by coming to NJMS in Newark, because there is a lot of HIV in the community.
IMpact: If a student wants to do internal medicine and is considering doing international health, would you recommend infectious disease to them as a fellowship?
Dr. Ellner: There are international studies related to areas other than infectious disease, but infectious diseases cause tremendous morbidity and mortality and are more amenable to intervention. In Uganda, for example, it would be nice to do something about hypertension or heart disease, but there’s no facility in the country to do a cardiac catheterization. For someone from Uganda to get a coronary artery bypass, they would have to go to India, UK, or the US. There are areas of health that have not been addressed because they are so costly. In infectious disease, however, if you have a vaccine, you can have a great deal of impact with little cost. Bill Gates has said that if an effective AIDS vaccine becomes available, he will use all his resources to make it available worldwide.
IMpact: What do you see as the top three diseases that could be cured by vaccines in the next 20 years?
Dr. Ellner: Malaria, Tuberculosis, and HIV.
IMpact: What would you say to medical students who are not choosing internal medicine as a career choice due to decreased salary, difficulty dealing with managed care, and lifestyle issues?
Dr. Ellner: I don’t have any easy answers to broad societal issues. I think if you want to do internal medicine, you can do it. There are many areas of the country that are underserved. The costs of malpractice insurance for internal medicine practice are much less than other areas of medicine, such as ob-gyn. I think more residents are choosing specialty training, but the pendulum shifts. There was greater interest in primary care, and now there is more subspecialty interest. There are many physicians who have received subspecialty training who are now practicing general internal medicine. I think training in infectious disease is particularly useful.
In terms of the financial consequences of career decisions, I think they receive a little too much play. Most people don’t choose medicine as a career because compensation is the biggest issue. I think it requires a little bit of soul searching as to why you chose a career in medicine and what your overall goals are. Do you want to take care of patients? Do you want to work in underserved communities? Do you want to work in affluent communities? There’s nothing wrong with that; someone has to take care of affluent people.
Many students already have a strong interest in nephrology, or cardiology, or whatever. My advice is to pursue whatever interests you most—even if you’re not sure exactly why it interests you—as opposed to trying to imagine where medicine will be 10 to 20 years from now. For example, right now within internal medicine, gastroenterology is a very popular specialty. If you come back 10 years from now, it’s possible that virtual colonoscopy will replace actual colonoscopy and we’ll have over-trained gastroenterologists. You never know. If you’re trying to get ahead of the wave, there are changes in internal medicine that I can see and others that I cannot. My advice is to follow your inclination. Hopefully profitability is not a major motivator for most medical students.
IMpact: So where do you see the field of internal medicine growing, expanding, or changing in the next 20 years?
Dr. Ellner: I think that there will probably be more pharmacogenomics. Therapy will probably be individualized based on the patient’s genomic structure. We’ll have a lot more information about whether someone is likely to respond or have adverse events than we currently do. I also think that there will be new diagnostic techniques so we’ll use approaches such as micro-arrays to try to diagnose tumors and infectious diseases. A lot of the current approaches might be extinct.
IMpact: So where do you see the field of infectious disease growing, expanding, or changing in the next 20 years?
Dr. Ellner: About 25 or 30 years ago, it was said that there was no longer a reason to train anyone in infectious diseases. Public perception was infectious disease had been conquered in the US. At that time, infectious disease was becoming too cerebral—then HIV came along. There’s a whole new chapter of infectious disease which is driven by acute medicine with new approaches to understand, prevent, and treat.
Infectious disease is one of those specialties perfect for those who have an interest in research because it allows them to still see patients clinically and also have a laboratory. If your interest is in dealing with diseases where the etiological agent can be identified and there’s a possibility of curing and/or preventing the disease, there will always be opportunities in infectious disease. I would definitely consider infectious disease as one of the bench-top to bedside specialties.
IMpact: Is there anything else you’d like to tell our medical student readers?
Dr. Ellner: Some of the genuine needs in global health are not evident to students as they go to college, then to medical school, then to residency, and ultimately make their career choices. I think that every student should try to have an experience in a developing country. Travel is one thing, but to actually be engaged in something related to your profession in a developing nation is different because it can make you rethink your career choice. I think almost every individual who came to work with us in Uganda had a life or career changing experience. I would encourage people, particularly in medical school, where you have some flexibility in your schedule, to try to do something internationally.
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