In-depth: Taking part in the Duke research experience

Friday, April 12, 2013

[caption id="attachment_10933" align="alignright" width="300"]Andrew J. Muir, MD, MHS Andrew J. Muir, MD, MHS[/caption]

[dropcap]A[/dropcap]ndrew Muir, MD, MHS, says he has learned a key to having a successful research and clinical career at Duke: Be assertive.

“I’ve always thought that one of the strengths of Duke was the tremendous expertise throughout the medical center, and you haven’t really taken advantage of everything Duke has to offer unless you have developed those collaborations and participated in interdisciplinary research,” Muir said. “If you are a passive person, you’re probably not right for Duke, but the assertive person who is hungry, those are the people who get the full Duke experience during their time here.”

Muir, an associate professor of medicine and director of clinical research (Gastroenterology) and director of Gastroenterology and Hepatology Research at Duke Clinical Research Institute, has been at Duke since 1989. Having completed medical school, residency, chief residency, and fellowship at Duke, Muir knows how to take advantage of the resources and relationships that are available here.

“He is a good example for balancing a successful clinical research career with patient care and mentoring,” says Mary Klotman, MD, chair of the department.

Clinical research and patient care

Muir has two leadership roles at Duke. He runs the site-based research program in Gastroenterology, and he is the director of Gastroenterology research at the Duke Clinical Research Institute.

As the director of clinical research for Gastroenterology, Muir leads the group that enrolls Duke patients in clinical trials. His personal research interest is in liver disease and Hepatitis C.

“Hepatitis C is an area where there have been a lot of developments in the last decade, and our patients have been able to be a part of a lot of trials,” Muir said. “Hepatitis C treatment started off being rather ineffective, with a lot of side effects, and over the last 15 years, treatment has become better. We can now see, within the next few years, where we’ll be able to offer treatment to most patients and we’ll be able to cure them,” he said.

Time is an important factor with Hepatitis C. As the disease progresses, a patient may develop complications, such as liver cancer, or may require a liver transplant. But if patients have timely access to new drugs that have made Hepatitis C a more treatable condition, they are less at risk for these conditions, he said.

“We’ve participated in phase one, two and three trials, and my main goal for that whole program was to provide access to our patients for drugs that they otherwise would have to wait several years for,” Muir said.

Duke’s reputation as a top clinical site has allowed patients here to participate in studies with most of the large companies that are developing drugs for Hepatitis C. The team of researchers working on the studies includes Muir, Keyur Patel, MD, associate professor of medicine (Gastroenterology); Hans Tillmann, MD, associate professor of medicine (Gastroenterology); and a team of coordinators, clinical trial assistants and phlebotomists who are led by Loranda Ross.

“It’s been really rewarding for our team to be able to offer those opportunities to patients,” Muir said.

Clinical research model

In his role as director of gastroenterology and hepatology research at the Duke Clinical Research Institute, Muir leads a team that coordinates large, worldwide clinical studies. He says the DCRI model, where physicians are paired with an experienced, full-service clinical operations team, has been successful for the gastroenterology group.

“A relatively common example for us is that a small biotech company that may have a new drug in liver disease needs help running their trials, and it may not have physicians with expertise in liver disease, so our faculty provide that expertise and help their team with all the aspects of clinical trials. We’re engaged from development of the protocol all the way through the completion and publication of the study,” Muir said.

The gastroenterology and hepatology program at DCRI started in Hepatitis C research but is now expanding to include research projects in fatty liver disease, inflammatory bowel disease and primary sclerosing cholangitis.

Muir said fatty liver disease is the next big problem in liver disease after Hepatitis C has been resolved, and Duke is fortunate to have two of the world’s leading researchers in fatty liver disease: Anna Mae Diehl, MD, professor of medicine and chief of the Division of Gastroenterology; and Manal Abdelmalek, MD, MPH, associate professor of medicine (Gastroenterology).

Diehl and Abdelmalek have established one of the top clinical and clinical research sites in the U.S. for fatty liver disease, and DCRI is now coordinating two fatty liver disease trials.

“This all fits within the model of where our patient needs are and how we can use the resources we have at Duke to improve patient care,” Muir said.

Muir said he would be happy to talk to anyone who wants to better understand how DCRI works and what it takes to run effective trials. At the department Research Retreat in February, he facilitated a discussion about building a clinical trials team.

“I do think it’s such a unique place within academic medicine in the U.S. and therefore it’s an important resource for anyone who wants to participate in clinical trials at that level,” he said.

Research collaborations

Muir’s work with DCRI has led to collaborations with researchers in other Duke divisions and departments.

Muir said one of his closest colleagues at the DCRI is Susanna Naggie, MD, assistant professor of medicine (Infectious Diseases). Muir and Naggie are collaborating studies on treatment of Hepatitis C in patients with HIV-Hepatitis C co-infection.

“About one-third of Americans with HIV also have Hepatitis C and there are rising rates of complications of liver disease as patients live longer with HIV,” Muir said. “It’s critical that we help them cure their Hepatitis C to avoid any further progression of liver disease or the development of liver cancer.”

The studies are examining therapies that have been successful in Hepatitis C infection and extending them to HIV-Hepatitis C co-infection.

“Early indications are that the drugs that work well in the patients who just have Hepatitis C and that those agents also work very well with patients who have HIV and Hepatitis C,” Muir said. “We need to work through all the issues of drug interactions, how they work in patients who have HIV and advanced liver disease and a number of other issues.”

Muir’s research has also led him to collaborations outside the Department of Medicine.

Muir was part of a 2009 collaboration with David Goldstein, PhD, professor of molecular genetics and microbiology and director of the Center for Human Genome Variation at Duke, that looked at the genetic predictors of Hepatitis C, and he continues to collaborate with Goldstein on other questions within liver disease.

Muir has also worked with Chip Bailey, PhD, RN, associate professor at Duke School of Nursing, on several studies including one current study looking at the patient and caregiver experience while dealing with chronic liver disease.

And Muir is working with Rae Jean Proeschold-Bell, PhD, a psychologist from the Duke Global Health Institute, to apply research on substance abuse interventions for patients with HIV to patients with Hepatitis C.

“There are different challenges for the patient populations, but the established model was really helpful. We had an R21 grant that was successful in demonstrating that half the patients who were using alcohol, which is not good for their Hepatitis C treatment, were able to stop drinking during their treatment period,” Muir said.

Muir is waiting to hear about a grant built on that study that would be a three-site collaboration for Duke, the Durham VA Medical Center and the UNC Liver Clinic.

Muir is also involved in a partnership, through the Duke School of Medicine’s Office of Continuing Medical Education, with Carl Berg, MD, professor of medicine (Gastroenterology). The project will allow Muir and Berg to consult with physicians in West Virginia on the care of patients with Hepatitis C and patients who may need a liver transplant.

Muir said that there is a shortage of hepatologists in the U.S. and there are none in West Virginia, so patients from that region have to travel great distances in order to see a physician and often do not make the trip.

“The opportunity to work closely in a telemedicine relationship with practices in West Virginia is a way we feel that we can help them, support them in their care and hopefully improve the experience of patients in West Virginia,” Muir said.

Fellowship mentor

Outside of his research and clinical responsibilities, Muir is also the program director for the Gastroenterology fellowship program. He oversees the day-to-day management of the program, working with program coordinator Jill Rimmer.

“The fellowship remains probably the most rewarding thing that I do because we are very fortunate that we are able to attract top fellows, and watching them and helping to nurture their career development is very rewarding,” Muir said.

The gastroenterology fellowship program has two tracks, a clinical track for full-time clinicians and clinician-educators and a research track. Muir is currently mentoring two fellows, Lisa Jones, MD, who is studying informatics and mobile health technologies in liver disease, and Cristal Brown, MD, whose interest is in palliative care in liver disease.

Muir says part of his role as program director and mentor is to help fellows make connections with other researchers.

“I actually see one of my main responsibilities as director of GI research at the DCRI, whether it is with other faculty there or mentoring the fellows, is to help them explore what’s available at Duke,” Muir said.

Making connections and benefiting from mentors is something Muir says has had a great impact on his own career.

“I have been very fortunate that every step of the way in my career people have looked out for me, and they have been different people over the years, but I always felt that people wanted well for me and supported me,” Muir said.

Among those at Duke who have helped, supported and trained Muir include Paul Killenberg, Bart Haynes, Dawn Provenzale, John McHutchison and Anna Mae Diehl.

Diehl said Muir has strong organizational, leadership and team building skills that have allowed him to successfully balance research and patient care.

“He is an outstanding clinician and can understand the clinical problems and gaps in knowledge, so he knows what needs to be studied and improved,” Diehl said. “He is also well-respected as a good doctor and can advocate for his patients. Other physicians trust and respect him, and he is able to build collaborations for patient care and to solve clinical problems.”

Muir has been able to harness these skills to assemble teams that have the right expertise to solve problems he thinks are important in liver disease, and his opinion is sought out by pharmaceutical companies interested in clinical trials, Diehl said.

“We are very fortunate to have him. He is the epitome of what you would like a clinician-investigator to be, and he is a great colleague,” she said.

Muir was recently recognized for his contributions and leadership in the field by being elected to the American Gastroenterological Association Institute Council.

Muir said as he was starting his research career Duke stood out as a place where he would have access to unique resources like DCRI and protected time for research.

“I feel very fortunate that I do have this job that is split among the three missions of the department. I know that is not very common anymore to have someone participating substantially in research, education and patient care,” Muir said. “But I do enjoy the aspects of each and I think they blend well for my job.”

[caption id="attachment_10935" align="aligncenter" width="1024"]Andrew Muir and research coordinator Loranda Ross work on clinical trials together. Andrew Muir and research coordinator Loranda Ross work on clinical trials together.[/caption]