Leadership Q&A with Scott Palmer, MD, MHS

Monday, December 19, 2016

Scott Palmer, MD, MHS has turned his love for research and discovery into making a lasting impact on pulmonary patients across the country. Dr. Palmer is professor of medicine (Pulmonary, Allergy, and Critical Care Medicine) and immunology, vice chair for research in the Department of Medicine, and director of respiratory research in the Duke Clinical Research Institute.

In this Q&A, he elaborates on his path to being a pulmonary researcher and its life-changing experiences, and his insights on why medical research is vital for progression in medicine.

When did you start to feel that you were really interested in research? Was there someone who nurtured your interest in research?
I think I’ve always been interested in research, even at summer jobs in high school. I worked at a research lab in Camden, New Jersey. There was something there called the Coriell Institute and I did a lot of cell culture lab work. I didn’t totally understand what research was or what it meant but I always imagined I would be doing something like that. As a third-year medical student, I worked with David Pisetsky, MD, PhD, who was the chief of Rheumatology and Immunology at the time.

He was a great mentor. He really encouraged me to think about research even more. I took immunology graduate courses that third year and that really was great because the medical classes tended to be “memorize facts and spit it back.” In graduate classes, it was “read the paper and understand the process.” We would think about the mechanism. There was a lot more critical thinking. I really think that got me excited about research and how science really takes a lot of critical thinking.

When I became faculty, I ended up doing more clinical work since I quickly became the Medical Director of Duke lung transplant, one of the largest such programs in the world. I was very involved with taking care of the patients. What really drove me back to research was the patients I was taking of and the fact that lung transplant while effective in some patients, isn’t a perfect therapy. I saw so many problems that the patients would face. Ultimately, many of them died because of chronic rejection.

We didn’t really understand why people developed rejection or we didn’t have good treatments for it. It motivated me to say “all the things I’ve done along the way including training in immunology, clinical research, and pulmonary/critical care medicine provide me with the unique skills and tools to do innovative research that will improve the outcomes of these patients I’ve now specialized in taking care of.

What inspired you to do research in Pulmonary Medicine?
When I was training, there was some great clinicians like William Fulkerson, MD, professor of medicine (Pulmonary, Allergy and Critical Care Medicine), who’s hospital leader in Duke Health System now, was much more active as a pulmonologist. He was a consummate professional and really set the standard in terms of being a role model physician. Surrounding yourself with someone like Dr. Fulkerson and others in pulmonary medicine like Victor Tapson, MD, who has since left Duke, was key. Dr. Tapson was a great clinician and was great with patients. Tapson also happened to do lung transplants. His enthusiastic personality helped encourage me to think more about lung transplant.

The combinations of mentors I had as I went through my training led to me to pursue pulmonary. The pulmonary diseases and the research opportunities were interesting.

What has been your favorite research project and why?
I think one favorite project was this one clinical trial that we did in lung transplant for acute cytomegalovirus (CMV) prevention. It was my favorite project for multiple reasons. The study identified a better to prevent CMV infection after lung transplants and as such our results have translated into changes in practices in most of the centers around the country, so our work made a difference for patients.  It was also the first project where I really got involved with the Duke Clinical Research Institute (DCRI) and learned about the power of the DCRI to advance patient care

At the DCRI I coordinated the clinical trial and learned about how painful it is to work through all of the challenges of having 11 or 12 sites work together, enroll patients, get enough funding to keep the study going, analyze and quality check the data.  Once those processes were complete and the study was done, it was a beautiful thing working with all of the excellent resources and faculty at the DCRI, particularly our study statisticians.

Whether it’s basic research data or clinical data, there’s still that sense of discovery when you look at the results of the study or a basic experiment. Whether it’s what you expected or not, you’re still seeing from it and learning from it.

All of my diverse experiences in training at Duke and on faculty have shaped my current research focus: to improve outcomes of the patients I have specialized in taking care of here with advanced lung disease and transplant. 

What challenges have you faced in your research career?
One of the biggest challenges was just no funding or support. It’s not like lung transplant is nearly as common as cardiovascular diseases or cancer. Even within National Institutes of Health (NIH) funding to organ transplant, more common transplants like kidney tended to get most of the funding. I picked an area where it wasn’t high on the radar screen in terms of funding so I think I had an uphill battle to publish enough research and advance it far enough that I could make a very compelling story that became fundable.

Another challenge is trying to be translational. In immunology research, investigators use mouse models that are very basic. It's difficult to tell whether these mouse models will relate to what's happening with patients in lung transplants. I really want it to be translational and that requires finding novel ways to combine human samples with mechanistic questions and that’s not an easy thing to do.

In 2013, you became the vice chair of research for the Department of Medicine. What is it like being this involved with research?
It’s been a great experience. It’s challenged me to think about not just my own research but the entire Department’s research. I’ve learned about great things going on in the Department and there’s all kinds of research projects that I didn’t know were going on. More importantly, I’ve been able to represent the Department in a lot different formats with the School of Medicine and advocate for our faculty interests.

I'm able to see connections that I wasn't aware of. I try to connect the dots and bring our faculty together with great opportunities in the School of Medicine, campus-wide, and even within the field of medicine.

Mary Klotman, MD, has been a great role model as Department Chair. I have learned a lot about leadership from her. We do have a great team too, like working with Anton Zuiker our communications director and Laurianne Torres, and others in the leadership who are very good at what they do. I'm learning a lot of different skill sets. I hope I'm contributing to the Department by passing on what I've learned as a successful investigator. Lately, I continue trying to figure out ways to translate lessons I learned in the research process to benefit others in the Department.

Nurturing the next generation of researchers has been a priority for me as Vice-Chair. Going back to when Barton Haynes, MD, professor of medicine, was Department Chair, there is a Chair’s Award that funds research fellows who become faculty members. It gives them support in their research. We have continued to emphasize and expand this approach.

In addition, I recognized the trajectory to get a first grant takes longer now. Under my tenure as VC for Research we have created a K Bridge Funding mechanism to complement the Chair’s Award. We’ve formalized that mechanism and others to help nurture people along that want to go that research career route and ensure they will succeed.  So far several of our young faculty supported with K bridge awards have gone on to successful external funding. 

What do your patients mean to you?
It's bittersweet for me, because I see many patients and grow quite close to them, and I feel their frustration and pain when complications such as chronic rejection develop. I know there’s a finiteness to it. That finiteness is what motivates me to keep pushing the limits to do research that will improve outcomes for lung transplant patients. There are a hundred stories I can tell —they are all amazing and inspirational but not all of them are here. It’s hard. Some of them were very young people, or people that have genetic disorders such as cystic fibrosis or familial pulmonary fibrosis. It was things that they couldn’t control that led to them have very advanced lung disease at a young age and while transplant can extend their life, additional research is needed to make transplant work more effectively.

What are the challenges of researching idiopathic pulmonary fibrosis?
Unfortunately, idiopathic pulmonary fibrosis is a progressive disease that often results in respiratory failure and death. As of November 2014, two drugs were approved for treatment and those two drugs slowly decline at lung function. However, there is no cure for the disease. There are no truly effective treatments. There’s a lot to learn about IPF. There’s a lot to learn about the biology of IPF, targeted treatments, and personalized treatments. I recognize that we can only help a small fraction of IPF patients with lung transplant and have become interested in advancing IPF care through translational research in our lab and at the DCRI.

As one example, an ongoing IPF PRO registry coordinated by an outstanding team at the DCRI will help us understand IPF better, as patients are treated with approved therapies in the real world, and translational components of the research will help us understand how those therapies modulate some of the biology. We’ll be able to look at signals in the blood and understand who might benefit the most from the therapy and who doesn’t benefit from the therapy at all. Through that, hopefully we can generate ideas for personalized care and new therapies.

What are some of your most memorable accomplishments?
A study we’re funded to do right now, which is called “Clinical Trials in Organ Transplant (CTOT),” is significant. It’s a huge accomplishment, and I’m incredibly fortunate to have the funding for it. We’ve collaborated with other faculty at Duke including John Reynolds, MD; Laurie Snyder, MD; and Jamie Todd, MD, and at DCRI including Megan Neely, PhD, and five major North American lung transplant centers for this study.

We’re conducting studies looking at the clinical factors and biological mechanisms that lead to the development of chronic rejection after lung transplant. We’re also doing a study to look at how to personalize prevention of cytomegalovirus, which is a common infection patients get after lung transplantation. We are so honored to be a part of CTOT because the funding will allow us to truly move the field forward and complete research that will make difference for our patients, and contribute to making lung transplant even more of a life extending treatment.

Tia Mitchell is a communications intern for the Department of Medicine. She attends N.C. Central University.