Duke GI Oral History: Rodger Liddle, MD

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Transcript

Dr. Andrew Muir: Rodger, thank you for agreeing to do this. I wasn't sure if you would. I'm glad we could talk today. I wanted to be the one to interview you mainly because you've been pretty important in my career here as well.

Dr. Rodger Liddle: That's nice of you to say that.

Dr. Muir: You were the person who called me to offer me a GI fellowship, that was how that went back in the day. You also hired me. You were the division chief when I joined the faculty.

Dr. Liddle: One of my better decisions.

Dr. Muir: Thank you. I'm glad you can say that now. Also, I think in these last few years since I've been division chief, I value your council more than I can say and you've been there a number of times.

Dr. Liddle: I appreciate that.

Dr. Muir: It's very important to me, so I thought I would do this interview. To start, I wanted to take you back to when you first came to look at Duke. You had trained in GI in San Francisco, and taken your first faculty appointment there. I'd like to know what it was like when you came to visit Duke and what led your decision to come here.

Dr. Liddle: Yeah. Actually, I knew a little bit about Duke before I came. When I was in medical school at Vanderbilt, we were on call every other night when we did our medicine and surgery rotations. The only place worse in the country was Duke because at Duke, they were on call five out of seven nights. I knew about Duke from that time, and when I was in San Francisco, one of our faculty members had trained at Duke, [inaudible 00:01:28] an MD-PHD from Duke.

A couple of people came out to do their fellowship when I was a fellow and on the faculty. Jackie Mar had trained at Duke and Bill Putnam had actually joined our research lab from Duke. They were excellent in every way, excellent clinicians, had a commitment to doing research. When Ian Taylor called me, he had taken the job here at Duke, I thought it was an interesting opportunity. Having grown up in Nashville, Durham was an option to come back to the southeast, so that was important from a family standpoint.

The reputation that Duke had was that it was academically excellent, clinically very strong and Ian was recruiting people with similar academic research interests. He had trained at CURE in Los Angeles, and that was a center for GI hormone research, and I had an interest in GI hormones and that was the area of my research. It seemed like a natural fit.

Dr. Muir: What was Durham like? Do you remember?

Dr. Liddle: A real estate agent took us around and she said that the only reason to go down to downtown Durham is if you're being taken to jail or you need a lawyer. Yeah, there was not much. People had sort of left downtown Durham and had moved to the suburbs. It was only the last 10 or 15 years when that area's been revitalized again.

There was not much in Durham. There were maybe five restaurants that you would consider going to, Magnolia Grill, Angus Barn which is still around. Nana's might have been there, but yeah, there was not much in Durham. Big town.

Dr. Muir: It sounds like Ian was a big draw for you.

Dr. Liddle: I liked Ian a lot. It was a very personal relationship that we had, and he was very energetic, very enthusiastic. That was important.

Dr. Muir: Tell us about those first few years as you were building your laboratory. Who was around to help you and who were the key faculty during that period?

Dr. Liddle: I had a part-time appointment at the VA, and my appointment when I came was chief of the GI section at the VA. I viewed the VA as an opportunity to do research in an environment where there were a lot of other people. We used the VA to recruit faculty who were interested in research because they could apply for VA research funding as well as NIH funding. It was two pools of money that you could use.

That was important. There was one building which no longer exists, building two where they had the GI research labs. Ian Taylor had a lab there, Steve Vinya, Peter Manin and Steve Corfurt who was a liver researcher had labs in building two at the VA. It was an old converted nurses' quarters. Nurses used to live on campus. That wad the VA research lab.

When I came, there was no more space at the VA so I had my lab in the Sands building. There were several of us in the GI division who had lab space in the Sands building. John Cohan was there, Chris Hunt came about the same time I did. Then, a year after I arrived, Greg Fits came back from San Francisco and we were all in the Sands building.

Dr. Muir: How would you describe that environment for your investigators back then?

Dr. Liddle: There was a lot of enthusiasm for research. These were people who had trained in basic research laboratories and were committed to doing GI research. Twang Win was another investigator who was recruited from Stanford to come to the VA. There was a lot of interaction that I didn't really predict when I came.

When I came, I thought that I would ... I was doing a lot of translational research where we had developed essays for looking at blood levels of [inaudible 00:06:26]. We were doing studies in people. I got involved in the clinical research unit at Duke, and over time, because of the interest of people who were around me in the laboratory, I was able to learn techniques that they were using that we could incorporate into our research.

Greg for instance was an electrophysiologist, so we started doing electrophysiology on enteroendocrine cells at a time when nobody else was thinking about that sort of thing. It was that type of thing that I didn't predict, and it was only a result of being in a research intensive environment that allowed me to expand what we were doing to other areas

Dr. Muir: Sounds very collaborative though.

Dr. Liddle: Very collaborative, yeah. That was another thing that I was impressed with in coming because I had heard that Duke was sort of a tough environment, and they were hard on house staff. I was surprised because it was extremely collegial. The way people treated house staff related to house staff and fellows was extremely cordial.

What I really enjoyed was the relationship that we had in GI with people in other departments, particularly the surgery department. Ted Pappas and I came at the same time, and Ted had done work with actually Ian Taylor before, when they were both in Los Angeles when Ted was doing his research training. Ted came at the same time, so we had this natural affinity. When you become a GI fellow, the surgeons treat you a little bit differently because they need you.

Dr. Muir:  I recall that.

Dr. Liddle: Clearly as an attending, you were colleagues. That was really very nice. I've really enjoyed the relationship we had with people in other departments, particularly the department of surgery.

Dr. Muir: You mentioned the VA, and you've had a couple of stints as the VA section chief, but you've also had a constant presence there throughout your career. I wonder if you could expand a little bit on how you've seen the VA and the role it's played for Duke GI.

Dr. Liddle: Yeah. When I came to the VA, we had two old biochemistry laboratory rooms that we used for endoscopy. The patients would sit in the hallway and they'd get called in for their upper endoscopy, or their esophageal dilation, or their colonoscopy. These rooms were not modified. They were used as biochemistry labs.

We would do these procedures, and the patients would then either be on a [inaudible 00:09:27] that we would wheel down the hall to the recovery area, or they would sit in the chair in the hallway and recover. That was the endoscopy unit. When I arrived, Stan Branch I guess was a senior fellow, and he had been assigned to oversee the clinical activities at the VA. It was Stan and Nick Nichol was the other fellow who were doing a lot of the clinical oversight at the VA.

Fortunately, we were able to build a new endoscopy unit. We moved down onto the first floor and had a three procedure room endoscopy unit there. Then, in 2010 we built a new endoscopy unit in the basement level of the hospital. We have six endoscopy rooms. That's grown a lot. We had a clinical staff that were the attendings like me who would do endoscopy, supervise endoscopy, supervise clinics. That was the clinical GI unit. We had one secretary, we had a nurse and a nurse practitioner for all of the endoscopy that we did.

Dr. Muir:  I remember that period of time.

Dr. Liddle: It's grown a lot.

Dr. Muir: We have four to five fellows there every day. It has been a major influence on the training program as well, would you say?

Dr. Liddle: Yeah. We've been fortunate. The clinical activities at the VA have grown a lot. This particular region of North Carolina in general, a lot of people have moved into the area and every year, the VA population has grown. As a result, we've been able to grow the clinical service at the VA, so we've gone from two GI fellows to now five GI fellows. Clinical activities have expanded a lot. We now do all aspects of therapeutic endoscopy, we do ERCP, endoscopic ultrasound.

...was recruited. He's doing EMR and EST. The liver program at the VA has grown a tremendous amount. With the hepatitis C epidemic, which has been a priority for the VA, the liver program has grown a lot. Steve Joy has done a tremendous job.

Dr. Muir:  The resource they had and then what they're able to do. The VA I think is really the only entity that's handled hep C appropriately.

Dr. Liddle: They've done it great. Steve took our VA at Durham and I think he had the highest treatment success rates in hepatitis C. It's really been a testament to his work and direction there.

Dr. Muir: I think particularly those years I was the fellowship protector, it was so meaningful that all those things incorporated the fellows into [inaudible 00:12:45] and gave them these great training opportunities with some of our best teachers. It was a really important side for us, and I'm so glad it's continued that way. At the same time, I think it's remained a good place for some of our young research faculty to build their careers.

Dr. Liddle: Yeah. I think that's right. I've always believed that the VA is a tremendous place to train students, and residents, and fellows. We have been able to provide ample clinical material for training. The fellows are instrumental in our ability to deliver the care that we do provide.

Dr. Muir:  I continue to hear it's just a wonderful environment. The veterans have changed in some respects, but there's still that same approach and mentality. They're a wonderful group to care for.

Dr. Liddle: Yeah. We don't see as many World War II veterans as we used to.

Dr. Muir: No. I do want to move you further. When Ian Taylor left, you became the division chief. That was in 1993. I'm curious what you were prioritizing back then, what you saw as your role, and maybe you could expand on what was the best part and what was the toughest part of the job.

Dr. Liddle:  Joe Greenfield was chair of medicine. It was interesting the way he had approached this because he brought me in and he said "I've talked to every faculty member in the GI division." I was the last one for him to talk to. He said "They're uniformly supportive of you being division chief. Would you take this job?" I said "Well, I'm honored. Could I think about it?", and he said "Yeah. Come back in a day or two and let me know what your decision is."

I came back and I said "Okay, I'll take the job." He said "Okay, good. Now, what I didn't tell you was that you need to write the training grant." I though to myself "I wish you had told me this before I had to make this decision." That was fine, although there were some surprises along the way. Paul Facker told me, Paul was the business administrator for the department, he says "You have a great division. You guys make money. It's a fantastic division. You're really gonna enjoy this."

A month later Paul calls me and says "You're 400,000 dollars in the red," and I go "Paul, I haven't even done anything yet. How could that be?" We went through a tremendous transition, so this was a time when there was a move. The general belief was that medicine was gonna be under the direction of primary care physicians. We don't need specialists anymore, in fact the AGA president at the time and his presidential address is we don't need to train anymore gastroenterologists.

Dr. Muir: That was my fellowship year.

Dr. Liddle: For 20 years.

Dr. Muir: That was a big cut.

Dr. Liddle: When I became division chief, we had 23 fellows. I asked Virginia Sharon who was the division business administrator. I said "How do we pay for these fellows?" Nobody knew. Well, this is gonna be an issue here.

Dr. Muir: You didn't have to worry about money before, it sounds like.

Dr. Liddle: We never had to worry about money. The GI division owned the endoscopy unit. They got all the technical fees from endoscopy, and the revenue from that was used to subsidize the fellowship program. There was a huge interest in the entire medical center to centralize laboratory resources in the hospital.

The hospital took over the endoscopy unit. This was shortly after they took over the cath lab. Revenue that was available in divisions in the department of medicine was no longer available. That was the toughest part of the job, was to deal with the finances of the division. That was in flux.

At the same time, the PDC was increasing their investment in primary care, so they were studying the primary care practices around the area. A PDC overhead went up, and so for every year for 10 years, the PDC overhead went up 1%. It went from 18% to 28%. Every year, you'd do the cost adjustments that you could, and then come July 1st, you were a thousand dollars in the red again. That was the toughest part. My priorities just by necessity were how to deal with the finances.

Dr. Muir: About the best part.

Dr. Liddle: The best part was nurturing the careers of young people. We were very successful in recruiting particularly women into the GI division. I don't know why we were able to do that, but I think we had the greatest number of women on our faculty of any division in the country on a per capita basis for the size of our division.

I think we probably had more women in our division than any other division. That was a source of great satisfaction. That was really good. We were able to selectively develop certain areas of research. The liver transplant program was very small at the time. We set in motion I think. It didn't really grow until a little bit later on, but sort of instilled the importance of liver transplantation.

You have taken that to a new level now, but it wasn't an easy sell initially because of this interest in emphasis away from subspecialty medicine.

Dr. Muir: It was a very important time. I think you get to take some credit for some of the leadership decisions there as well. You came to build a research career, and I have to think that time impacted your research. What was it like to balance that between being the administrator while you still had your clinical responsibilities at the VA, and yet you're running a large research laboratory?

Dr. Liddle: Yeah, that was challenging. One thing that I came to realize, and I'm sure you appreciate it now too is that the division activities come first. Your research, if you can do it in your spare time then great, but the things with the division came first. I think that's just the way it has to be, but you do make some sacrifices in your own personal research.

The rewards are what your faculty are able to accomplish, and being able to facilitate those activities. That's worthwhile. The clinical activities, issues with general administration involving the staff, fellowship program, making sure the educational activities are strong, that all takes priority.

Dr. Muir: It's a great job. I personally enjoy it, but it is a service role.

Dr. Liddle: It is a service role.

Dr. Muir: I think you need to feel good about that in order to be able to enjoy it.

Dr. Liddle: Yeah.

Dr. Muir: And to take pride in what those other people accomplish. Many of us are grateful to you for that period of time. I actually think you probably shepherded us, and maybe even make us all aware to the degree, particularly the junior faculty, aware of the degree of some of those financial struggles you were talking about early on. I just feel grateful for that. I don't feel personally as impacted by that as I think some other folks in other divisions perhaps were.

Dr. Liddle: Yeah. I think that's your role as a division chief. You're dealing with the administration on a different level and you're advocates for your faculty, and that's important. It is satisfying to be able to do things like that. It's rewarding.

Dr. Muir: Good. I'm glad. You stepped down in 2002, and around that time you took a sabbatical, which I don't know all the details on but I gather it was important for you professionally and personally. I'd love to hear a little bit more about that.

Dr. Liddle: Yeah. I had met a CEO of a small startup company here in RTP. He had asked me if I would be interested in working more with them, and would I consider spending a year with them on a sabbatical. I liked the idea because it was new and it was an opportunity to look at medicine from a different perspective.

They were trying to get oral proteins absorbed, and wanted to know how the GI tract worked. I said "Well, I can certainly help you there. We're gonna have to deal with gastric acid and pancreatic enzymes, and all of that sort of thing." I went to our chair Bart Heinz and I asked him if I could do a sabbatical. He said "Yeah, you could do it here."

The other thing I wanted to do during that time because it was local, I could work for this company half time and work in my lab half time. I thought I needed to rejuvenate some activities in the lab. That's what I did. I remember waking up the first day of this sabbatical, and I had not even gotten out of bed, and it was a cathartic experience. I said "Wow, this feels different."

Instead of turning left to go to Duke, I was gonna turn right and go to RTP. I said "Wow, this feels different." I didn't realize until that moment how much the responsibilities of running the division really weighed on me. I enjoyed working with this company, and about halfway through, Bart asked me to come back because I was still formally the division chief. He said "Would you come back?", and I said "No. I promised this company a year and I haven't really achieved what I need to do in the lab." I said "No, I can't come back."

That sort of set in motion the plans for me stepping down and finding a replacement. It was important for me personally. I have some regrets about how that might've impacted the division, but I think it indicated to me that it was time for somebody else to do this. Maybe I shouldn't tell you this or make this publicly available, but I would encourage people to take a sabbatical if you can. It's renewing.

Dr. Muir: I get the sense it's not as common as it used to be.

Dr. Liddle: No. In fact, I don't know of many people now who take sabbaticals. It's hard because financially you have to have a way to cover your salary and so forth in order to do that. It's one of those academic benefits if you can take advantage of that.

Dr. Muir: I think the other thing that's been nice is that your lab has been incredibly successful since then. You seem as busy as ever, which is really nice to see that you could have this [inaudible 00:25:38] in your life that you served that role, and you've returned to the research focus and you continue to make major contributions, another great paper last month. I'm curious what that period's been like for you, and what you're working on now, and what you hope to accomplish.

Dr. Liddle: It's nice of you to say that. I do enjoy it, and it's kind of interesting. I think our research is going better now than it ever has. You sort of hate to see that as I kind of wish I was 35 years old again because of a lot of things that we want to accomplish.

My lab is focused on two areas. When I was a fellow, I developed an essay for measuring blood levels of [inaudible 00:26:26]. We've had an interest in enteroendocrine cells. Our lab has always studied enteroendocrine cells. Network has evolved from studies that we did measuring blood levels and we did that in rats, and mice, and dogs, and baboons, and people, to evolve to looking at the cell biology of these cells.

Over the last several years, we discovered that they actually connect to the nervous system, so it provides a direct link from the gut to the brain. I've been fortunate to work with a number of really bright enthusiastic people who have carried on that work. I hope [inaudible 00:27:06] like Diego Borg has to do great things with that.

With that discovery, I looked at how that might impact disease or how diseases may be related. Now of all things, we're working on Parkinson's disease and how that might be related to these cells in particular and this gut-brain connection. About 15 or 20 years ago when we were working on these essays for CCK, we worked with pancreatic acini as a bio essay for CCK. We would always be working on acini pancreas tissue. I trained in a pancreas lab, and I thought "I need to make this research a little bit more clinically relevant."

There are basically two diseases of the pancreas. You have pancreatitis or pancreatic cancer, so we decided to work on pancreatitis. We've been fortunate being able to I think make some reasonable discoveries in that area. I hope that we'll be able to develop some therapy for pancreatitis that we could translate into a human treatment. That would be fantastic if we could do that. If I can do that before I retire, that'd be very exciting.

Dr. Muir: The way things are going, I sure hope so. It really is great to see. The lab's a vibrant place. I was talking to some of your team members the other day. They're very excited. It's great to see.

Dr. Liddle: It's fun.

Dr. Muir: It's really great to see. One of the other fun things you and I get to do is while you're back on the T32 [crosstalk 00:28:44]. I'm grateful that we get to do that together. In that role, we both interact with a lot of trainees. Your interest in their research I think is really nice to see. Your enthusiasm for their research comes across when you're interacting with them.

This is another one of those times in which NIH funding rates are tough, some people question what a career in research might look like. When you have someone come to you, what are you trying to tell young people interested in science? How do you envision their career going? What advice do you give them?

Dr. Liddle:  I think that the career as a physician scientist is the best career in medicine. There aren't many jobs where you can do something completely of your own choosing. When we choose a research project, we can work on anything that we want. To get paid for doing that is pretty amazing.

It's a fantastic career choice. Fellows who come into the lab, if they find that they enjoy the research, if they enjoy the technical as well as the intellectual activities that are involved with thinking of questions that are important to ask and how to answer those questions, and then have the tools to do that, that's a luxury. It's exciting.

You're right. The downside is funding for that, so yeah, you can work on whatever you want, but you have to generate revenues that could do that. I think the NIH will always fund important worthwhile projects. The process of writing grants, some people really do not like, but it's purposeful, and I think it actually helps you synthesize your ideas and formulate them better. It's a worthwhile activity. When you do get funding, then you can take off and run with that.

I think if you enjoy that process of thinking creatively and thinking of questions that you want to answer, it's a fantastic opportunity.

Dr. Muir:  Are there any key pieces of advice that you have for your fellows?

Dr. Liddle: Yeah. What I've continually believed is that I've always tried to surround myself by people who are better and smarter than I am. If you're in that environment, good things tend to happen and you absorb. You sort of learn by seeing, by osmosis if you will, how to conduct research, how to ask questions, how to learn new techniques and so forth.

I think now in particular with the way the technology has changed, it's important to be multidisciplinary. Yes, we still work on questions that are fundamentally related to a GI problem, but we talk to people in other fields whether it be neurobiology, or cell biology, or microbiology, to learn how those tools, how those people ask questions in those fields, can be related to the questions that we want to answer. It's this cross-fertilization that I think is really important.

Fellows who are interested in research need to extend themselves to learning things beyond just what the mentor does in his or her laboratory. I think that increases the likelihood of one's success. I've been fortunate to be at great institutions and be surrounded by people who I can learn from, who continually teach me things that I can do better.

Dr. Muir: You've created that environment for a number of people who've benefited too. You're clearly passing it out.

Dr. Liddle: It's nice of you to say that. I hope so.

Dr. Muir:  Along that line, you are notoriously humble, maybe for the sake of your family and grandchildren if you could ... What are you most proud of in your career?

Dr. Liddle: Well, there are personal things that we've been able to do in the lab which have been satisfying. There's some recognition from those things. That's also really nice. Professionally from a career standpoint and from the perspective of the division, I'm proud that we've been able to foster the careers of many young people. I'm proud that we were able to develop the female faculty in our division. Hopefully, that's a legacy that's still continuing, that you've been very supportive of.

When I was running the division, we were always ranked in the top 10 in GI divisions. That's satisfying. I don't know how important that is, but it's some form of recognition. I think it's really the careers of the young people that is gonna be the legacy of what Ian Taylor did, what I did, what [Mel Tire 00:34:50] did before us, Anna May did, what you're doing. It's those people. When you go out and look at the photographs of the trainees on the wall, those are the things that are really, really gratifying, and see those people go on to do great things in clinical medicine or in their own research careers, those are the things that are really satisfying.

Dr. Muir:  I agree. I also like looking at those photos. You're never quite sure of what's gonna happen to your research. You hope your patients will do well, but I think that investment in those young people pays off [inaudible 00:35:28] what they go do is really nice. You're in the homestretch here.

As you were talking, and particularly when you were talking about some of the changes in medicine that were going on when you were chief, I feel like we always hear things like that. Right now, it's preparing us for value-based care and all the other things that are coming in, and then how will that impact our research mission and our education mission. This evolving nature of healthcare in the United States is something we think about a lot and try to plan for. With all those things in mind, what advice do you have for me as the division moves forward over the next few years?

Dr. Liddle: That's nice of you to ask. I don't know that you need any advice from me. I think that as we go forward, I think having a sense of history is important, knowing what makes Duke unique and why should Duke be at the forefront of what we're trying to do both locally, regionally throughout the state, nationally. Duke even has a footprint internationally now, but what's the history of how we got there.

I think you're doing a very good job of bringing that sense of history back into the GI division. Having interviews like this, I think it's important. As far as concrete advice, I think you have to be flexible. The way that I tended to view individuals on the faculty was I wanted to know what they wanted to do and what was best for them, and how I could support what they were good at and fit that into what the institution needs.

If you can find that sweet spot, then those people are gonna succeed, and it's gonna benefit the institution. There are gonna be challenges, you're right. Again, a lot of it's gonna come down to how you deal with the financial issues. Once you have that and people realize, and they know this about you because they know that you are concerned about them as individuals and what they do professionally.

They have that sense about you and I think that's extremely important for people in the division to know that you care. That [inaudible 00:38:04] students and residents that you work with, particularly the fellows and the faculty. That makes a huge difference. When those challenges come, knowing that you're there to support them, you're on the frontlines, you're dealing with those problems that come about, and only the things that have to filter down to the faculty and fellows are things that they have to deal with. I think that's hugely important. You don't need coaching for that. You know how to do that.

Dr. Muir: Kind of you to say. In many respects, I think I see my approach is similar to what I saw that you were doing for us early on. You're the kind demeanor [inaudible 00:38:58] went about leading, I think is one that I remember and that people have seen throughout your whole career. There's a generosity in the way that you conduct yourself.

Dr. Liddle: It's nice of you to say that.

Dr. Muir: Really, I think the gentleman and the scholar is the phrase that often comes up, and that really is you. There are many, many people that would want to extend their gratitude to you, and I hope that feels good because it really should. It's been a remarkable career that continues on. We are very excited to see what you do over these next few years. I'm grateful that you'll still be around for council, and I look forward to what you'll do in this next phase of your research.

Dr. Liddle: Thanks. I've been very fortunate to be here, and you've been very generous. Thank you very much.

Dr. Muir: Very mutual. Thanks Dr. Liddle.

Dr. Liddle:  Thank you.