Innovating to Prepare Future Clinicians for New Roles - Dr. Mary Klotman, Dean of Duke University School of Medicine

Shiv Gaglani: Hi, I'm Shiv Gaglani and today I'm delighted to welcome a nationally recognized leader in academic medicine to Raise the Line. Dr. Mary Klotman is Executive Vice President for Health Affairs and dean of the School of Medicine at Duke University, where since 2017, she's overseen advancements in research, teaching, and administration that have propelled it to new levels of national recognition and research activity. 

A physician known for her research in HIV at the NIH and elsewhere, she was chief of the Division of Infectious Diseases at Mount Sinai for thirteen years and co-led its Global Health and Emerging Pathogens Institute, a program designed to develop therapeutics for newly emerging and re-emerging infectious diseases. 

Dr. Klotman is a member of the prestigious National Academy of Medicine and a fellow in the American Academy of Arts and Sciences, and I should note that her name may be familiar to you as she was recently in the news for being under consideration by the Biden administration as the next director of the NIH. 

I'm looking forward to learning about how she is building on Duke's reputation for innovation in medical education as well as her other key priorities. So, Dean Klotman, thanks for taking the time to be with us today. 

Dr. Mary Klotman: Well, thanks for inviting me to be here. 

Shiv: So, we always like to ask our guests to, in their own words, tell us more about themselves and what got you first interested in medicine and then a career in infectious disease. 

Dr. Klotman: So, I can't say I had the whole roadmap thought out when I started, but when I look at key points in my life, it started with really interesting Sunday mornings where my uncle -- who was a general practitioner in the town that I grew up in -- would come over and visit my mom and tell stories. I would sit there fascinated. I had very little understanding of medicine, but I loved the stories. Then fast forward, in high school, I fell in love with biology, a very important aspect of medical training, and then I was fortunate enough to go undergrad to a place like Duke. But even then, I didn't really have a clue as to what it was to practice medicine, what the specialties were, had no idea what academic medicine was, but I was very fortunate to get into Duke Medical School and that started to put the pieces together. 

First of all, I always thought I want to be like those that were teaching me and they had this amazing ability to take a case, bring in all of the medical knowledge in discussing that case, and use that knowledge to come up with a solution. I was in awe. I didn't know how you do that. But I rapidly understood this intersection between science and medicine and in academic medical centers, that's kind of practiced every day. 

But the real coming together of everything happened when I became an infectious disease fellow. I went into infectious diseases because I loved reading about them. Whether they were fiction, or New England Journal of Medicine articles, it was always the infectious disease cases. And then the first cases of HIV came to Duke and that's when it all came together. A new disease, 100% fatal, clearly needed a scientific approach. I realized that that's how I could put my love of medicine and my love of biology together and so I pursued HIV as my major focus for most of my career. 

Shiv: Wow. What an incredible background and so let's dive into HIV because that's actually one of those stories that seems to be a very positive outcome now after a period of years of intense research by people like yourself. So, can you tell us a bit about the fact that it's gone from a virtual death sentence to now being managed as a chronic disease? Any highlights, any things you're most proud of, or you want to share with our audience about HIV research back in the day? 

Dr. Klotman: You're absolutely right. It did go from a diagnosis that was a death sentence, and I took care of some of those early patients. Once we knew they had HIV, we knew they were going to be dead in a couple of months. Now, it is entirely treatable with essentially a full expectation for a full lifespan with therapeutic intervention. 

So at the time, we thought this was a really rapid evolution. First cases in 1981, approval of

first antiviral in 1990. That was nine years, and it used to be it took twenty to thirty years to get a new therapeutic. Then highly effective antiretrovirals in 1997, the drug cocktails that made all the difference. So, that was fast. Why did that occur so fast? Well, we had the basic tools. Molecular biology grew up in the 70s and really rapidly evolved. So, you had these new scientific tools to take a fairly small virus, nine kilobases, take out each part of that virus and understand what those proteins did and they became targets for therapy. The science developed before we understood the virus. 

But then there are some interesting things that I think were unique. One was the real unique partnership between NIH, which funded a lot of the research, with these big academic health systems like Duke that not only had the scientists, but had the clinical training to provide a workforce that knew how to use the rapidly evolving tools. And you had a partnership with industry, where industry worked with NIH and the big clinical trials network to bring these new compounds to robust clinical trials and then implementing them in care. That part was kind of unprecedented. How do you do that? How do you align incentives? I think it worked extraordinarily well. 

Fast forward now to what happened with COVID. I think some of the positives of what happened with HIV really facilitated the rapid development of the vaccine for COVID. We had the network of institutions that had the workforce, had the know-how, had the background and infrastructure to do the clinical trials; you had industry that knew how to partner, and with the right incentives, they will partner. So you saw what was an incredible timeline from the discovery of the etiologic agent to a vaccine, which made the HIV story look like it was slow. But I think a lot of things were learned, particularly through the HIV experience.

Shiv: Well, you've definitely preempted a question I was going to ask a little later, but might as well -- since we're talking about COVID now -- talk about it a bit. We launched this podcast, Raise the Line at the beginning of COVID because everyone was talking about flattening the curve and we also wanted to make sure people talked about raising the line, which is how do we train more healthcare professionals, keep them in practice longer, and then equip them with tools -- like remote patient monitoring and telemedicine -- so we can provide more higher quality care to more people at a lower cost, hopefully. 

You've obviously had leadership roles and been considered for leadership roles at NIH, and I know the CDC will have new leadership. We're continuing to chart this post-pandemic course. Where do you think the focus should be in terms of strengthening public health and research, and are there any bright spots right now at the federal level with regards to medical science that you want to share with our audience?

Dr. Klotman: Yes, so great question, and one that, frankly, I'm really asking all of my team members to not forget the experience and to use the experience to do better. I think the good news is that we learned a lot, and we had to. We had to do it, and we had to do it fast.

I think we learned that our institutions can rapidly pivot -- we use the word pivot sometimes too much -- but rapidly pivot all of those resources that the government and NIH have invested in. We were able to bring that all to bear to this single disease, whether it was our workforce that knew how to work under very challenging conditions, it was our investigators that knew how to set up these clinical trials within weeks to months, or our infrastructure. We had these buildings that were built. Actually, interestingly, after 9-11, there were a lot of containment facilities built so that we could work with this new virus. So, I think that all worked incredibly well, and I think we should be very proud of that. But I think we learned a lot of things that we need to do better. 

Just beginning with clinical trials, if we had a national information system that allowed all of us to exchange information rapidly, we probably could have done those trials even faster. You know, one can imagine one national database where we're all entering patients at the same time. I mean, we did not lack for patients for these trials. So, we’re really in need of a national approach to data sharing and data science. Again, working on incentives. How do you make sure we're all incented to do the right thing and making sure that there are not too many barriers to being able to pivot? 

Now, fortunately, I don't know if you remember, but early in the COVID period, the NIH allowed all of our investigators to have a few months leeway in their funding, because if they were held to productivity in all the different areas they did work in, they wouldn't have been able to pivot to focus their efforts. That was a brilliant move, because it allowed our investigators to say, “Okay, I don't have to focus on whatever I'm funded to do the next ten years. I need to focus

right now.” 

I think one of the two challenging areas that were unanticipated was the struggles in public health and the connections to infrastructure. We all worked with our local communities to the credit of, I think, the primary drive for everybody wanting to do the right thing. But it wasn't that we had a robust infrastructure that aligned state, local communities and institutions like Duke. So, we really had to be more thoughtful in how do we connect that infrastructure. 

The other big area that I'm still scratching my head over is understanding why misinformation and disinformation spread so easily and how it was that so much of our population was willing to take misinformation and disinformation and frankly, do things that were not for their own health and safety. I don't think we had an understanding of basic social science and I think that's where we really have to put a lot of effort and on the top of that, improve our communication skills. 

If you look back, you can see so many opportunities to have done that better and for me as a dean of a medical school, it's thinking about how do we educate our workforce? I have PhD students, hundreds of health professional students...how do we build in communication skills so that they become the local ambassadors for scientific truth? Because unfortunately, what that has resulted in is a fundamental distrust of science and that is devastating. We have to understand that, and so we are joining with our partners in the Research Triangle Institute to sponsor the first meeting nationally, scientific meeting, on understanding misinformation. But at so many levels, we have to do better. 

But I think we did learn a lot. Unfortunately, some of those lessons are going forward. All of us are much better partners with the local communities now, real partnerships. I think we have to build on that experience.

Shiv: Yeah, those are some incredible takeaways that hopefully our audience will be taking notes from this. On the subject of misinformation, you're speaking our language because one of our core pillars is to take on the infodemic. Partnering with the right organizations -- like, YouTube is a big partner of ours, or the CDC, another partner -- to create content like what you see behind me, that simplifies science, but doesn't trivialize it and makes it accessible to even elementary school students, and hopefully all the way up to professionals as well. 

Can you tell our audience a bit more about the symposium as well as any other thoughts you have on what things we should be doing to combat misinformation and disinformation, especially now in the age of artificial intelligence and deep fakes? It feels like the problem could maybe even get worse. 

Dr. Klotman: First of all, I love the tools that you're developing and I wish I had had them in medical school, because some things were just very difficult to understand conceptually. So, having different tools for different learners, I think, is just a huge advancement of understanding science, even for those that are fairly sophisticated in science.

The meeting that we're sponsoring is the National Forum on Best Practices to Address Health Misinformation. Again, it is really a focus on the science and understanding of communications at the social science level, to understand what resonates with different people, and using that information to develop communication strategies. One size does not fit all, one message doesn't fit all. Fortunately, we've been working with the Research Triangle Institute for a while on this whole idea of communication science. The simple tools when we're educating is listening, understanding where individuals are coming from and that helps inform how you deliver a message, the force with which you deliver a message and the content and detail of the message. 

So, I think we have a lot to learn about why it was so easy for people to listen to misinformation and disinformation, even though it wasn't to their benefit. If you really look back, you could say up to 300,000 deaths were avoidable because of the difficulty in getting a level of comfort and acceptance of a vaccine. It's one of the safest vaccines that's ever been generated, so we have a lot of work to do there. I think it is a scientific question to understand and I think it's an education imperative because if you looked at all the schools in the country, we have thousands of learners that can be educated to become communicators of science. I'm a general optimist, so I like to start from what's the opportunity and going forward, how can we use this? But I must say, it took us all by surprise.

Shiv: Yeah, absolutely. It's still very surprising. But I agree with you. I like to lean towards the optimism. People like Steven Pinker and Matt Ridley are people I like to follow for that

reason. 

Dr. Klotman: By the way, one other thing on the forum. One of the groups that we are working with is this Coalition for Trust in Health and Science and if you look at that, it's forty or fifty organizations and they represent a very broad swath of biomedical and basic science organizations. So, I think we have a pretty engaged community to help with solving this

problem. 

Shiv: That's great. Yeah, it'll require a huge coalition, both at the local and at the national levels. So, going from the national conversation which we've been having towards a more local conversation...as your title implies at Duke, you have responsibility for more than the School of

Medicine. Can you give us a bit of an overview of the programs that you oversee and broadly speaking, what you think are the key strengths that Duke offers to learners in the health

professions? 

Dr. Klotman: I'll start with the latter. One of my kind of very simplistic themes as a dean of a school like Duke is what I call One Duke. That concept is, at a place like Duke, whether you're a student, you're a junior investigator, senior investigator or a clinician, you take advantage of

everything that is here to solve a problem. That gives you a multidisciplinary approach, whether it's engineering in medicine, or it's data science. That is the nature of scientific problem solving today. There is no science problem that can be solved as an independent

investigator. 

If you have institutions like Duke, where you have this broad expertise, I tell the faculty and the students the same thing: take advantage of it. Seek out areas of expertise, individuals that might be in a different school. We have a law school, policy, engineering, medicine and I think that is the general approach to science today. I'm very fortunate to be at a university that has all those disciplines. So, I really promote this idea of a multidisciplinary team approach to virtually everything we do, because there isn't a single problem that isn't solved by going across disciplines. 

At Duke we have a number of health professional programs: MD, physical therapy, occupational therapy and a physician assistant program, which was started here. Then we have all the biomedical PhD and master's programs. So, a really broad array of learners and we are trying to bring those learners together in this One Duke approach as well, trying to train our MDs side-by-side with other health professionals so they understand that when you're delivering care, it is a team approach. It's not just an MD.

You have to be able to understand the role of all of those other health professionals and so we have put together opportunities to have learners side-by-side and then we even bring the PhDs into the clinic so they can kind of look at a problem from the clinical point and then work back. That is really popular among our PhDs. They love to see the tangible application of what might start as a very basic interest in immunology, for instance, and they get to understand what rheumatoid arthritis is. It starts to put everything together. So, it is this kind of multidisciplinary approach to science, education, or whatever we're doing. 

Shiv: Yeah. On a very personal note, actually, when I was in high school a Duke researcher named Miguel Nicolelis -- who I'm sure you know well -- who does a lot of very pioneering and interesting work in brain-computer interface that helped motivate me to study biomedical engineering in college. I've still maintained this passion and interest in that. He's MD-PhD, but I know from his lab that PhDs will scrub into neurosurgeries and vice versa. The MDs will do bench science. So, that's just one very specific example of what you're describing as One Duke. The rankings aren't everything, but seeing how Duke has risen throughout the last decade or more is testament to, I think, this approach. 

Going into medical education specifically, you know, Duke has a longstanding reputation for innovating. I also heard about this patient-first curriculum and that you're expanding training to include more ambulatory settings. Can you talk to us a bit about those initiatives? 

Dr. Klotman: So, Duke curriculum has been known to be innovative for years and for years, we've talked about a new curriculum that was actually developed fifty years ago, and we've kept that. A main element is our third year is all scholarship. To this day, our students

do a very compressed first two years so that they can do their own primary scholarship and that to me is the essence of a place like Duke, where you can have students really do kind of a self-motivated study around something of interest. The good news today is that interest is very

broad. It could be global health, health policy or laboratory-based investigation. 

But the piece that we've worked on in this new curriculum is a much more focused integration of all of the science that is the fundamental underpinning of medicine into the direct patient care experience. For years, students have asked for that. You know, they get to medical school and they're so excited. They think they're going to see patients, and they don't see patients for two years. So, very simply, we have a boot camp in the first two weeks. Boot camp is you come to Duke as a med student, you see patients in the first two weeks. Now, that's just kind of the tip of a very big iceberg, but it gets them thinking about how it all comes together. Then in the basic science, really pushing our curriculum team to build in that connection constantly between basic science and clinical care. So take, for instance, a complaint of shortness of breath. That goes all the way back to fundamental respiratory physiology and really understanding how respiratory physiology can explain shortness of breath, and you can do that in every system of the body. 

Then another big component is this realization that for decades, medicine has been taught inpatient, in the hospital, with very, very sick patients. We know that 90% of medical care occurs outside the hospital and yet, up until recently, everybody has been training inpatient. It's easy. It's, you know, geographically, you're in one place, you have faculty in one place. So, we're really trying to shift that, as many schools are, to substantive ambulatory experience. 

Now, ambulatory medicine occurs over time. If you have congestive heart failure, you don't see your doctor once. You see your doctor on a regular basis. Disease evolves, therapeutics evolve so it’s a longitudinal experience. So, we're introducing that part called the Pioneer Program this year. We've rolled out this patient first curriculum over the last couple of years and we are always getting student feedback, which is really important. Some assumptions that I might have about what's important might not be well informed with what our students in front of us think they need. So, then we come up with some blend that really appropriately presents the material in a way that the students are going to get excited about it. They were involved in the generation of the new curriculum, and they give us feedback as we roll out each part and then it's modified based on what we're hearing. 

So far, we're hearing really, really positive feedback. But that is really important, because the environment in which the students are learning today is such a different environment. First of all, there’s massive amounts of information. There's no way that you can take a textbook of medicine, and that's what you need to accomplish. It's really learning how to think and so we have to teach students how to think, how to access information, and how to know what's good information.

So, there's a lot behind changing curriculum and it really is important to check yourself every couple of years and evolve new disciplines. Data science now is underpinning everything from basic discovery to healthcare delivery and you can bet with ChatGPT it’s going through a massive evolution. We have to be thoughtful about how we integrate those new areas into our curriculum. So, that's all built into this patient-first curriculum. But I have no doubt it's going to be evolving and continually evolving over time.

Shiv: I love a lot of things you said there, especially incorporating student feedback and having that humility, which you clearly have, as a leader. Obviously, you have a point of view on how to train the next generation of healthcare professionals, but you also know that many of these students grew up on TikTok, and now they're using ChatGPT. The way they're going to be practicing medicine in ten years may be very different than what any of us can imagine because of tools like large language models and many others, and so it’s about being able to iterate quickly, like you do on the research side of things. 

Plus, I love the unique aspect of Duke, which is the third-year scholarship focus, because I think as information gets commoditized -- you can learn a lot of the basic material online on YouTube and Coursera -- but working with someone like you or Dr. Nicolelis...that's why I think you go to a place like Duke, in my opinion, for those mentors and the research you get to do.

Dr. Klotman: Well, I like to think we do put it in context, you know. We put the massive amount of information and the new tools in the context of patient care and how it all comes together at the bedside, ultimately.

Shiv: I agree. I agree. You need the patients and you need the guides, the residents and teaching staff. So, I know we're coming up in time, so I only have two other questions for you. The first is, what advice would you like to give to our audience, many of whom are early career healthcare professionals or students, about approaching their careers in healthcare?

Dr. Klotman: Well, first of all, I know that the last couple of years have presented different challenges to students interested in healthcare. I mean, certainly students that had already entered healthcare, it’s been very challenging to learn under the circumstance of the pandemic. But the ups and downs of the pandemic, I think, had different effects on individuals thinking about this career. This career has just so much enormous potential. With the coming together of the incredible advances in technology and science and data science, we are going to see a real revolution in healthcare and diseases that really we haven’t had breakthroughs in for years, like degenerative CNS diseases, whether it's Alzheimer's or related diseases. So, I think that the excitement and scientific promise is enormous, but I also think the challenges are there and have been very visible through the last couple of years. 

I like to encourage the students to not be afraid to take detours. If you see something of interest to you, take those detours. I mean, I went to the NIH after I finished my training. I thought I was done, and then I basically became a student again for several years...you know, the lowest person on the totem pole in a very big lab. But it was absolutely game-changing for what I did and I really encourage everybody in medicine, if they have a curiosity and interest, take the time to take the detour. There is no absolute timeframe for when you have to be finished with certain levels of training and our careers are so long. We're very, very fortunate in healthcare and related fields to have so many options to explore. 

So, I always use the word detour and really encourage people to follow those interests and, you know, a lot of our systems are much more flexible today that they can do that. But all in all, these are incredibly gratifying careers with so many options. I don't understand why everybody doesn’t want to be in healthcare and be a health professional. But, you know, occasionally you do have pandemics that stress the system for sure. 

Shiv: I think that's wonderful advice. It obviously resonates with me having taken a ten-year detour to get an MBA and start Osmosis between second and third year. Lisa Sanders is another guest we've had on who you may know. She writes the Diagnosis column for The New York Times and she was a TV journalist for many years before she started med school at the age of thirty-seven. So, I think a lot of people like yourself who contribute locally and nationally have taken these detours, as you said. 

Is there anything else you want to share about yourself, infectious disease, about Duke? I know DEI is an area of focus of yours as well. Anything you want to leave our audience with before we let you go? 

Dr. Klotman: Well, I think just reiterating a few points. First of all, that health professional careers, biomedical science careers, are so gratifying and to me -- and I would think most people -- so innately interesting. So, I'd encourage people really exploring, because the options are so broad. It's everything from public health to very fundamental discovery science. You can find so many things within that continuum. 

The other thing is really the issue we talked about a little bit earlier, that anybody in these careers needs to become scientific communicators. It's a really important part of our profession. It doesn't matter, you know, what part of science you're in, what part of a health professional continuum you're in, you become really trusted communicators in your communities, whether they're your family -- and you know the kinds of discussions that have been in the families last couple of years -- or your church. 

I really have challenged the students that have graduated from Duke the last couple of years to consider being ambassadors for science, for communication of what is good science and the other area that I'm passionate about is also to embrace understanding health disparities. Because again, no matter what profession you go in, you will see it, and you need to understand it. So, I think those are the two areas that go across specialties, across the various health professions, but I do hope that students embrace them in their training.

Shiv: Absolutely. I know a lot of our audience is very interested in both of those, and hopefully will take your advice to pursue those and the detours to heart. So with that, Dr. Klotman, thanks so much for taking the time to be with us today on Raise the Line, but more importantly for the work that you've done over the past several decades to actually raise the line

and strengthen our healthcare system. 

Dr. Klotman: Thanks for having me. 

Shiv: And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show. And remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.