Martin Dawes | Innovative Science in Medicine as both doctor and patient

First, lets talk about your academic career

Martin Dawes: I didn’t plan it.  I think that’s the important thing to say. I took opportunities when they arose.  So, I was running the Centre for Evidence-Based Medicine and one of my students at the time was a Visiting Fellow who was the Professor of Surgery at McGill University and he and I came to blows, verbally, about evidence-based surgery and whether we should be using more evidence and creating more evidence in surgery.  This got back to the Dean at McGill and I was invited to go there and have a look at the department.  Things were at a stage in my career where I’d been in the practice for 17 years, I lived in Oxford where I grew up, and I thought, why not actually take the plunge.  I come from a family who have travelled- my sister is in California, my brother is in Ottawa.  So, it wasn’t a huge leap, although my wife might disagree. The kids were at university and we thought, why don’t we do this.  

I took on the role of Head of Department in McGill. And it was an eye-opener.  One of the little asides is that I thought medicine might be different in North America and I was lucky enough to be invited on my second day there to sit in on consultations for a morning, with a GP who became a close friend.  And it was really reassuring how people who were worried came in and had a conversation.  Physicians knew their patients, knew the family, and it felt very much like being in England. There were nuances of difference but generally the whole process was the same.  Then, fast forward… I had had a lovely time there for eight years but the Dean of Medicine at UBC, when I was at a meeting with him,  said “would you ever think of coming across to UBC and Vancouver”?  We’d had eight winters in Montreal and, while it was fun, I didn’t want to get into my 70s and 80s being restricted to walking in a mall because I was frightened of slipping on the ice for six months of the year.  We thought we’d have a good look and we fell in love with the place.  It is a beautiful area and UBC has been a fantastic University to work for. I took on the same role as Department Head and, in the meantime, I was able to carry on my research career.  They were very welcoming and, talking about genetics, I work closely with a group here.  I was able continue my academic contribution in an administrative role as well as in a research and clinical role. I could practice in British Columbia just as practicing in Quebec, and that’s been a real privilege.

DMacA: It’s been very interesting to look at your academic career. From the beginnings in  evidence-based medicine,  you’ve now moved on to some really interesting genetic research.

MD: Again, this is taking opportunities. One thing I would say, towards end of my career, is that leaping into those opportunities has been the best thing for me.  It’s always about the people and, with genetics, I had had an introduction at McGill to a colleague who wanted to look at Warfarin genetics using a pharmacogenetic variant, in order to predict a more accurate starting dose for patients. I won’t go into the details of the pharmacogenetic variant but he said- can we get it into a family physician’s electronic medical record.  And this makes all this genetic allele stuff clinically relevant to us in Family Medicine, which is where we want it.  So, we did that study and it worked. We were able to do the genetic test, put it into the electronic medical record, and use the information to adjust Warfarin doses within Primary Care.  Then, when I got to UBC, I was immediately introduced to someone called Pieter Cullis.  And, he asked if we could we put a grant application together within two weeks. It was that sort of rush.  This was all about primary care and genetics so, yes, whether it’s disease prediction, whether it’s pharmacogenetics for medication, whether it’s picking up rare diseases using family histories, everything is going to happen in Primary Care. Like any other new technology, of course, it happens in big hospitals first, but then most gets shifted into Primary Care. Genetics is no different.  What I’ve been doing is on the software side – how can we create software that makes it easy for a physician to identify drugs that might work for an individual adjusted for everything, the liver, the renal, other conditions, the other drugs they’re taking, and their genetics.  And its possible to create these algorithms.

DMacA: When I first heard of your research, I thought it was the most exciting piece of research I’d ever heard in Family Medicine because it integrated all those things we value-  the science,  the cutting edge genetic science, personal care, and individualized care. You are immersed in this.  Where do you think is going?

MD: I think the UK has got a great leader in Professor Sir Munir Pirmohamed and I think it’s actually going to happen. I have a huge respect for the process the UK is taking of stepping back and saying, first of all, how many patients might a family physician actually have to use this technology in a week.  Actually Dr Essra Youssef did that, and showed that it would be about 12 patients.  You take a panel of genes, where there’s really really strong evidence for drug gene interaction that leads to 40 or 50 drugs potentially.  How often are those drugs prescribed in Primary Care de novo – about 12 patients a week.  Now we can work back, we know we’re going to be using this technology in 12 patients and we’ve got to use it with other things.  So we need a good clinical decision support system,  we need to have laboratories that can do really robust genetic tests,  we need a system that can store that information so it can be used anywhere in the country, at any time, with that individual, and the NHS is addressing those things right now and I’m getting very excited by that.  In North America it’s sort of wild west so that clinics are doing the same quality of tests as the UK but the lab information is residing in different places. If the patient then goes from wherever they had the test done, say in Chicago, to New York, the New York doctor won’t have that information.  The NHS in the UK is creating a system where everyone will have these tests done and the information will be easy to use .

I think more are realizing that rare diseases are common.  It’s a peculiar thing to say but if you bundle all the rare diseases together,  every one of us as a family physician has a handful of those patients.  Yes, of course, the colorectal cancers, the breast cancers, are more common examples of inherited diseases but that information, the genetics,  will be shared up and down generations in software that will be embedded into the two major UK Primary Care electronic records.

 I think that this is coming.  No it’s not ‘is’ coming, it has come.  There are people who’ve had pharmacogenetic tests done in the UK and that information is being used right now.  Across the world it’s being used right now and, what we’re seeing is the move from it’s new to,  now its standard practice of care. If you think about a patient who’s going to have Plavix or clopidrigrel post MI , it’s almost standard today in North America to do a pharmacogenetic test.  It’s coming and it’s very exciting because it will improve the outcomes for patients.

DMacA: We’ve spoken about the advances of science and integration with Personal Care in an abstract form. From a personal point of view, you’ve had your own experience of the science of medicine and the advances of science in medicine. How has it been as a patient?

MD: it’s been unbelievable.  I got a nasty dose of stage four melanoma.  As a family doctor I’ve had had one particular patient who I looked after who was in his 40s and, while we thought a lipoma, it was a melanoma and he died within three months.  We all had those patients.  And there was with a phenomenal family physician who came round on a Saturday lunchtime, after I’d had the CT on the Friday,  and said “okay you’ve got a brain tumor, I’m going to put you on dexamethasone, a bit of Ativan and we’re gonna get you sorted, and I’m going to look after you”

She knew the three things to say to me that would sort of calm me down. “now I’m going to look after you”. Its so important to hear that as a patient.  However much you might know about medicine and genetics and science, having someone actually touch you and say I’m going to look after you is critical.

Then, just to take the therapeutic option out of your hands in that critical moment and just say “I’m going to give you dexamethasone and a bit of Ativan”

And then to say, ” and I’m going to organize a CT” or whatever the test is and “you’ll get the test done this week, and you can call me on my cell if you don’t get the appointment”  So, you now know what’s going to happen, you know what you’re going to take, and you know someone’s going to care for you. I think that was, for me, as important as the amazing immunotherapy that I got.  I got some stunning tests,  MRIs, gamma knife, which is radiotherapy to the brain down to the nearest millimeter that destroyed the brain tumor, and then immunotherapy every two weeks for two years. It’s unbelievable, it just kicked my immune system back into recognizing the eight lesions in my chest and saying no we don’t want those. And now I have CTS of my chest that say “no lesions seen,  no metastasis” And to be on the other end of that incredible science, where T cells that have stopped reacting have been turned on. We’re talking amazing science.  And, to be a recipient of that Nobel prize winning work is truly incredible.  Medicine has gone so far and this science,  and inclusion of science ,while still retaining that personal element of – I’m going to look after you. And my oncologist has been exactly the same- if you have any problems- and, it’s not just doctor to doctor -they do this for everyone.  They’re really concerned for the individual and what they’re going through, and help them through that journey.  Mine had its ups and downs but I’m now over two years post, so my survival prognosis is back to that of a 68 year old which is truly remarkable. It is an unbelievable thing to be on the end of that sort of treatment.

DMacA: As I listened, I thought that’s a wonderful description of the integration of the Nobel Prize winning science with the kindness and care of a GP.  Martin, thank you very much for sharing your academic journey, your scientific journey and, of course, your personal journey.  As always it’s a pleasure to talk to you. Thank you.