In 1968, I was near the end of my training in renal medicine, at University of Texas SW Medical school,Dallas, and it was time to plan my next few years. I had a job, back at the school I graduated from – University of Chicago – stationed at Michael Reese Hospital. I had some money to build a program and no idea of what to do.
The picture is from 1968 and shows the Chair of Medicine meeting with house staff. I was not in this picture.
William Yeats and Unity of Being
My last teacher, Donald Seldin, Chair of Medicine at UT SW got me reading Yeats. Among his ideas this one seems somehow very important to me. Life has a way of scattering one’s energies so not a lot gets accomplished. I vowed to follow him and stand against diffusion. That was just a vague impulse, but it came to dominate my behavior.
Patient Care vs Research
Like all new faculty in medicine, I was expected to practice medicine and perform research, and of these I knew it was research that would decide my fate, for promotion depended on it however much patient care and teaching were lauded as a special grace.
But research and medical practice do not go well together, the one in a lab the other in a clinic or on the hospital floors, the one all thought the other all action.
Commonplace shrewdness said simply this: Do research, let the clinical go as much as you can. Fine doctors sans research become galley slaves at best, or just let go when their contracts run out. That was then of course, things are more balanced now, I think, though I am too old to know for sure.
So there I was, no real plan of my own, not in love with my options, for I wanted research and medicine both, and had no more idea how to meld them than those who had come before me. Unity of Being seems impossible. Out of this the kidney stone program rose up, part inspiration, large part impractical dreaming of an inexperienced man trying to find his way.
Patient Care = Research
The idea came like all ideas do, instant.
Study my patients. Discover new things that might help them or at least let everyone understand them better. Use what’s new for their care, so they will fare better and all manner of things will be well.
Ride the Comet
At the same moment I thought how computers were rising up like a comet, would soon dominate the world, and I would make computers central to my patient care and my research. I would ride the comet.
Specifically, I thought to put all the data from every patient into computer records so they could be analyzed in a new way – electronically as opposed to the slow tedious hand methods I grew up with. I imagined patterns of abnormalities, and outcomes of treatment would be easier to document, as examples. I also imagined that perhaps computers could eventually be programmed to analyze the data from a new patient and give back a diagnosis and treatment plan, permitting us to scale what we found so many physicians could benefit their patients.
The idea of studying the patients who come for care was not at all novel. For example Fuller Albright had done the same concerning stone formers in the 1940’s. Likewise, using what one discovers for the patients who served as subjects is an ancient medical hope. So the original idea that led to the program was new only to me. When I presented them to my teachers, however, they did not recognize this fact nor point me to Albright – that was unfortunate as he was an ideal model.
Computers were mammoth at that time, and not available to any but the rarest medical scientists, so I was bold to assume I could employ them. Their use to store and analyze data is pure empirical science, more or less asking ‘what is there’ in the mass of information. No hypotheses, only the general idea that if we knew what patients looked like in numbers those benefits would emerge.
Using computers to transmit medical diagnosis and treatment recommendations to a broad community was visionary and hopelessly early. It is an example of fashioning a new form of medical education, one delivered at point of care and specific to the patient in the room. Eventually we did this by forming a company, but that was decades later,
In 1968, research I had done on the hydrazine rocket fuels – USAF years – appeared in print. I had left the USAF in June 1967 to begin my Nephrology training, so these papers trailed into my new life. This lag between the doing and the appearance in print of research makes it hard to associate papers with real life, but the alternative – putting papers into the years the work was done – is even worse.
Pat Korty was my chief lab tech in the USAF, Howe and Goetting were airmen lab assistants. Bitter was my boss – a Major. Scott, was my friend, a scientist trained at Harvard and, like me, doing mandatory military service during the Viet Nam conflict.
The solo author paper was the last of a series of mathematical modeling studies that began years before with an interest in renograms and early hemodialysis. I have not included these earlier years here.
Korty P, Coe FL. The effects of hydrazine upon the concentrations of free amino acids of plasma and urine. J Pharmacol Exp Ther. 1968;160(1):212-216.
Coe FL, Korty PR. The effect of hydrazine upon renal excretion of sodium, potassium and water. J Pharmacol Exp Ther. 1968;161(1):183-190.
Coe FL, Howe RW, Goetting JA. Mechanism of monomethylhydrazine excretion by the mammalian kidney. J Pharmacol Exp Ther. 1968;163(1):216-221.
Clark DA, Bairrington JD, Bitter HL, et al. Pharmacology and toxicology of propellant hydrazines. Aeromed Rev. 1968;11:1-126.
Farquhar JK, Scott WN, Coe FL. Hexose monophosphate shunt activity in compensatory renal hypertrophy. Proc Soc Exp Biol Med. 1968;129(3):809-812. doi:10.3181/00379727-129-33430
Coe FL. Mean life in steady-state populations. J Theor Biol. 1968;18(2):171-180. doi:10.1016/0022-5193(68)90159-8