Prof
R.N. Foley
Associate Professor of Medicine,
Memorial University,
St. John's Newfoundland,
Canada
Zoccali:
You worked in Canada, Britain, USA. Could you tell us the reason why you decided
to move from Ireland to Canada, and then to Britain then to USA?
Foley: Well, I did my basic internal medicine training in Ireland,
which amounted to 4 years. I like all the rotations, but nephrology in particular
had grabbed my interest, and I decided that was going to be my career. The reasons
for this included stimulating mentors, the weird and wonderful nature of the
subject matter, the thrill of acute nephrology, and especially the fact that,
clinically, it depended so much on physiology and biochemistry. The fact that
numerical reasoning was involved also attracted me.
At this time, the Irish system was not really set up for specialty training.
Basically, deciding to do a specialty was the same as deciding to do emigrate.
As always, word of mouth and serendipity played a large part in the process.
My friend and mentor, Dr Patrick Parfrey, was looking for a nephrology fellow
at Memorial University in Saint John’s, Newfoundland, Canada, and a casual
conversation with the Professor of Medicine in Cork led to us hooking up. Two
other Cork graduates, John Harnett and Brendan Barrett had gone before me, and
the set up was getting a reputation as good place (if a little cold and windy)
to train. So, with a heavy heart, leaving family and friends in Ireland, and
equally, the excitement of anticipation, I headed west. Newfoundland was great
in all respects. The clinical training was excellent, and I was surrounded with
colleagues that were incredibly dedicated to clinical research. At the time
I left, I could hardly turn on a computer. Soon enough, I was getting messages
from the University about all the computing time I was eating up. I had always
loved mathematics, and clinical epidemiology, data-mining and clinical trials
had become my passion.
I had always hoped to return to Ireland, and I had a romantic notion that I
would be able to do what I was doing in Newfoundland in Ireland. As time went
on, this was getting improbable, as my interest in research was growing, and
new jobs in Ireland were rare. I had been in Newfoundland for 9 years, and was
ready for new challenges when another conversation with a good friend led to
a job offer in Hope Hospital, Salford, Manchester. So, I quickly added things
up (a season ticket to Old Trafford might have been mentioned, and I would be
a mere 30 miles from my beloved, and eternally-frustrating Liverpool football
club). They were very keen on clinical research, I would get protected time,
great colleagues, proximity to family in Ireland. Why not? So, off again, leaving
great friends in Newfoundland. England was everything I expected, and I settled
in well.
Throughout this time I had been a co-investigator in the USRDS Cardiovascular
Special Study, centred in Minneapolis. In addition I was working latterly as
a co-editor for AJKD. I was busy on both the clinical and data-fronts, but very
happy…..another job-offer ‘Rob how would you like to come work with
us at Hennepin, with us full-time, working with the Medicare claims data?’
For someone who likes data, this was very attractive. Also, what would you leave
a place where you very happy, after only 3 years. Anyway, here I am!
Zoccali:
Your main research interest is in cardiovascular complications of chronic renal
diseases. This is now a rather rewarding research area but till 10 years ago
or so this was considered a rather awkward theme. What led you to be interested
in this topic?
Foley: The growth in this area has been incredible. For me
it started accidentally, and in many senses, I was in the right place at the
right time. Pat Parfrey had been running a very long-term cohort study of dialysis
patients, which was about to finish, and was ready for analysis, involving a
lot of echocardiograms, and a lot of clinical data. Before this I had done a
project involving how accurately statistical modelling could predict those who
would die in the first 6 months of dialysis. I found that I really liked data
analysis and clinical epidemiology, even though I remembered that I found these
subjects unexciting in medical school. So, I was more or less left alone with
all this data to analyse. I found out quickly that ESRD a mixed blessing for
outcome studies… many events, but incredible admixture of disease already
developed, disease now developing and disease yet to develop. I also became
convinced that intervention should be early in CKD, but equally convinced that
intervention trials should also target those on dialysis and those receiving
transplants. In addition, it became very clear that traditional cardiovascular
risk factors and interventions should be rigorous, but would not be enough in
these patients.
Zoccali:
The cost of clinical trials is tantalising. Do you think that interventions
trials in patients with chronic renal diseases should be embedded in larger
cardiovascular trials?
Foley: I truly believe this. The HOPE trial is a good example
of this. We have seen that many trials that excluded those with creatinines
above 2.0 mg/dl, typically. Yet, even within these studies the subset with mild-to-moderate
CKD have provided useful information to the nephrology community. The CARE statin
trial is a good example of this. It was almost by accident that the benefit
in CKD was shown. As you say cost is a major issue. A lot of the cost of clinical
trials is driven by logistics. Embedding a CKD arm is a great idea, but the
CKD arm should be powered adequately as an independent research question. Bearing
in mind that cardiovascular events probably occur more frequently in the CKD
arm, and the fact that a pre-existing logistic system is being used, the extra
cost in the current era is probably marginal. Underpinning all of this is the
fact that CKD is common, which has become very clear. This fact needs to be
disseminated to the non-nephrological community.
Zoccali:
Do you feel that clinical epidemiology is still not properly valued in medical
training and in academic career paths in Britain and more generally in Europe?
Foley: This is a tricky one. Probably not. Funding issues and
institutional academic status will almost mean that there is competition with
basic science, which is a pity, as they should complement and enhance each other
beautifully, as with the convergence between clinical epidemiology and molecular
genetics. My own perception is that basic science is always seen as ‘science’
in Europe whereas clinical epidemiology is not always. For example in Britain,
it is common to use the term ‘audit’, with the connotation that
no scientific research is involved. Clinical trials are seen as legitimate science.
It is always instructive to see how interested triallists (I am one of these
too!) get interested in outcomes analysis, when trials are being contemplated.
A good triallist must be a good clinical epidemiologist. This was imbued into
me in Newfoundland-you do epidemiology to pick out plausible modifiable factors-then
you do the trial. I digress! The distinction between ‘audit’ and
‘clinical epidemiology’ is, of course, non-existent. As with basic
science, there is good clinical epidemiology, and bad clinical epidemiology,
(or good and bad audit). I always say several things to people thinking that
doing outcomes research, who think it may be viewed as ‘dirty’ science,
or worse. You have to measure the size of a problem to convince anyone that
is needs to be addressed. If you are going to study an intervention, all things
being equal, you would choose one with the biggest associated risk, and for
this you have to have clinical epidemiological data. We collect and store vasts
amounts of data - Why? Is there something wrong with looking at these data,
knowing their strengths and weaknesses? The Framingham study would be called
‘audit’ by many, yet is rated, rightly, as one of the top 10 medical
scientific advances in the last century. Finally, clinical epidemiologists don’t
win Nobel prizes.
Zoccali:
For a clinical investigator which is the best way for balancing clinical and
research duties?
Foley: This is dependent on many things, like being able to
multitask, how collaborative your colleagues are, both in the hospital, and
across institutions. I personally favour having periods where clinical and research
predominate 80 or 90% or more, such as ‘research’ month, ‘clinical’
month, realising that patients come first, clinical follow up must be continuous,
and doesn’t stop and start like research and clinical months. Also, the
team needs to value and reward clinical duties, teaching, administration and
research are all equally well.
Zoccali: What were the main difficulties you encountered when
moving from British to hospitals in Canada and USA and vice versa?
Foley: The biggest problem is the fact that not all qualifications
are recognised in all countries. Moving to Canada, for example, I did a qualifying
exam for foreign graduates, an exam that is done as a pre-requisite to practice
in Canada that is normally done leaving medical school, internal medicine exams,
nephrology exams in around 2 years. Afterwards, things were similar in ways,
different in others. I did more outpatient work in England, more chronic dialysis
unit work in Canada, more hands on acute nephrology in Canada. I have yet to
clinical work in USA, so it is difficult to comment.
Zoccali:
Which is your favourite hobby.
Foley: I have many but I suppose running is number one, followed
by football. I run a lot, including marathons.
Zoccali:
Which advice would you give to a young doctor interested in renal diseases?
Foley: People will tell you that it is hard and unrewarding,
and you only deal with rare but fatal diseases. It is none of these. It is physiology
in action, and no two days are the same. You will never be bored. Also, the
progress made in all areas of nephrology is incredibly rapid, and would recommend
it to anyone who wants to keep their mind active.
