What Happens When All the Great Doctors Are Gone?

“Thought you would want to know” — that is how I learned early Saturday morning about the death of Elihu (Eli) Estey, MD, professor of medicine at University of Washington.

Eli Estey was a cancer doctor who specialized in caring for people with acute leukemia, and someone I had come to know over the last few years. He was the product of a different era. He graduated from Yale University in 1968, finished his MD at Johns Hopkins University in 1972, and came of age in oncology in the late 1970s and early 1980s.

Cancer medicine was different then. The majority of cancer research was funded by public sources and philanthropy, and the role of the biopharmaceutical industry was virtually absent. Research moved fast and chaotically. A clinical observation could rapidly transform into an investigational protocol, and paperwork and bureaucracy had not yet metastasized and sapped the strength of clinical researchers.

Professor Estey spent over 2 decades at MD Anderson Cancer Center before moving to the University of Washington in 2008. He published hundreds of articles on the stock and trade of oncology — clinical trial results and basic science experiments — but also a steady stream of curious and unique observations about risk factors, predictors, surrogates, statistical interpretations, and treatment strategies in leukemia.

A career in academic oncology was different when Professor Estey embarked on his. It was not possible to enter the field and build several spin-off companies of which you held substantial equity. It was not conceivable that you would spend 10 years at a university, and then transition to be the External Vice President of Something Important at a large pharmaceutical firm. Instead, the only carrot for the person who pursued clinical research, who remained in the academy, was to make a vital observation, contribute to a scientific debate, or refine a treatment or combination. You entered cancer medicine to do good, and were under no illusion you could stay to do well.

And that is what Eli Estey talked about most with me: the shifting nature of what it meant to be an academic physician, the changing career goals and incentives. His goal was always to apply his intellect to help people with cancer, but in the modern world that increasingly felt like the afterthought. Now the principal goal is to network, to partner, to promote (the interests of major pharmaceutical firms), and the system works to reward those collaborations.

Many adjectives have been used to describe Eli Estey: iconoclastic, skeptical, brilliant, original. All of those are true, but a friend put it more simply. His death, she wrote, is a big loss to, “people who liked common sense.” She is right of course. More than anything, that is what Eli Estey stood for: a basic and unyielding common sense in medicine. He applied it mercilessly as drug companies sought to promote costly, novel products that were no better — or only marginally so — than older, cheaper drugs. He applied it with vigor when investigators tried to pull the wool over his eyes, and get him to think a flawed, limited, broken study was good enough to change his practice.

In the years I knew him, Professor Estey frequently found himself at the microphone after the speaker. There, patiently, he asked a series of questions that often left the speaker in doubt, and the audience dazzled. Everything he said was just common sense, but boy did he know how to ask it.

Occasionally, Eli was direct with me. When I wrote an article he liked, he told me so directly, and cited the paper. But at other times, he was indirect. He often made it a point to tell me about some bit of oncology history — some example where despite pushback, often fierce pushback — someone pushed against the status quo. Eventually, I figured out why he made it a point to tell me these stories: it was his way of giving me encouragement.

Like many, I am saddened by the loss of Eli Estey, but I want to think for a minute about what happens when they are all gone. When all the Eli Estey’s are no longer with us. By that I mean when all the doctors of a certain generation who trained in medicine — who lived through unprecedented changes in American medicine as it entered the age of the medical-industrial complex, as Arnold “Bud” Relman, MD, put it in 1980, but retained their common sense — are no longer with us. What happens when they are all gone?

I fear that medicine won’t be the same. The baton will be dropped. Academic medicine will slide even further into the hands of corporate and donor interests. Freedom of inquiry and scholarship will diminish. I recently heard from a colleague who had criticized just one (!) cancer drug trial that their cancer center had advised them to take it easy, as the company had several more trials on site. More of that will come. Careers will increasingly be made by being the oral presenter on a multinational trial that the speaker didn’t conceive, didn’t analyze, and didn’t write, using slides they didn’t make. At the oral presentation, every new cancer drug will be a miracle, revolution, gamechanger, or cure, and when the lights rise, the first comment from the microphone will be, “Terrific talk, I agree.”

Eli Estey was a leukemia doctor who benefitted the lives of thousands of trainees and many more patients. He knew what he stood for and was unapologetic about it. In his honor, I am re-releasing an interview of him on my podcast Plenary Session. You can find it here or wherever you get your podcasts. Episode 4.22.

Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer.