Today’s issue of JAMA has a commentary on the meaning of translational research by Steve Woolf, one of my favorite people and someone I respect tremendously. He is concerned at how few resources are devoted to T2 (bedside to community) translation. He knows that T1 (bench to bedside) translational research is more expensive due the the infrastructure that must be supported and the crap shoot involved in such research. T1 comprises everything from histone ubiquitylation to Phase III clinical trials plus all in vitro and in vivo work in every conceivable species between. Without the T1 part of the equation, there is no T2. Plus, we need the hope made possible through and the excitement generated by T1 research.
But I work both sides of the aisle, so I understand Steve’s frustration on the T2 side. Personalized medicine to a family doc does not mean taking blood to run a genomic profile (see commentary on why not in NEJM) … it might mean automated alerts in a patient’s electronic health record regarding the need to ask about dietary salt/sodium intake, side effects from a recently prescribed drug, or Hemoglobin A1c screening; for the pharmacist, perhaps an alert that a prescription has not been filled on schedule. More difficult is how, upon learning the patient with diabetes does not routinely check blood sugar, to motivate such behavior. How to get a morbidly obese 12 year old to eat sensibly and become more active when nothing in the social environment supports adherence to this advice. How to convince politicians to ban smoking in public spaces (Viva La France!). The solutions seem so common sense that funding them does not.
T1 research keeps getting funded because it generates measurable, reproducible, statistically significant, and scientifically valid results. It succeeds, which in turn allows NIH ICs to justify their budget requests. T2 efforts all too often … do not. And they’re hard to distill into an attention-grabbing sound bite (“Impact of Medicare Part D and Racial Disparities in Treatment and Outcomes for Hypertension”). Sometimes the T2 side of the equation does come out ahead, such as NYC’s impressive success in reducing smoking rates among teens and adults (and commentary as to why Connecticut does not do as well). As the disease-of-the-month lobbies have learned, the key is to capture headlines, hearts, and then pocketbooks and budget line items. This is easier when you can say you’re funding work to cure disease XYZ than when you say you’re funding a Markov decision processes model for optimizing statin start times for patients with Type II diabetes.