Highlights

Q and A with Dr. Gary Fleisher, MD

Dr. Fleisher

Gary Fleisher, MD, is the chairman of the Department of Medicine, physician-in-chief and pediatrician-in-chief at Children’s Hospital Boston. He treats patients in the Emergency Department and inpatient medical units. Dr. Fleisher graduated from Jefferson Medical College in 1973 and trained in pediatrics and pediatric infectious diseases at the Children’s Hospital of Philadelphia until 1979. Subsequently, he achieved board certification in Pediatrics, Emergency Medicine, Pediatric Emergency Medicine and Pediatric Infectious Diseases. He remained on the faculty at the University of Pennsylvania until 1986, at which point he came to Children’s Hospital Boston to be the chief of the Division of Emergency Medicine. In 2002, Dr. Fleisher was appointed the chair of the department. We had the rare opportunity to sit down with Dr. Fleisher and ask him a few questions related to innovation at Children’s.

How has innovation impacted your own career as a clinician?

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I guess I would look at innovation in my career in 2 parts: innovations I have been involved with and then those that have changed my practice. In terms of innovations in which I have played a direct role, I think the major one for me is the fact that I practice pediatric emergency medicine, which was not a specialty when I graduated medical school and was not a specialty when I finished residency. I was privileged to be able to start the first program in emergency pediatric medicine, begin the first fellowship, write the first text book, edit the first journal, work with the American Board of Pediatrics to start the certification process, initiate several lines of research in the field and train many individuals who have gone far beyond me in terms of research and innovation.

If you look at the impact of innovation on a disease specific basis in pediatric emergency medicine, there are a few areas that have changed dramatically. When I started out in the field, I had a lecture I put together on life threatening infections. It covered four infections, three of which for all practical purposes no longer occur, either because we have vaccines to prevent them or we have developed ways to detect them in their incipient stages and prevent the evolution into full blown disease. One is bacterial meningitis, which has gone from 30,000–40,000 cases a year down to 1,000–2,000 cases. Initially through some of the work I did, we were able to identify children who had bacteria in their bloodstream that were at risk for developing meningitis and then brought forth therapies to prevent that process from occurring.

The whole field of single dose therapies for infections has emerged over the last two decades. Some of the studies were my own but many researchers and clinicians have contributed. For a number of the diseases we treated, we had to write a prescription and depend upon the patient to follow a therapeutic regimen for a week to 10 days. Now we have single dose antibiotics that we give orally or intravenously and eradicate some of these diseases within the confines of a single visit.

The whole field of antiviral therapy has grown up in the past 25-30 years. Diseases such as herpes simplex encephalitis, neonatal herpes simplex, and varicella (chicken pox), which were untreatable when I started, are now managed with appropriate antiviral agents. There are a whole group of patients to which we used to have to say to the parents, “we can only provide supportive therapy,” where now we have specific treatments we can offer to them. Some of these drugs are life saving and, if not life saving, at least prevent most major complications.

What are the current trends and future directions that you see in pediatric medicine and what do you think their impact will be on clinical practice?

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I think there are several trends going on and they are driven by some very basic factors. One is the explosion of knowledge—no one physician can know everything about pediatrics, and even in a subspecialty—gastroenterology, cardiology, or endocrinology—no one physician can have full command of all the different disease processes and treatments. We are increasingly seeing complex patients with multiple medical problems who are technology dependent—much more than when I began 30 years ago. In order to really care for the full spectrum of children, you have to have a number of subspecialists with varying expertise in each discipline.

The other factor is the increase in technology. More and more imaging modalities and interventional approaches are coming online. These are expensive and you have to have physicians who are trained in utilizing the technology or interpreting the data that comes from its application. In the long term, I think these two factors, the expansion of the knowledge base and the march of technological innovation, are producing a centralization of pediatric care.

In modern medicine, we really depend on the people around us and the milieu. Clinical care has really become much more of a team sport. For instance in my practice, I rely heavily on the nurses, on colleagues in other disciplines, on the facilities, and on additional services such as radiology and the laboratory, and I think Children’s provides the ideal environment. Particularly I think the nursing staff is absolutely superb.

How does this team culture inspire discoveries and innovations that improve healthcare?

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In a team based environment, collaboration and crosstalk is often a source of innovation. Every individual on a team can bounce ideas off others and sometimes the perspective of an individual in another discipline really stimulates you to think creatively about issues that are more germane to the work that you do.

Children’s has committed resources to support technology development and translational research. In your opinion, why are these important to support?

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Children’s has long supported innovation and all of us, both on the administration and medical/scientific side of the equation, have considered the pursuit of innovation to be paramount. Having said that, it is becoming even more important—actually essential—that we provide the resources. We need to have the proper spectrum of specialists and subspecialists and the right technologies to take care of children with complex diseases. If we are going to do our best job, we have got to be innovative. We are going to continue to be faced with situations for which there are no treatments and with families who have exhausted the resources at other institutions. The onus falls on us to be innovative and provide new forms of care. I think it is a clinical imperative. It is somewhat paradoxical that there have been so many advances in medicine yet so many diseases remain where we have no effective treatments or the treatments are only partially satisfactory. And I think that is our challenge—to try to innovate in those areas and advance the therapies to the next stage.

In addition to licensing inventions at Children’s, TIDO works to establish collaborations with company partners around our research and clinics. How does collaborating with corporate partners support Children’s mission?

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In academic medicine and academic pediatrics, we develop ideas and often perform the initial research and some of the testing in the process of advancing innovations. We seldom, or even perhaps never, bring a product all the way to market. So partnership with industry, with the pharmaceutical companies or medical device makers, is essential for us to fulfill our mission. I have been involved with several stages of that process and found collaboration key to complete all the steps and to offer children new therapies. Moving forward, I think it is an avenue we have to pursue more extensively if we want to innovate to the point of bringing more new treatments to the patients.

What advice would you give to clinicians, particularly those beginning their careers, about the importance of innovation to clinical care?

I would advise trainees and junior faculty not to be satisfied with the status quo. Always be thinking about and looking for new approaches to treat diseases.

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