By all accounts, Halsted R. Holman, MD, Guggenhime professor of medicine, emeritus, at Stanford Medical School (Calif.), has been a major presence in several different scientific arenas. From a stellar career as a laboratory immunologist, he went on to become chair of medicine when Stanford Medical School relocated to Palo Alto in 1960 and help found and shape the Robert Wood Johnson Clinical Scholars Program. He has been a visionary thinker about patient outcomes measures and the need for a better form of care for patients with chronic disease.
Through each of his major career paths, Dr. Holman has manifested his talent for gathering other gifted and motivated scientists, and for encouraging their collaborations and creativity. The results have been far reaching—not just for rheumatology, but also for how we view chronic diseases in general. Vibeke Strand, MD, clinical professor of medicine in the division of immunology at Stanford University in Palo Alto, has known Dr. Holman for over 15 years. “He has really made tremendous contributions to rheumatology,” she says, “first as an immunologist and then in terms of patient-reported outcome measures and self-help.”
Previously, Dr. Kunkel had studied liver disease and liver function, but had decided to change the direction of his investigations to the rheumatic diseases. That decision, says Dr. Holman, was based on the emergence of two new major techniques for laboratory investigation: preparative electrophoresis and ultracentrifugation, which allowed the separation and identification of serum proteins. Dr. Kunkel was interested in using these techniques to elucidate the origins of two laboratory tests: the rheumatoid factor and the lupus erythematosus (LE) cell.
Dr. Holman recalls that his mentor said, “I’ll take rheumatoid arthritis and you take lupus.” Just like that, Dr. Holman embarked on a line of investigation that ultimately led to identification of anti-nuclear autoantibodies.
Those were exciting times in immunology, when new investigations were disproving the formerly entrenched beliefs that autoantibody formation was not possible. In those times, Dr. Holman encountered the first of many examples in his career of the way in which conceptual changes occur—the “paradigm shift” first explicated by Thomas Kuhn.
The Move to “the Farm”
When Stanford University moved its medical school from San Francisco to Palo Alto (“the farm”), another opportunity arose for him.
“They wanted a clinical faculty that knew both clinical medicine and emerging scientific medicine,” he recalls. “The older, good clinicians didn’t know the science, so they had to seek younger people for the faculty. I got the job because I could do both. It opened up the opportunity to build the department out of young people.”
Edward D. Harris, Jr., MD, the George DeForest Barnett professor emeritus at Stanford University, has been a colleague of Dr. Holman’s since the early 1970s. “One of his most important contributions was recruiting so many very fine clinical scientists to Stanford,” says Dr. Harris, “and then encouraging them to be leaders as well as investigators and clinical teachers. That was pretty unusual at the time.”
Paradigm Shifts
Dr. Holman continued to publish multiple studies on lupus throughout the 1960s, but he was also known for his thoughtful publications on the wider relationships between science, medicine, and society.2
The promise of the earlier discoveries of the anti-nuclear autoantibody, however, was not yielding the hoped-for breakthroughs. “It was becoming clear to us, by about 1970, that we were not going to be able to establish a direct linkage between autoantibodies and disease genesis,” says Dr. Holman.
During the same time period, several treatments for rheumatic diseases—notably, corticosteroids and the early NSAIDs—were allowing people to live much longer with their disease. A different construct for viewing medical treatment was needed.
“The rheumatic diseases were becoming among the first prototypic chronic diseases in which patients continued to live with their handicap,” says Dr. Holman. “We could not use the old standards [i.e., the acute disease model of cure or death] to figure out how well we were affecting patients. We had to come up with new systems for measuring outcome.” He and James Fries, MD, professor of medicine at Stanford, began to analyze long-term data in patients with rheumatic disease. These were the beginnings of the American Rheumatism Association Medical Information System (ARAMIS).
Nurturing the Next Leaders
The 1970s were a fertile time in medical education. The decade’s receptiveness to new ideas and drive to test established ones were hallmarks of the Robert Wood Johnson Clinical Scholars Program, set up to train clinician scientists to become health service researchers in disciplines such as epidemiology, sociology, economics, and community medicine. The genesis for the Clinical Scholars Program occurred when Dr. Holman and four colleagues expressed dissatisfaction with current medical education at a conference they had all attended.
“We began to realize that new ideas, outside of conventional biomedicine and clinical medicine, had to be added to the curriculum,” says Dr. Holman. “These were disciplines that interacted with patients’ sociological, legal, psychological, and economic consequences of chronic disease.”
Initial talks with the Carnegie Foundation and the Robert Wood Johnson Foundation led to the Clinical Scholars Program, designed to train graduate physicians in relevant disciplines that were not in biomedicine or clinical care, but could inform their future approach to medicine. Dr. Holman helped run the joint Stanford–University of California, San Francisco (UCSF) Clinical Scholars Program.
Matthew H. Liang, MD, MPH, director of special projects at Robert B. Brigham Arthritis and Musculoskeletal Diseases Clinical Research Center, professor of medicine at Harvard Medical School, and professor of health policy and management at Harvard School of Public Health in Boston, was one of the beneficiaries of the Clinical Scholars Program at Stanford.
“At the time, the Clinical Scholars Program was brilliant—and it still has cachet,” says Dr. Liang. He recalls his time as a Clinical Scholar as a period when “great people had a laissez-faire approach, but helped people feel free to make errors and to really pursue their dreams. A lot of my ideas [about outcomes measures] started about that time … Dr. Holman was a tremendous influence on all of us. He could really ask and appreciate hard questions, and I think we [former Clinical Scholars] have tried to do that in our subsequent lives—to pass on the example he gave to us.”
Dr. Liang recalls his first presentation at a weekly Friday seminar, when he began to formulate his ideas about the functional consequences of chronic disease. According to Dr. Liang, Dr. Holman’s first response was, “Who cares?”
Dr. Liang laughs and says, “He wasn’t saying ‘who cares’ in a negative way—he was just pushing us to defend ourselves.”
Patients Key to Good Care
What emerged from the experience with chronic rheumatic diseases and from the Clinical Scholars Program, says Dr. Holman “was an understanding that helping patients with chronic disease wasn’t just a question of bringing to bear some sociological, psychological, or economic knowledge. Rather, since we couldn’t cure chronic disease, we needed to develop another approach to clinical practice.”
It had also become clear to Dr. Holman and his colleagues, as they dealt with their rheumatic disease patients, that their patients were the key to good care. “They were really the principal caretakers because they had to live with the disease, take the medications, change their behaviors, and adjust to the consequences [of their disease] socially, economically, and emotionally.”
Shortly thereafter Dr. Holman; Stanford Shoor, MD, adjunct clinical professor of medicine and rheumatology at Stanford; and others organized the Midpeninsula Health Service, a health service that sought to involve patients through supervised self care and make them the physicians’ partners. Then, new federal funding for multipurpose arthritis centers created an opportunity to further their work with patient education. The funding required an educational research component, recalls Kate Lorig, RN, DrPH, director of the Stanford Patient Education Research Center and professor of medicine at Stanford. In 1979, she was a doctoral candidate at UC Berkeley and applied to conduct the patient education research.
Dr. Lorig initially turned the job down. Her expertise at the time was in maternal and child health, and she felt the project would be too time-consuming while pursuing her thesis. Dr. Holman called her to encourage her to take the job. “I told him … he needed to know I wasn’t terribly interested in arthritis and that I was probably going to go elsewhere in two years.”
That was 29 years ago. Since the initial research project, the two have collaborated on the Arthritis Self-Management Program and the Chronic Disease Self-Management Program, and contributed to developing the Chronic Care Model of practice created by the Improving Chronic Illness Care program of the Robert Wood Johnson Foundation.3
Current Concerns
Dr. Holman continues his work at Stanford, helping to introduce the Chronic Care Model into medical practices in California. He voices frustration that the model has not been adequately addressed in medical education, but sees some progress with a recent experimental program set up through the Association of American Medical Colleges (AAMC) to include the Chronic Care Model in resident training at 22 medical colleges. As a result of that success, he is participating in a new program of the AAMC and the California Health Care Foundation to install the Chronic Care Model in California medical schools. In his time off, Dr. Holman enjoys playing tennis, spending time with family and friends, and the challenges and rewards of parenting (he and his wife Diana have a son in college).
A Gift for Mentoring
“I think a great deal of [Dr. Holman’s] work has been done through others—guiding them, giving his insight,” says Dr. Lorig. “I’ve heard Hal talk about giving people all the freedom they will take and all the support that they need. And I was a very good example of that. I have always truly appreciated that he was willing to work with a non-physician and a woman. Very few physicians would take seriously a doctoral student who was a nurse. It wasn’t commonplace [even in 1979], and I think that we tend to forget that today. Again, it’s another example that he was well, well before his time.”
Dr. Liang also praises Dr. Holman’s teaching style. “When we presented patients to him as fellows, he would do a piece of the exam or history, and you could see that his style was really collaborative with patients,” he says.
Dr. Liang—who wrote Dr. Holman’s festschrift in collaboration with Drs. Shoor, Lorig, and Harold Goldberg, MD, professor of medicine at Stanford—notes that Dr. Holman never backs away from socially relevant causes. “He is unbelievable, and you’d never know it just by talking to him,” says Dr. Liang. “He’s essentially a modest person.”
Gretchen Henkel writes the “Metrics in Rheumatology” series.
References
- Liang MH, Goldberg HI, Shoor S, Lorig K. A festschrift in honor of Halsted R. Holman, MD: Action research in health care. Medical Care. 2002;40(4):SII-1-II-2.
- Holman HR. Thoughts on future relationships between physicians, medical students and citizens. Walter Bauer Memorial Lecture. Arthritis Rheum. 1965;8:183.
- Lorig K, Laurin J, Holman HR. Arthritis self-management: a study of the effectiveness of patient education for the elderly. Gerontologist. 1984;24:455.
