By Dr. Nidhi Garg
During ACEP, I had immense pleasure to sit down with Dr. Cairns and learn from him regarding his views and opinions regarding research in Emergency Medicine. Charles B. Cairns, MD, FACEP, FAHA, is a nationally recognized leader, researcher and educator in emergency medicine and critical care. He has served in university leadership roles in medical education and curriculum reform, clinical research, health information technology strategy, university system campus security, faculty practice, hospital operations and health-care system strategic planning.
Dr. Cairns’ research interests include the host response to acute infections, asthma, trauma and cardiac resuscitation and regionalization of emergency and critical care,
preparedness and response. Dr. Cairns has published more than 200 articles, commentaries and reviews. His work has appeared in such prestigious journals as the New England Journal of Medicine, Annals of Emergency Medicine, Academic Emergency Medicine, Critical Care Medicine, Circulation, Journal of Trauma, Academic Medicine and Science Translational Medicine. He has received numerous awards and honors, including the Emergency Medicine Foundation (EMF) Established Investigator Award, the American College of Emergency Physicians (ACEP) Outstanding Contribution in Research Award and the 2014 John Marx Leadership Award, the highest award of the Society for Academic Emergency Medicine (SAEM).
Dr. Cairns has served in leadership positions in emergency and critical care medicine organizations, including the EMF Board of Trustees , co-chair of the ACEP-SAEM Research Working Group, SAEM program chair, ACEP Research Committee chair, ACEP Scientific Review Committee chair, the Leadership Committee for the American Heart Association Council on Cardiopulmonary and Critical Care, the Steering Committee for the Critical Care Societies Collaborative Task Force on Critical Care Research, the Coordination Committee for the NIH National Asthma Education and Prevention Program and as a co-chair of the NIH Roundtables on Emergency Research. He has served on the editorial boards of Academic Emergency Medicine, the Annals of Emergency Medicine and Critical Care Medicine.
Dr. Cairns is director of the U.S. Critical Illness and Injury Trials Group and the founding principal investigator (PI) of the National Collaborative for Bio-preparedness. He also recently served as the PI of the National Regionalization of Emergency Medical Care Services Framework Project funded by the National Quality Forum and as co-PI the project on the Rapid Assessment of Acute Illness and Injury to Enhance the U.S. Response to Public Health Emergencies.
Dr. Cairns was in Washington DC for only a day but he was very kind to take an hour to speak to me for our research section members.
GARG: Thanks Dr. Cairns for taking the time to interview with us. Our opening question, which we ask to the most researchers, is how did you ended up in the research world? What was your first project?
CAIRNS: Well it’s a pleasure to be here Dr. Garg. Both of my parents were researchers and so I was exposed to research at a pretty young age. My first research position was during my freshman year in college at the National Institute of Environmental Health Sciences (NIEHS) near where I grew up in Chapel Hill, North Carolina.
GARG: Oh, wow!
CAIRNS: I was a student researcher studying metabolism and spending a lot of time trying to understand how mitochondria worked. There, I got a very good understanding about basic science research. The role of studying a particular organelle and how it all plays out in the larger system of an organism. Of course, the NIH is a huge organization and a great place to learn. I then translated that learning into trauma research and looked a lot of issues in trauma resuscitations, starting with head injury and hemorrhagic shock and then looking at just the fundamentals of how oxygen gets delivered, how it’s consumed, and what are the implications of that on inflammation. Later, I went into cardiac research and spent a lot of time looking directly at the interaction between inflammation and metabolism. Further, started applying research skills to other conditions like asthma, respiratory distress, and infections. I then spent a fair amount of time looking at sepsis with that same kind of fundamental spark of studying metabolism; how we use oxygen and how it affects the body. Now we do research that’s pretty sophisticated and on a large-scale when studying systems and metabolomics. That’s the whole new science. We started applying it to emergent conditions like sepsis, trauma, and will hopefully broaden it to areas of what we now call precision medicine. So, we have a large scale extension to population as we were just were awarded the precision medicine initiative grant at the University of Arizona. It’s really a pleasure to take a key role in that study because we can start looking at not just a thousand people, but tens of thousands of people – we are planning on enrolling a hundred and fifty thousand people in Arizona and a million people over the country.
GARG: Wow. So that’s very cool. I’m going to ask you a little bit more.
GARG: What was your timeline? How did you get started and how did one thing lead to another? Please shed light on your initial phases and some of the difficulties were.
CAIRNS: That’s a great question. So I was in college when I started doing research at NIEHS and then I joined a trauma surgery lab at the University of North Carolina. At the same time, a group at Duke University was studying something new called near-infrared spectroscopy and had just discovered it as a new way to look at oxygen delivery and mitochondrial metabolism. So the idea was, how can we actually use that to better understand first basic issues in physiology? Then, I started pushing how to use it to understand pathophysiology, particularly the pathophysiology of shock, hemorrhage and how we might apply this concepts to brain injury. It is rewarding to see that the same sort of technology is now being used clinically today. I literally was working with the inventor of that technology Frans Jöbsis at Duke after he had recently discovered it and was one of the first to use experimentally (and eventually, clinically). That kind of translation was fabulous. In medical school, I had the benefit of being named a Holderness Medical Fellowship at the University of North Carolina which enabled me to do research throughout my medical school career.
GARG: I see. So it was not through a MD/PhD program, because that’s where medical students think that they can do research.
CAIRNS: I had been recruited to the MD/PhD program, but frankly, my mentor had convinced me that I had already published enough papers that I didn’t need the PhD. He thought what I needed to do was to apply that research to medicine so that was my charge (it’s just the way it is when you’re 22 years old). Then you flash forward to how I made the decision to go into Emergency Medicine. In 1985 there weren’t many emergency medicine programs and neither UNC or Duke had one. In fact, there were so few - and very few doing research - that despite the fact that the dean, and my mentor, and everyone else wanted me to go do either surgery or neurosurgery, I ended up going into emergency medicine because of another student in our laboratory, Herb Garrison.
GARG: We can get that. So the name of the mentor who uh
CAIRNS: My mentor was a trauma surgeon at UNC, Herbert Proctor, and was kind of a pioneering trauma surgeon who was really interested in understanding these fundamental issues. So we were doing things that were at the very forefront of artificial blood and how it might be used in the brain. We were taking a look at some of these new models including hypothermia and how it might be used for resuscitations. I was really pleased to be in his laboratory as well as the Duke laboratory of Frans Jöbsis at Duke, the same time. But then, I met Herb Garrison who was a medical student along with me at UNC. Herb had a vision that emergency medicine was the future. He had been a paramedic and was studying cardiac resuscitation in our lab. Herb convinced me over the summer to go into emergency medicine. Herb eventually went on to the University of Pittsburgh emergency medicine residency program. He was one of the first in emergency medicine to be named a Robert Wood Johnson Clinical Scholars and he is now a leader at East Carolina University and a Vice-President of Medical Affairs at Vidant. I chose to go to Los Angeles and trained at Harbor UCLA Medical Center with Jim Niemann who was really interested in some of the basic approaches to cardiac resuscitation and understanding how blood flow occurred during CPR to support metabolism. I worked in Jim’s lab and ended up doing a fellowship there. I think I was one of the first Emergency Medicine Foundation research fellows and that was valuable because it gave me resources and time to pursue research after my residency training. I then got recruited to specifically continue metabolic research in a really large trauma research lab at the University of Colorado in Denver where I spent 13 years. I was able to explore across multiple dimensions of trauma and resuscitation but frankly go deeper and deeper into the basic science of metabolism.
GARG: So during this time in your younger years, post-residency, did you get enough protected time? Or, were you working clinically a lot? These are some of the real time problems researchers are faced with these days.
CAIRNS: I absolutely agree with protected time as a challenge. That’s why it was so critical to have the support of the Emergency Medicine Foundation early in my career. The Emergency Medicine Foundation paid for my research fellowship, it paid for my career development award, giving me protected time at Harbor-UCLA, and I was able to leverage that work when I moved to the University of Colorado. Ironically, they had a different philosophy in Colorado those days and that was that you worked a full shift clinical load and do your research in addition to that.
GARG: Oh, wow.
GARG: When you say full shift clinical load I know this may be before the work hour rules were in effect for residents. What were those hours?
CAIRNS: Well, you know it was a totally different world. I remember, we once got audited by Medicare when I was working at Harbor UCLA during my year as faculty there and turned in a work card that was 120 hours one week.
GARG: Oh, wow!
CAIRNS: Of course, Harbor was clinically demanding. There were a lot of educational opportunities, and I loved it all in addition to research. In Colorado, I started off doing full time clinical but then after two years in the lab, we got a really large NIH grant called a P-50 Award and it became a trauma center. I was the PI of the metabolic core so that gave me protected time for the next 13 years as baseline. That led me to get my own independent funding with the NIH as well as a career development award from the American Heart Association. Hence, I developed some really interesting collaborations with other people from different specialties.
GARG: Wow, that’s a splendid career I would say.
CAIRNS: Well, I think the key thing that I learned, and you asked about, are about the challenges in transitions.
CAIRNS: I think that first transition is trying to figure out how you meld clinical training and research. There are two ways to do it. I came in with a fair amount of research experience and so finding a clinical home where they valued research was critical. I think the second one was finding the mentor, someone who’s been there, who understands how to be successful and will support you whether you need resources for preliminary data, or need some help on honing your ideas. Or, frankly just help in getting your ideas out whether they are presentations or publications. And then finally, I think the last piece is finding an area of passion, that you can just weave through. I think that those are kind of the guiding principles on all of these transitions, almost independent of resources. But at some point, if you’re not getting enough resources, you’re not going to have the freedom you need to pursue research and it’s going to be very difficult to sustain a research career in the long-term.
GARG: I see. So that’s very valuable advice and you know I’m very realistic, too. So I’m going to ask you, when you look back at your career -what’s one peak moment, one moment where you thought that I had really overcome the challenges, and was a magical moment of your career?
CAIRNS: I think the first time I got my first NIH grant.
GARG: Which one was that? What grant?
CAIRNS: It was an R-1 equivalent to our center grant. In addition to running the metabolic core, which was a core component of the center grant, I then got my own independent project grant to study mitochondrial function.
CAIRNS: And that’s when I knew I really had been successful. We were publishing papers in really high-level journals and we were really making some fundamental discoveries that I still get re-print requests on even now nearly 20 years later.
GARG: Wow. So and my next question is in contrast to that. What was your pivotal moment when you felt like you did everything under the sun and you failed? Because people don’t talk about their failures.
GARG: So, if you don’t mind.
CAIRNS: Sure, I think one of the biggest challenges is getting a series of grant rejections. I remember during that time I was successful in career development awards. I had core lab funding, which was great, but trying to get that first independent award was very difficult. There weren’t very many emergency physicians who had received one and honestly, some of the critiques would criticize the field of emergency medicine in addition to me as a candidate and the science of my project.
GARG: Oh, wow.
CAIRNS: So that’s when you wonder, is this the right pathway? But again my mentors at the University of Colorado, Ani Banerjee and Alden Harkin, the chair of surgery, who ran the lab were really supportive and gave me a lot of support and guidance. In fact they, as well as Fred and Gener Moore in Denver were always so supportive of not only what I was doing, but the area of research I was pursuing. To have it pay off was great in terms of a grant but more importantly, those kinds of things are now routinely being clinically monitored, driving clinical trials and it’s interesting to see if it’ll come to its fruition in the age of precision medicine.
GARG: That’s wonderful. Thanks for sharing that with us. My last question is about having a fulfilling research career and transitioning into a dean. So, the question is multifold. What led you to do that? How was the transition? How do you feel now?
CAIRNS: One of the more interesting moves I made in my career was to leave Colorado and a very productive and very comfortable academic environment and go to Duke University where emergency medicine was really a brand new entity. I joined the Duke Clinical Research Institute (DCRI) and one of the reasons I did that is because I really wanted to have a bigger impact on populations. I’m not sure at that point the DCRI really understood the opportunity in acute and emergency care despite having run the GUSTO trial and a bunch of really impactful heart attack trials. I learned then that big research is big science. It was a quite fulfilling experience not only because I got to work on large trials, a hundred and fifty countries, tens of thousands of patients, but I also learned that there are opportunities to really move a field forward. I learned a lot from my mentor there Robert Califf who was director of the DCRI at the time and eventually became the FDA commissioner. I also learned that research in isolation isn’t innovation. Innovation is research with impact on outcomes. I think it was at the DCRI I began to realize that there are large opportunities for innovation. At that point, I got recruited to UNC in Chapel Hill, where I had grown up and gone to medical school, and offered the chance to become the Chair of Emergency Medicine, succeeding Judy Tintinalli. It was great to be a chair at UNC at that time. We had an explosion of research, education and training while I was there. In addition, the field of emergency medicine evolved quickly, we were able to establish the NIH Office of Emergency Care Research through the remarkable efforts of ACEP and the joint research working group between ACEP and SAEM that worked tirelessly to get that done. Then the University of Arizona started asking me to be their dean. I thought maybe I could think on a bigger scale beyond the specialty of emergency medicine and go to a larger institution and see if we can cross multiple specialties and take on the population of a state. I wanted to see if we could evolve that kind of discovery, technology development, model implementation, and apply it to a broad population with impact. So I see it as a natural continuum of my career and a natural continuation of my quest to take clinical experience and research and turn it into innovation and impact. It is certainly a different role but we still do our research and I still practice and teach emergency medicine. I’m still funded about thirty percent of my time to research, but obviously there’s a lot of team-based research consistently with this broad population of precision medicine initiative and taking a look at bio-surveillance and bio-preparedness in large-scale clinical trials.
GARG: Sometimes there is a notion in academics that researchers have limited career flexibility options and therefore people often resist entering into a research career. People tend to think that they will be saturated to one position and it may compartmentalize their career. What are your thoughts?
CAIRNS: You know that’s a really interesting point because I think there is a danger that research can become so focused that is marginalized or even siloed off from clinical emergency medicine. I think that would be an extraordinary mistake, emergency medicine has always been a dynamic, evolving field. We’ve always been responsive to external environments and health system needs. Frankly, the need for emergency medicine in the clinical house of medicine was based on filling the gap of acute care and then expanding upon that opportunity to serve populations and geographies. Now, that’s so clear that our scale of course is beyond individual patients and is actually populations of patients. When you think about the EMS system and you think about the integrated systems of care in trauma, cardiac and stroke and you begin to realize the impact that we have as a group is extraordinary. Not just on day to day issues of patients but across the whole spectrum of populations, all diseases, all conditions, all ages, all genders. You begin to realize what impact the field can be. But in order to be as successful as we become we have to be on top of innovation. If we don’t, then we will be subject to the direction and influences of others. Yet if we continue to innovate, then we will be able to provide that direction, hold that leadership position, and frankly shape our own future. I honestly think the only way to do this is through evidence, through sound methodologies and a profound understanding of what we are trying to achieve, how to best do it and learning from any mistakes along the way. I think that’s what research is. I believe that researchers are frankly well positioned to the advantage of it. So I turn it around and say, if you don’t have research as part of your agenda you’re not going to be successful. That’s at the clinical level, academic level, and even system level.
GARG: That’s amazing
CAIRNS: So in other words, if you want a research career the way to go is to just keep thinking big. Thinking about impact and use your skills, talents and background and make it happen.
GARG: That’s amazing advice and perspective as well for research members. That was my last question. But I’m going to ask one more thing!
CAIRNS: Cool! Sure.
GARG: What’s your view on current status of EM residents regarding research during residency?
CAIRNS: You know, Emergency Medicine is an interesting field. I was in it in at such an early stage in its development that I sought out research experience with particular people and programs. I think there should always be an avenue for that to happen. You know the mandated resident research activity is one that I’ve struggled with. I haven’t had to do that at anywhere that I’ve been. I’ve had a wonderful career in Emergency Medicine between Harbor-UCLA , University of Colorado and Denver Health, Duke, UNC and now Arizona. I didn’t have that mandated resident research experience, but the program coupled this with a philosophy that every resident who wanted to do research should have that ability. It’s important to make sure we have appropriate mentors, many of whom are outside of emergency medicine and can enabled them to successfully pursue that passion. Rather than a mandated resident research experience, I have established research fellowships in all those places because I think that research fellowships are just critical to the knowledge and experience necessary to be successful in transitioning to a faculty position. So, while I think that residency experience is important, it’s not sufficient for a research career. I think that providing fellowship experiences would pave the way for the development of many independently funded, successful faculty members of emergency medicine and serve as mentors to residents, as well as students, who are interested in Emergency Medicine research.
GARG: Thank you. That was great insight. Thanks for your time.
CAIRNS: Oh, my pleasure and honor, thank you. Thank you for doing this Dr. Garg. I really appreciate what you are doing for our field.
GARG: Thank you.