• diagnostic research

Alvan R Feinstein did not write extensively about the history of medicine. But in the 20th century he himself was a protagonist. He influenced the very meaning of clinical research. He eschewed the concept of the patient as merely the ultimate beneficiary of clinical research and closed the loop by demonstrating that the best clinical data were provided by the patient. Feinstein died on 25 October 2001 at the age of 75. He had been a physician for almost 50 years and a teacher of medical sciences for at least 45. He was a distinguished graduate of the University of Chicago in mathematics (BSc 1947; MSc, 1948) and medicine (MD, 1952). He progressed to specialisation and related academic pursuits at Yale and Columbia universities as well as the Rockefeller Institute. He was Board Certified in Internal Medicine (1955). He published his first paper as a medical student in 1951 and his 410th this year. He wrote six major textbooks, finishing the last one, Principles of medical statistics, just before he died. At the time of his death he was the Sterling Professor Medicine and Epidemiology, the highest academic distinction at Yale University.

He became different things to those of us who came to know him well. We all cherished him as a teacher. Many who became close, particularly three and four decades ago, have become teachers of medicine ourselves. This article, a brief recognition of his life and his work is personal but I am sure it is not unique. I will dwell on his life as a teacher, a teacher's teacher and an innovator. Feinstein founded clinical epidemiology. Inspired by his first major book Clinical Judgment and taught by him, I became a clinical epidemiologist and have taught the subject for 31 years. At his memorial service on 14 November 2001, I was fascinated to learn that Professor Ralph I Horwitz, a distinguished investigator and teacher of clinical epidemiology and now Chairman of the Department of Medicine at Yale University, enrolled to become one his earliest pupils simply because of Clinical Judgment. In contrast, I had already been trapped in a Yale programme when I was transformed by the book.

In respect to the mastery needed to meet challenges he took on or were thrust upon him and to attain his greatest achievements Feinstein generally taught himself. I have seen him “dug in” both in his office at the university and in his study at home. I would hear him react in muttered grumbles such as “Why doesn't anybody know anything about this?” I evolved from perplexity to an understanding of his way of doing things. If anyone had indeed taught and written cogently about a subject or a viewpoint important to him he would not be struggling with it. If it proved to be poorly understood and poorly communicated, yet important and relevant, he would learn all he could about it, synthesise the concepts, add his ideas and then write himself about a new insight, a new principle, a mistaken “mainstream myth”, or a better analysis. When he found nothing at all he would start from “scratch”.

Most of us who are medical doctors, especially those in teaching centres, manage to find a colleague in our community who has the reputation of being the “doctor's doctor”. The doctor's doctor could be an outstanding GP, an unusually wise internist or a sharp and understanding gynaecologist. The specialty doesn't particularly matter; the person does. As I reflected and thought about Alvan since he died, the importance of a lateral shift has grown in my mind. He started influencing me when I was already embarked on a career of teaching and research. He was this teacher's teacher. I have confirmed these last two months that a good number of prestigious academics in many universities also see him as I do. Alvan would have wanted more about these ideas; he would insist on verifiable quantitative evidence. Feinstein wrote 410 primary peer reviewed articles. Just six of his earlier “disciples” have written 853 (N Boyd, M Charlson, J Esdaile, R Horwitz, M Kramer, W Spitzer). I will mention that two of his intellectual grandchildren (of different “parents”) have already written 162 primary articles. As a Canadian, I am proud to report that in this country alone his former students have been recognised by the Canadian Institutes of Health Research as Distinguished Scientist in four cases, Senior Investigator in nine, and 16 awards were granted as Investigator. Just in the past 10 years the financial resources for clinical, epidemiological and health care research raised from various sources by his Canadian students has exceeded 13 million dollars. His 1993 Gairdner Foundation International Award (Canada) was given in large measure due to the enormous influence exerted directly and indirectly in nearly all faculties of medicine across the country. Nevertheless, the vast majority of his 200 lifetime fellows and trainees are American. I cannot give the details in this brief paper, but it is easy to demonstrate that what they have accomplished as clinical scientists in the United States overwhelmingly exceeds the attainments in any other country. Such evidence further validates the notion that Feinstein catalised historical medical innovation in the last century. He received countless awards for such activities. In my view, the one he deserved most was given by The American College of Physicians in 1998: Distinguished Teacher Award “ . . .in recognition of the ennobling qualities of a great teacher who has achieved leadership in the field of medical education.”

Feinstein taught equally well orally and in writing. He loved the English language. He loved language. I used to call him a logophile (which he liked). He created many words during his writing career. Colleagues have had their favourite “Feinstein word” either in adulation or in disagreement. I will cite only three, ordered according to acceptance: comorbidity¹ (most accepted); protopathic² (gaining acceptance); and trohoc,³ most rejected (even by me).

I struggled for some days about the way to communicate other attributes of Alvan that would be coherent with his stellar role as a teacher's teacher. At his memorial service I listened in awe to the brief and comprehensive summary of those qualities shared by our friend Jack L Paradise, academic paediatrician from Pittsburgh University. Jack and Alvan had been close for 60 years since they were both 15 years old. Alvan used to brag warmly and often about his oldest and best friend. This is what Dr Paradise told us (personal communication):

A number of descriptors come to mind: Brilliant. Articulate. Erudite. Incisive. Original. Witty. Entertaining. Engaging. Charming. Flamboyant. Irreverent. Iconoclastic. When called for, outrageous. Other traits may have been less obvious, but were apparent to those who knew him well: Warm. Caring. Concerned. Empathic. Generous. Loyal. Devoted. Loving.

Nobody could have expressed it nearly as well. Those who really knew Alvan agree wholeheartedly with Jack.

Four years ago, he expressed what was for me a surprising statement. I had been chatting with Alvan about personal and family matters. When the conversation dwelt briefly on his wife Lilli he said, “I am blissfully happy. She makes me happy.” In 33 years I had never heard him say or write anything like that. He had not been known to make such statements. He was a positive and constructive man but his demeanour and speech were typically those of a dour Scot or Finn. It was obvious immediately to me that Lilli had become the greatest and the most deserved reward he ever experienced. Alvan knew how to convey that in two sentences. This article is also a personal tribute to Lilli.

We grieve the loss of our beloved giant, our great teacher and example. We will help keep the spirit of Alvan R Feinstein alive by diligent inquiry, by clear writing and by teaching as he taught us to teach.