Marvin Rallison Oral History - Transcript

Transcript of interview with Marvin Rallison, M.D. ('57) conducted on August 13, 2015. This oral history is one in a series of interviews conducted by the Office of Alumni Affairs and the Eccles Health Sciences Library to document the history of the University of Utah School of Medicine.

Marvin Rallison 19 August 2015 *Interviewee was allowed to make changes to the transcript so the recording and transcript may not match* TODAY IS AUGUST 13TH, 2015. AND THIS IS THE START OF AN INTERVIEW WITH DR. MARV RALLISON AT HIS HOME IN SALT LAKE CITY. THIS IS PART TWO OF OUR INTERVIEW. MY NAME IS HEIDI GREENBERG, AND I WILL BE THE INTERVIEWER. THIS INTERVIEW IS BEING DONE IN CONNECTION WITH THE HISTORY OF THE UNIVERSITY OF UTAH SCHOOL OF MEDICINE. WE'LL BE TALKING ABOUT DR. ROLLISON'S RECOLLECTION OF HIS TIME IN MEDICAL SCHOOL AND HIS CAREER. HG: Dr. Rallison, you talked about your practice at the Salt Lake Clinic, from 1961 to '63. So where did you go from there? MR: Well, while I was at the Salt Lake Clinic I had a bit of an interest in endocrinology. And they had - at the medical school, which was at the county hospital, they didn't have an endocrinologist. Al [Done ?] was sort of being the endocrinologist. And he was running a diabetes clinic that he didn't really want to. And he invited me to come down while I was at the Salt Lake Clinic one day a week and work at the diabetes clinic. I'd actually had some good training at Minnesota in diabetes with [Etzwiler 1:26], Donald [Etzwiler ?], who later became the president of the American Diabetes Association. So I was interested in Diabetes. And I was happy to run the clinic. But there came a point where at the Salt Lake Clinic they said, "Either you choose to follow your endocrinology business, or you better stay at the clinic because you're falling behind. You're not putting money on the books." And about that time, Gene [Layhee ?], who was chair of the Department of Pediatrics, said, "We don't have an endocrinologist. We need one. Would you mind getting some extra training? And we'll hold a position open for you if you will." And he referred me to Frank Tyler at the medical school. And so I called my mentor in Minnesota, Bob [Ulstrom ?]. He said, "Marv, you've had all the good training in pediatrics that you need. And you've spent some time on our metabolic ward so I know you're interested in 1 Marvin Rallison 19 August 2015 endocrinology. So get your training from Frank Tyler. He's a good man. And you'll make it into a pediatric endocrinology while you get the training from Frank Tyler." So that's what I did. I signed up for an NIH-sponsored fellowship in endocrinology, with Frank Tyler. And so I was trained as an internist. But all the while I was being trained as an internist, I was taking them with me on rounds on kids. So I was learning all about the endocrine problems in kids while I was learning the endocrine problems. HG: And how prevalent was diabetes? I mean, did you see a lot of diabetes in kids at that point? Was that the most prevalent? MR: Well, that was probably the most common endocrine problem that pediatric endocrinologists deal with, yes. But during my training with Frank Tyler, I got two good leads. First of all, Lindy [Kumagi ?] was working with Frank Tyler at the VA hospital. And he and I became interested in a family with hypothyroidism and goiter. And so he said, "We ought to really do the benchwork on finding out what their inborn error of metabolism is." So he introduced me to paper chromatography, which used a big, round, tall jar and put paper strips on it and then put the material you were trying to test on it and see how fast it moved down the paper. And apparently, the T4, which is tetraiodothyronine, moves at a different rate than triiodothyronine, than diiodothyronine, and monoiodothyronine, all of which are the ways in which the body makes thyroxin, which is the major hormone. And doing that, we determined that they had a block in the formation of thyroxin. And it was rather - it was the only benchwork I really did very well. But that got me, later, into the American Thyroid Association because it was really nice, original work, separating out the components of the thyroxin. And that got me interested in thyroid disease. 2 Marvin Rallison 19 August 2015 And later, when I finished my training with Dr. Tyler, I was involved in a thyroid nodule study, which I'll talk about in a minute. But the other thing that happened during my training with Dr. Tyler was that Dr. [Perkoff ?], working with Dr. Tyler also at the VA hospital, had me doing diabetes studies on veterans. And while he was doing that, he was contacted by a lady named Charlotte [Edlin ?], who had a daughter with diabetes, who wanted to go to a girls camp but couldn't because she had diabetes. And she asked Dr. [Perkoff ?], who was taking care of the daughter - she was about a 13-year-old. She said, "Can you do something about this?" And he said, "I don't know. I've got a fellow working with me, Virgil Parker" - who was a medical student along with me. And he was now on an NIH diabetes fellowship. And his wife, Jackie Parker, was a registered dietician. And the two of them sort of made up a metabolic unit at the VA hospital, studying diabetes. And [Perkoff ?] said, "I'll check with Virgil and see if we can work something out." As a matter of fact, at that same time, they had another patient named Frank Robles, who was a young adult Burroughs Wellcome representative. And he had diabetes. And the three of them put their heads together and decided that they would - they would try and find a camp for this daughter of Charlotte [Edlin ?]. So they contacted the YMCA, and the YMCA, which used Camp Roger up in Uintas, said, "Well, we could put together a program if you'd provide the medical care." So they put - they got a nurse, a dietician, a physician, and a pharmacist, and gathered up 17 young diabetics, including Charlotte [Edlin's ?] daughter, and started a camp for diabetics. And I came in just as they'd finished the first year. I was assigned to the VA hospital labs to do my work. And they invited me to join them the second year. And that was the beginning of Camp UTADA. And I've been in it for 50 years now. 3 Marvin Rallison 19 August 2015 HG: Right. So you were - let's see. What year was this started? MR: This would've been 1962, '63. HG: Okay. And is it still going? MR: Yeah. Oh, yeah. Instead of 17, the next year there were 35, when I joined them. And it's now about 500 kids that they take care of summer and winter. That's really a going concern. And that's sort of been my main interest; with the ADA, and I received a national award. HG: "Outstanding Contribution to Camping and Diabetes Award." That's great. MR: Took a while to get it all together. But that got me started on diabetes. And the thyroid business came as a consequence of the government. There was concern that thyroid cancer was getting more common and especially in places like Utah, which was downwind from the radiation - from the atomic bomb testing. They thought maybe the I-131 that was created from the atomic bomb testing was getting into the food chain and was causing thyroid cancers in young people in Utah. Because the - I'm trying to remember what the - Bureau of Radiological Health was what it was called. And they had done a sort of a records study and decided that young women in their twenties had more thyroid cancer than expected nationwide so that they said, "I think we ought to really study the appearance of thyroid nodules in young people who may have been in exposed to the fallout radiation, the I-131 in the fallout radiation. So they contacted our health department, and they said, "Well, we've got a new endocrinologist, an Assistant Professor of Pediatrics, who's just starting his career. Why don't you grab him?" So I became the go-fer. Go-fer this and go-fer that. So that they said, "We'll put together an examination team in Maryland, and you put together one in Utah. And we'll send them down to Washington County, Utah, and Graham County, Arizona, so that we'll have two cohorts: one that might've been exposed in Utah, and one that clearly wasn't exposed in 4 Marvin Rallison 19 August 2015 southeastern Arizona. And so we started that. And in 1965, '66, and '67, our teams examined all of the school-age children from the sixth grade to the 12th grade in Washington County and Graham County. And about the second year, they added Lincoln County, Nevada, as well. So that we, altogether, were looking at over 5,000 youngsters each fall. And then they decided that they were actually finding some things. They sent me down to check what the examination teams were finding. And sure enough, I agreed with them that there were about 70 kids in Utah that had palpable nodules of some sort, and not quite as many in Arizona but about 50 of them in Arizona that we were a little bit concerned about. But mostly concerned about the ones from Utah. So they said, "Well, we'll get some experts. And in the spring, you study these kids from Utah and present them to this panel of experts that we put together." And what they did was they went to the American Thyroid Association and said, "Who do you have that we could use?" And it turns out they spoke to Ed [Rall 15:06], who was chair of the NIH division on endocrinology and gastrointestinal diseases. And he said, "I've got two friends in the ATA, in the American Thyroid Association. All of us have, at one time or another, been at the Mayo Clinic." But [Brown Dobbins 15:35] from Cleveland, a surgeon; Ray Keating, from Mayo, an internist and a really, really good thyroidologist; and Ed [Rall ?], who was sort of the research guru at the NIH for thyroid diseases; the three of them volunteered to come out to Utah and take a look at the kids that we'd chosen. And they examined, in the spring of - it would've been spring of '66, they showed up. And there were two interesting things that came out of this. One is that both Dobbins and Keating were avid birders and easterners. And they said, "The only reason we're coming to Utah is because it would allow us to examine western birds, and they're different." So they came out and spent some time birding before they showed up at the high school for examinations. 5 Marvin Rallison 19 August 2015 HG: That's a good way to get them here [laughs]. MR: Yes. It's a double-edged sword. It worked very well. And I was a little bit baffled by all this because I was not a birder at that point. But they were pretty avid about it. And as they looked over the 70 kids from Utah and the 50 from Arizona, they said, "You know, there's really something here." They picked about 12 from Utah. They said, "I think these need to be studied." And they picked about six from Arizona and said, "And we probably ought to study some from both places." So they sent them up to the University of Utah. And Larry Stevens and I - well, we studied them, sort of with Frank Tyler's help. And there was a radiologist named Chamberlin, who liked to use a fast-acting radio-iodine, either 132I or 124I and the 124I was too long acting. So we used 132I or technetium, actually, to study the thyroids. And so we did scans on them to identify the nodules. And on a few of them, we even decided to do surgery. And see, that would've been fall of - winter of '65, '66. HG: So, did that conclusion satisfy everyone? Was that the end of the study? MR: Not quite. There were quite a few people, who on hearing they were living downwind from the atom bomb testing, thought many of their ailments might be related to exposure of fallout radiation. Labeled "downwinders", they complained enough to get the attention of the National Cancer Institute and push them to re-examine levels of radiation to which "downwinders" might have been exposed. Although most of the fallout radiation was radio-iodines (131-I, 124-I, etc), which affect mainly thyroids, there were other problems seen in the survivors of the atom bombs which destroyed Hiroshima and Nagasaki, so the National Cancer Institute suggested looking at leukemia and bone cancers as well as thyroid neoplasms. HG: So, how were you involved in that phase of the study? 6 Marvin Rallison 19 August 2015 MR: With the help of epidemiologists we were able to track down two-thirds of our Phase I cohorts and arrange for re-examination in 1985-87 of the 3,000 + young adults by P.As and N.P.s. This time, with more sophisticated studies, including needle biopsies, so we were able to show changes in thyroid disease which took place between adolescence and young adulthood. Not surprisingly, we found more thyroid disease in the 30-year old young adults. Simple goiter, common in adolescents, was 3 or 4 times as common in young adults. Thyroiditis was 10 times as prevalent in young adults and we were able to show that thyroiditis in one-third of our Phase I subjects became normal, one-third remained unchanged, and only one-third progressed to hypothyroidism…new information and my best research in thyroid disease in adolescence. HG: What about thyroid cancers? Did you find any? MR: Thyroid nodules were also 10 times as common in young adult as in teenagers. We found 10 new thyroid cancers in the young adults; 5 Utah/Nevada and 5 from Arizona. Most of the other nodules were "colloid goiters" or adenomas (i.e. benign thyroid growths/neoplasms) So when our epidemiology friends tried to tie nodular thyroid disease to radiation exposure, they found only about 15% of our subjects had been exposed to 250 rads of radiation or higher and there were too few cases of thyroid cancer to show a relationship. So they combined cancers and adenomas to show a "trend" that fallout radiation may have an effect on thyroids of young people - certainly not the "epidemic of thyroid cancers suspected by the "downwinders". HG: Was this like the radiation exposure in Nagasaki? MR: No, not really. Most of the victims of the Nagasaki bomb were vaporized or incinerated by the direct radiation or immense heat. Survivors were located behind a hill, which shielded them from some of the fierce initial heat. They had a variety of blood, bone, G.I. and skin problems. Our exposure to radiation was more like what was found in the Marshall Islands, near the Bikini 7 Marvin Rallison 19 August 2015 Atoll bomb tests. The exposed inhabitants of the Marshall Islands developed thyroid nodules, some of which were thought to be malignant…often associated with hypothyroidism and growth problems in children. HG: Were you involved in the Marshall Island study? MR: No, but in 1995, I was invited to attend a symposium in Nagasaki, commemorating the 50th Anniversary of the Nagasaki bombing and the effects of the radiation exposure on survivors. The theme of the symposium was to draw attention to the devastation of atomic explosions and a plea to never again use nuclear weapons against humans. I was asked to summarize our results of exams of those affected by the testing of nuclear devices in Nevada. Our experience was minimal compared to the devastation wrought by the bombing of Nagasaki. HG: Was Camp UTADA your main diabetes activity? MR: It was the springboard that got me working with diabetics, but along with camp UTADA, we organized diabetes clinics at Primary Hospital. It was a team effort, involving nurse educators, dietitians, social workers and pharmacists…a real team approach to care of diabetics. HG: Is a team still used in the care of diabetics, or is the care streamlined now? MR: It's very difficult for a single pediatrician to provide the kind of care that a young diabetic needs, though there were some, such as Stan Child, who did a very commendable job. Eventually we were able to organize team-based outreach clinics from Logan to St. George and into Idaho and Wyoming, based on team care we developed through the IRMP. HG: What is the IRMP? MR: That was the Intermountain Regional Medical Program, led by Hilman Castle, which allowed us to set up an in-house diabetes team teaching program in the Holy Cross Nurses Residence, to which patients and a family member (spouse, mother, sibling) were admitted for a 8 Marvin Rallison 19 August 2015 week of intensive teaching by doctors, nurses, dietitians, social workers or pharmacists and participation in activities, such as dinner at a restaurant, a movie or time in the gym. HG: You mean the patient and family member stayed in a room at the nurse's residence for the entire week? Day and night? MR: Yes, so they got a very full teaching, learning experience and got me interested in working out guidelines for better teaching practices…which led to my participation in the National Diabetes Commission study as workshop chairman for establishing educational guidelines for diabetes training...the NDC study introduced pump therapy to achieve tight control of the blood sugar in diabetes. HG: What changes have you seen in the care of young diabetics? Do they use insulin pumps? MR: Yes, many use either multiple insulin injections (short and long acting insulins) or insulin pumps to inject insulin as needed. The sophistication is such that the pump can calculate the need for extra insulin based on the blood sugar level, programed into the pump. HG: Does the pump measure the blood sugar, as well as deliver the insulin? MR: Not yet, but there is intensive study to try to develop a "closed loop" system, in which an instrument, attached to the pump measures the blood sugar at frequent intervals, allowing the pump to deliver insulin as needed…just like the pancreas. In fact, many researchers are trying to harvest islet cells, alter their antigenicity and insert them into a diabetic to act as an artificial pancreas…hoping they can avoid islet cell destruction by the patient's auto-immune reaction. HG: Were you involved in that research? MR: No, only as an observer. My interest tended toward education and teaching young diabetics to live with their disease…control, but not cure! But I did try to keep abreast of new means of control, with lead to my real contribution to diabetes. In 1988, a senior medical student and I 9 Marvin Rallison 19 August 2015 studied a family with three of five children who experienced infancy-onset insulin-dependent diabetes coupled with a bone disorder called multiple epiphyseal dysplasia. This was reported in the Journal of Pediatrics and became known as the Wolcott-Rallison syndrome. HG: Wow! So that was a new type of diabetes? MR: Yes, the genetics of the combination of diabetes and bone disease (plus kidney failure, anemia and some intellectual challenges) has not been fully discovered…though I have presented results of the study at ISPAD meetings. HG: What is ISPAD? MR: An International Study Group for Pediatric and Adolescent Diabetes. I was host for the first meeting in the United States in St. George, Utah. Later attended meetings in Oslo, Graz (Austria), Linkoping (Sweden), Zurich, Tel Aviv and Berlin. HG: Goodness! Sounds like diabetes made a world traveler of you…Were there other areas of interest that have involved you outside of the University? MR: Yes…early in my endocrine studies I was intrigued by the many faces of growth problems in children, and in the 1970s while I was finishing the first phase of my thyroid studies and getting involved in diabetes big time, human growth hormone was introduced in a limited way for treatment of short stature related to pituitary deficiency. HG: Where did they get the human growth hormone? MR: Initially, it had to be harvested from the pituitary glands by pathologists at autopsies. In the initial phase of the study, our goal was to determine how effective harvested human growth would be in hypopituitary patients and what side effects might occur. Unfortunately, it wasn't possible in those early trials to be sure the hGH was absolutely pure…there could be contaminants, the worst of which was a virus which caused Kreuzfeld-Jakob disease, a 10 Marvin Rallison 19 August 2015 degenerative neurologic disease resulting in death. One of my patients received hGH from a contaminated batch and at age 40, while teaching an elementary school, developed neurologic symptoms of Kreuzfeld-Jakob disease and died. HG: How sad! Did you learn how to purify the growth hormone? Or did you have to give up the study? MR: We were learning to purify the harvest hGH, but we eventually gave up harvesting hGH from cadavers when it became possible to form hGH genetically, free of contaminants. All hGH was initially genetically engineered by a company called Genentech; they enlisted pediatric endocrinologists to test their product to verify its safety and effectiveness in treating various forms of growth failure. HG: So you were able to study hGH safely? And cheaply? MR: Safely, but not cheaply! Genentech did provide hGH for study, but charged whatever insurance would allow for all uses outside a study. But we were able to study hGH use in patients with hypopituitarism, Turner syndrome, Prader-Willi syndrome and some rate growth failure syndromes. It was during this period I contracted t write a book on Growth Problems in Children. HG: You wrote a book about growth hormone? How difficult was that? MR: It wasn't just about growth hormone…it was a general reference text entitled: "Growth Disorders in Infants, Children and Adolescents." Included were chapters on normal growth and development of infants and children with standards; growth patterns in adolescents, with illustrations of levels of maturity; methods of evaluation of growth patterns and hormone measurements related to growth; and illustrated descriptions of growth disorders of infancy, children, and adolescent. 11 Marvin Rallison 19 August 2015 HG: That's impressive! So, how has your interest in growth problems contributed to your career in endocrinology at the University? MR: Well, it began in small ways with "growth clinics" sponsored by Genentech, called PERM. HG: What is PERM? MR: Stand for Pediatric Endocrinologists of the Rocky Mountains and included colleagues from Utah, Colorado, Arizona, and New Mexico. It started in Colorado but was rotated through each of the four states, providing an informal venue to discuss research and practice issues and continues to be popular. The 2018 session will be held in Utah in Park City. HG: So, now that you are retired, how do you think your training at the University of Utah School of Medicine influenced your career in medicine? MR: Well, I started out as a clinician, practicing general pediatrics, influenced by both my experiences in medical school and my pediatric training in Minnesota. My interest in endocrinology, beginning in Minnesota, but flowering in Utah, enhanced by participation in Camp UTADA and then solidified by participation in thyroid nodule study brought me into an academic career in which I enjoyed clinical research, teaching (in classroom and clinics) and clinical endocrinology. By participation in all three arms of academia, I was able to climb the academic ladder and retire as Professor Emeritus. HG: So how would you rate the University of Utah School of Medicine as an academic center of excellence? MR: I received very good training at the Utah and Minnesota and enjoyed my career in academic medicine at Utah; as an academic center of excellence, I believe Utah ranks well with any of the western schools with which I have been acquainted. 12 Marvin Rallison 19 August 2015 ©Spencer S. Eccles Health Sciences Library, University of Utah 13