Nobel Prizes in Medicine: are clinicians out of fashion?
Authors: Hutan Ashrafian, Vanash M Patel, Petros Skapinakis, Thanos Athanasiou
Journal: Journal of the Royal Society of Medicine (2011)

The Nobel Prize in Physiology or Medicine is widely considered to be the highest accolade in modern healthcare. Once a year, the Nobel Assembly at the Karolinska Institutet in Sweden announce a prize to recognize the significant medical contribution of up to three healthcare researchers. This annual tradition is associated with other Nobel Prizes including those for Physics, Chemistry, Economics, Literature and Peace. As a result, the reputation of the Nobel Prize now exists beyond purely scientific circles but offers a broader impact associated with the global political and media interest that it generates.

The influence of this prize in scientific circles is now immense and its winners go on to achieve numerous other scientific accolades, worldwide fame, and both academic and political authority. The prize offers its recipients the honour of being venerated with ‘hero worship’1 and a lifelong admiration irrespective of subsequent scientific or political accomplishment.

Despite a predictable level of controversy that is derived from ‘deserving’ losers (Robert Gallo for the discovery of the Human Immunodeficiency Virus, Rosalind Franklin for Deoxyribonucleic acid, Salvador Moncada for Nitric Oxide, Albert Schatz for Streptomycin, Roy Calne for transplantation and Raymond Damadian for Magnetic Resonance Imaging) and ‘unworthy’ winners (exemplified by the well-publicized disagreement between the winners of the 1923 prize for the discovery of insulin), the Nobel Prize is generally considered as a positive force in modern science. This is because it is considered to inspire1 the next generation of scientist to innovate future discoveries and inventions. As result, the Nobel Prize has been immune to broader scrutiny or objective examination.

We studied the overall trend in prizes and awardees to note that the proportion of clinicians receiving this award has been diminishing year on year. In the past 100 years of awards to medical scientists (excluding war periods where Nobel Prizes were not awarded to individuals); over 79% of Nobel Prizes in the first 30 years were awarded to clinicians. This contrasts significantly with the last 30 years, where only 26% of prizes have been awarded to clinicians (Figure 1).



Figure 1

Trend in the proportion of Nobel Prizes awarded to clinicians



In the modern era, the majority of prizes have been awarded for elucidating fundamental biological mechanisms that includes cellular, subcellular and molecular findings. Breakthroughs in basic biological mechanisms constitute a significant component of medical discovery; however there is a discernable deficiency in the translation of scientific discoveries to widespread clinical use. Although the proportion of highly promising basic science research that translates to constructive clinical applications is approximately 1%,2 prizes such as the Nobel primarily focus on particular themes without consideration of their subsequent impact.

Clinicians provide the day-to-day care for millions of patients worldwide but also offer the direct translation of countless basic scientific advances. Molecular and cellular healthcare endeavours predictably suffer from inappropriate focus in the absence of clinical input. Recently a publication in one of the world's premier journals proposed a complex biomedical technique where elephant eggs would have to be transplanted into mice to grow mature follicles in a tissue environment where the mouse's pituitary gland should be removed and subjected to an elephant hormonal cycle by external hormone therapy.3 The authors had not consulted a clinician to identify that the whole step could have been replaced by a feasible, well-established and less demanding surgical laparoscopic technique that is used in modern bariatric surgery.4 There are also many examples where clinicians have not been recognized despite contributing to discoveries that were subsequently awarded a Nobel Prize. One example includes the 2010 Nobel Prize for the development of human in vitro fertilization (IVF) therapy by the British reproduction biologist Robert Edwards. His discoveries would not have been made clinically significant without the pioneering efforts of Patrick Steptoe who worked as a gynaecologist in a non-academic hospital.5 Steptoe was able to apply the novel concepts of laparoscopy to produce the world's first IVF baby although he received no formal recognition for his work in the subsequent Nobel Prize for the development of IVF.

The Nobel Committee who select each year's winner, openly assert that they select recipients based on the criteria laid forth in Alfred Nobel's original Will written in 1895.6 Here he states two fundamental conditions: (1) ‘prizes to those who, during the preceding year, shall have conferred the greatest benefit on mankind’, and (2) ‘one part to the person who shall have made the most important discovery within the domain of physiology or medicine’.

Interpreting Alfred Nobel's Will is an important determining factor in awarding the prize.1 The definitions of ‘most important discovery’ and ‘greatest benefit’ have evidently focused on molecular science. While it is unquestionable and unanimously agreed that discoveries such as the structure of deoxyribonucleic acid (DNA)7 entirely fulfils these criteria, other examples of greatest benefit or most important discovery could include the global eradication of smallpox8 or the global screening and treatment for phenylketonuria (PKU),9 respectively. Both examples include healthcare circumstances were clinicians had a central role in saving millions of lives without Nobel Prize recognition.

Measuring the impact of medical research10 includes elements such as the quality of healthcare provision, clinical innovation, accrual of best evidence and clinical leadership.11 Although a large proportion of research translation12 and impact is delivered by clinicians, the proportion of prizes they receive has significantly dropped. The 1970–1979 period demonstrates a temporary reversal of this trend and may represent an era when the selection criteria for prizes was more considerate to clinical contribution. As the Nobel Prize in Medicine is arguably the most prestigious award in healthcare, it could be expanded to also reward individuals who deliver translational innovation and global impact irrespective of the scientific methodology that they apply.