William B. Schwartz, MD, 1923-2009

Article Outline

• Copyright

• 
  • View Large Image
  • Download to PowerPoint

• William B. Schwartz, MD

William B. Schwartz, MD died on March 15, 2009 in Los Angeles after a remarkable career that spanned more than 5 decades and encompassed multiple disparate disciplines including acid-base and electrolyte research, decision analysis, artificial intelligence, and health policy.

Born in Montgomery, Alabama and educated at Duke University and its medical school, he trained in internal medicine at the University of Chicago and in research in the laboratory of James Gamble at Boston Children's Hospital. His initial independent foray in research was at the Peter Bent Brigham Hospital in the laboratory of Samuel Levine, one of the nation's most distinguished clinicians. Though he started his research in cardiology, his interest in the role of the kidney in the fluid retention of congestive heart failure led him to devote the remainder of his physiologic research to the study of fluid and electrolyte metabolism and acid-base regulation. His work was immediately successful. In one of his early studies of congestive heart failure, Bill showed that sulfanilamide, then known to be a weak carbonic anhydrase inhibitor, had natriuretic properties. According to scientists at Sharp and Dohme (the predecessor to Merck & Co), this was the essential discovery that led to their subsequent development of oral diuretics.

In the early 1950s, Samuel Proger, Chief of Medicine at the institution now known as Tufts Medical Center, recruited Bill to run a “Renal and Electrolyte” service (nephrology was invented as a subspecialty years later). For the next 2 decades, with an outstanding cadre of colleagues at Harvard, Boston University, and the National Institutes of Health (NIH), dozens of American and international fellows, and with support from the NIH, Bill ran an extraordinarily productive laboratory. He made seminal contributions to the understanding of the acidosis of chronic renal disease, the colonic transport of electrolytes, the kidney's response to potassium depletion and to primary acid-base disturbances, and the integrated whole-body response to acute and chronic hypercapnia and hypocapnia. To adequately study whole-body responses, which came to be known as titration curves, he constructed a unique atmospheric chamber comprising approximately 85 square feet of floor space that made it feasible for experimental subjects to live for hours or days in rigidly controlled gas mixtures while researchers, donning masks, examined the subjects, collected samples, and made measurements. This work laid the groundwork for interpreting clinical acid-base disorders, a task that today is a routine clinical tool.

Another of Bill's early contributions in nephrology, and the one for which he is most widely recognized, is the discovery with Frederic Bartter of the syndrome of inappropriate antidiuretic hormone (ADH) secretion (SIADH). What is especially notable is that the discovery was not made by measurement of ADH (such analyses were unavailable in the mid-1950s), but on the basis of resemblance of the pathophysiologic response of 2 lung cancer patients to that of normal individuals given the exogenous hormone. (Bill often recounted with satisfaction his decision to submit this paper for publication against the advice of some of his doubting colleagues.) SIADH, which became known as the Schwartz-Bartter syndrome, is recognized in hospitals everywhere.

Working in the Schwartz laboratory was a defining experience for the 60 or so trainees fortunate enough to make the grade. The lab could serve as a model of the ideal research environment. Instruments, methods, data books, and derived calculations were impeccably kept; data were checked and independently rechecked. The integrity of the science was defended with utmost care. The same rigor attended converting studies into manuscripts. Bill was a formidable taskmaster, often insisting on writing 6, 8, 10, or more drafts at a time when retyping a draft meant starting from scratch. He often remarked that he wanted each sentence, and each paragraph to “sing”. Former fellows freely admit that it was “WBS” who taught them how to write. Notably, patients' letters to referring physicians received no less scrutiny. Yet this rigor and meticulous attention to order just provided the backdrop for Bill's favorite activities, namely delving into the nature of nature. Nothing seemed to please him more than to analyze a new set of data, to banter with a room of fellows about how the kidney reacted to a particular challenge, to constructing a comprehensive theory of acid-base regulation. Such an exercise could go on for days.

In the early 1970s, a natural progression for a division chief was to become a department chair, and Bill was eager for the chance. In 1971, he was named Physician-in-Chief of the hospital and Endicott Professor and Chairman of the Department of Medicine at Tufts University School of Medicine, thus leaving behind his wet-lab work. For a while he found satisfaction in the intellectual challenges of 2 new fields, decision analysis and artificial intelligence. By the early 1970s, neither decision analysis nor Bayesian analysis were in the clinician's lexicon, and Bill sought to change that. With others, he introduced these disciplines at conferences, published papers illustrating their use, and investigated principles that are now part of day-to-day clinical practice. With colleagues at Tufts and Massachusetts Institute of Technology (MIT), he published one of the first artificial intelligence computer programs for diagnosis and clinical disease management, and wrote how such programs might be used in patient care. Despite the intellectual attractions of these new disciplines, he found the administrative duties of running a large department “enormously frustrating” and it prevented him from doing what he liked most and was best at: understanding how a system worked, creating new insights, and testing them out. He left the chairmanship in 1976 to become a University Professor at Tufts, and in 1992 moved to Los Angeles and joined the faculty at the University of Southern California.

He found an outlet for his creative energy after a chance meeting with 2 young RAND Corporation economists in the early 1970s. Even before this encounter, however, Bill began to pay attention to broad economic issues, such as the ever-increasing federal cost of dialysis. In his characteristic fashion, he decided to develop expertise in an entirely new field—health economics and public policy—and he apprenticed himself to the 2 RAND investigators. As before, he was a quick study and in short order was publishing studies, analyses, and commentaries about an exceptional range of subjects: hospital costs, duplication of medical facilities, medical personnel needs and geographic distribution of specialists, malpractice insurance, and the efficacy of regulation. His book with Henry Aaron, The Painful Prescription: Rationing Hospital Care, is his best-known work. It pointed out the fallacies behind many proposed solutions to cost containment including weeding out inefficiencies and unnecessary care, and predicted that eventually our persistent national demand for new technology would require rationing of some beneficial services. In his last book (also with Aaron), Coping with Methuselah: The Impact of Molecular Biology on Medicine and Society, however, he sounded an optimistic tone, predicting after extensive study of genomics that the genetic revolution would allow many to remain vigorous and free of disabilities into old age.

Accolades followed his achievements. His former fellows, many of whom had achieved important academic positions, gathered on numerous occasions on both coasts to toast him, and in 2000 the Division of Nephrology at Tufts Medical Center was named in his honor. National recognition came in the form of election to the Institute of Medicine of the National Academy of Sciences and the American Academy of Arts and Sciences and he was given the John P. Peters Award, the highest honor of the American Society of Nephrology.

Bill's portrait should not be painted only in terms of science, creativity, attention to detail, and ability to reinvent himself. He had 3 fine children with his first wife Carol Levine. One, Ken, died prematurely of cancer. Bill is survived by his son Eric and his daughter Laurie and his wife Tressa Ruslander Miller, whom he once described in terms of her forbearance and generosity of spirit. He was an urbane man who rarely told a joke but would sometimes guffaw loudly when he liked one. He learned French and meditation as an adult and was quite an expert on the wines of the world.

On one wintry day in the 1960s when all 3 drafts of 2 chapters destined for the first textbook of nephrology, Diseases of the Kidney, took wings in a briefcase on the bumper of a Volkswagen during a fellows' snowball fight, I called him, expecting to be sent back to Buffalo. “Well, you learned something;” he said quietly, “we'll just have to start over.” He did have a soft spot.

Finally, it is a cruel and ironic twist that a man so keen, so curious, so creative, and so devoted to intellectual sparring should become a victim of Alzheimer forgetfulness.