Dr. Robert Califf | Centennial Oral Histories

I think we're all heavily influenced by our youth. And in my case, my dad was an architect, and he was teaching at Clemson University when I was born. So at heart, I'm actually a Clemson guy. But when I was five, we moved to Columbia, the capital of South Carolina, and he was very involved in designing buildings there. My mom was a schoolteacher. It was a very, I would say, intellectual and academically-inclined family, with dinner table conversations about politics and the direction of things. And of course that time, the early-to-late 1950s, was sort of a stable time as I think of it in American history. But then the 1960s were a very tumultuous time and particularly shaping me was this integration that was happening in the South. And I think a lot of people who are younger don't even realize how recent that was. I started out in totally segregated schools, and it was during my high school years that integration occurred.

When I was in high school, I was mostly interested in basketball. I ended up being captain of the state championship basketball team for South Carolina. Probably the pinnacle of my career in anything was the day after I won the state championship. That night, you're on top of the world. Then you recede back into normal life. It's kind of deflating. But I also would say I had a very political period then. It turned out one of my friends through school, all the way, was Lee Atwater, who was the famous Republican strategist. I was on the other side of the fence. We were arguing even back in junior high and high school. But I really didn't have designs on medicine or healthcare. It is noticeable that during that period of time, every year you took an aptitude test for what you should do with your life. And they kept saying I should be a doctor. And I mostly rejected that idea. It was only later, my junior year at Duke, that I switched to Pre-Med.

It was a fascinating time. There was a rule in South Carolina that the coach couldn't coach the team during the summer. And so as captain, I was actually sort of the proxy coach. And one thing that we did, I still have vivid memories of this. We had Black players on our team, but there were still all Black high schools. So we toured the all Black high schools and scrimmaged them, which was a spectacle. The crowds were -- it was a full packed gymnasium every time, with cheers that I had never heard growing up in the other schools that were a little bit disconcerting. But that toughened us up quite a bit. And I think it was part of the story of how we ended up eventually winning the state championship.

I had brief dreams of a college career, and I got some letters from, I would say, the lower-ranked schools, not the 1A schools. Also in 1968 and 1969 the assassinations had occurred, the Vietnam War was going strong. And at that point, I really sort of lost the intense focus on staying in shape and playing sports. Although I did play a lot of intramural basketball at Duke, and I switched to other interests at that point.

Well, my older brother had come to Duke, and he was a couple of years ahead of me. And when I came to Duke, it literally was the furthest north I had been in my life. You know, travel was different then. And I never really had hardly been to North Carolina for anything, other than up in the mountains occasionally when we lived in Clemson. So it was actually a big journey for me to come to Duke. And quite startling to walk into House L, the freshman dorm, with all these people from all over the country. It was an amazing experience. So the draw was really good academics and good sports, and kind of like the way it is now when I look at undergrads.

Well, I just remember it being intense, and we made a lot of friends. And in fact, last year we had our 50th Duke reunion. And although we had gone all over the country, in different parts of the world, doing very different things, it was as if we were back together again 50 years later. Still able to relate to each other very easily and just having amazing conversations. But the other part of it was, it was such a tumultuous time. In the history of the University, too. The year before had been the takeover of the Allen Building. The year before I came. Integration on the campus was a big deal. Not so much the students, as I remember it, but the workers in the hospital. It was a huge deal. But we didn't have classes most of the second semester because of the Vietnam War. And although I spend a lot of time in Washington now, my first visit to Washington was on a bus where I got tear-gassed. I take the Red Line transit line in Washington now, from my apartment building to the HHS offices next to the Capitol. And every time I go through DuPont Circle, I have a brief recollection of running into the basement of a church at DuPont Circle, having been tear-gassed. So the absence of classes was a remarkable period, I think, in the University's history. But things held together, and became more regularized as all that worked out.

Gosh, we had city administrators, dentists, people who wrote for newspapers or wrote books, engineers. It was really an eclectic mix from all over the country, and just about every profession that you can imagine. But we still had so many things in common, and it was easy to hang out together and chat.

Well, I developed a deep interest in psychology, actually back in high school, and was very focused on it. I was going to be a clinical psychologist, and I ended up working in the South Carolina state prisons for two summers, which was a tremendous experience. But I sort of concluded after that first summer that maybe I wanted to do something that was a little bit more tangible. It was tough to be -- it turned out some of my high school competitors are now inmates in the prison. And I got to see how difficult it was to exert change. So I've always had a lot of respect for people who work in the mental health field ever since then. But it sort of hit me that, maybe for me, I should do something that had a little more concrete application, where you might see a problem and could help fix it. And medicine, ultimately cardiology, really fits the bill. When you see someone in ventricular fibrillation and you apply some Duke power and defibrillate that person from being dead to being alive, that's pretty concrete. So that was a big switch. I had taken no science courses until basically finishing my junior year. So after graduating from Duke, I took a year off and worked as an orderly, because I had crammed all those science courses.

No, I was over in Greensboro. Got married. My now-wife Lydia Califf was in school at UNC-Greensboro. And that was an amazing experience. Well, the whole thing of marriage has been amazing. 1973 to 2024, we've had a long and great marriage. But serving the needs of people at a basic level is humbling. It also, I think, teaches you a lot of things that I worry a lot of medical students never think about until they may be too far along.

Well actually, it was surprising. I thought I was saying goodbye to Durham. And, you know, you mentioned Washington. This came up last night. I can't quite get over it. But one of the fellow awardees with me at the Founders' Day celebration last night is an animal behavior expert who had mentioned that there was a goat colony that Duke kept up for people to study animal behavior. And I actually did that for a semester, studying the hierarchical behavior of goats. It turns out that has been a fabulous background for dealing with Washington politicians. Very similar. Behavioral economics, quite interesting. There's a hierarchy, and the goats know exactly which goat gets dominance over the others in different situations. And I think the same thing -- it's pretty obvious in politics that it works that way.

So, I was not expecting to come back to Durham. And I'd actually paid the down payment at Tulane University when the Duke admission came through. And it was a hard decision. Tulane would have been great, but it ultimately, I think, worked out really well for us. You know, we didn't have a lot of money. We had a very meager subsistence, but Lydia was working as a nurse at Duke Hospital. She had gotten her nursing degree at UNC-Greensboro, and it was just a fabulous culture and experience. But, my first day we went to a medical grand rounds and got to see Duke's Dr. Eugene Stead in action. A neurologist was presenting a case and halfway through it, Dr. Stead got up and basically told the neurologist, 'You're wrong.' They got into an argument. And it was quite an introduction to the complexity and personalities in medicine. But what a bond that first year at Duke. Early on, Duke took this position to compress the basic sciences into one year. Very intense. And so you talk about friends and relationships, that first year class was remarkable and still something I think about a lot. And then that second year you're out there taking care of patients. An amazing experience in the old Duke hospital. Learned so much.

Yeah, I would say most of my undergraduate research was some observations and a little bit of writing, not heavy-duty research. But I needed to work part-time while I was a medical student to help pay the bills. And I end up working with this new thing called a computerized database that had been developed, actually by Dr. Stead. And it was amazing to me because at the time all medical communication, as you know, was handwritten. Including the orders for the patients and the clinic notes. Essentially everything was handwritten. And so doctors got to be well-known, basically by having good memories, or being able to concoct stories about their memories that were believable to other people. But it turned out when you had computerized data, very simple things that we take for granted today -- you could say that a lot of the recollections and beliefs of the doctors were just flat-out wrong. And the ability to aggregate information over time, it was just -- Dr. Stead was way ahead of his time, as he was in some other things. In this regard, he not only realized that capturing information in computers was important, but the longitudinal nature of the disease and outcomes was also. His rule that he put into place was that once you got entered into the database, you were followed for life. And there's so many cognitive tricks that we know about now but people still fall prey to them. Like how someone looks initially after a treatment is instantiated into your mind as that's how the treatment works. But there are many treatments that either have no effect early, or even a detrimental effect early, that show later benefit. And of course at the time, coronary bypass surgery was brand new. So he would take me to conferences, because every case was reviewed, and the cardiologists and surgeons would look at the old cinifilms.

When I was a med student. And he would say, 'They're going to say X, Y, and Z, but here's the computerized data and they're making the wrong decision.' Really.

1976, 1977. Wow. Okay. And so to this day in my job at FDA, I still see so many situations where common sense beliefs by doctors and patients and other practitioners don't fit with what the data actually show. And it's a lesson I think we have to learn over and over.

No, we had a thing called a PDP-11 that took up an entire room in Duke South. And you would enter your code, and for most things we did, you would come back the next day. It would run all night, and then you would get your answer to the question. This, of course, was a more genteel time of academic medicine. I was a student and I was working with all the cardiology fellows and they had a team -- it was a unique thing at the time -- but a multidisciplinary team. One of the original biostatisticians, Kerry Lee. One of the original engineers who worked with software, Frank Starmer. And one who sort of bridged it, Ed Hammond. Ed, of course, is still around. The team built new things and broke a lot of ground. This was a tremendous education for me, because I went with them to some NIH site visits where their pioneering work was not very well-received. It was considered avant garde and upstart. And in fact, one of the most important things Dr. Stead did, which you could never do now, is he took a grant that was given for physiologic monitoring -- again, hard for young people to believe, but we were just beginning to put rhythm monitors on people in intensive care units. But he took the money and built this database to measure patient outcomes over time. They did reverse site visits at the time. He totally shocked the site visitors. 'You gave me the money for this, but here's what I did with it.' They were not too happy. But at the time you could get away with that. And the kind of creativity that was shown in this group just -- I was sold. I mean, there was no way I was going back.

There's another thing that happened which was that the death rates at the time, coronary care units were filled with 50-to-60 year old people, mostly men who were cigarette smokers. And they died at alarming rates. And the Holter monitor had just come out, speaking of monitoring. So my project as a student was to put Holter monitors on people. I only needed 386 people, and then I followed them while I was still a student, like for a year. So many people died that we had very meaningful outcome data. And the question was, could we predict sudden death? And it turned out, the hypothesis was that the arrhythmias shown on this new Holter monitor would be the best predictor. And I put the data together and brought it to Kerry Lee, the statistician. He ran some regression analyses. And lo and behold, it wasn't the cardiac arrhythmias. It was the underlying left ventricular function. So we brought that up, and it was not a popular message. It was not well-received. People didn't believe it. And I went on out to UCSF for my internship. But our abstract was accepted to the American Heart Association in Miami. And it was one of those things where I just barely got a couple days off and got on the plane. At the time we had the slide carousels with our slides. I ran into the Fontainebleau Hotel, gave my talk, and the commentators just basically said I was stupid and I had gotten it wrong. But the conclusion of our study was that treating sudden death was going to be a matter of identifying people with impaired left ventricular function. Guess what? We were right.

It's LV function.

I loved it. There was an event that happened. Our first child was born, just as I was finishing that fourth year of medical school. And it turned out she had really serious congenital heart disease. But it was actually not diagnosed at Duke, even though she was not thriving. So we traveled across the country not knowing why our baby was not growing at a normal rate. And for people that have been to San Francisco in the summer, you'll relate to this story. But we arrived in June, started the internship, I took Sharon out on the porch on a July day when the fog was in. It was like 45 degrees in July. And she turned blue, right in my arms. And she ended up having a huge operation while I was an intern. So we would make rounds on all the adult patients while I was a medical intern. We would go around on my daughter in the ICU. That was a month of my internship. But, you know, it's amazing. The people everywhere are pretty much the same. They took really good care of us. We made friends for life. And I know you spent time there, too. So you have a sense of the community there. I fell in love with San Francisco. And it actually turns out San Francisco and Durham, in my opinion, have a lot in common. They're very heterogeneous towns. And the people in San Francisco tend to be really friendly and easy to talk with. Much like the people in Durham. It doesn't matter what your background or skin color is, you pretty much get along with everybody. I find Durham to be similar, and increasingly so, as a melting pot community. And I also think of the sense of collaboration at the university. Same thing in both places.

Yeah, that was actually a really hard decision. You know, those were the days of short-tracking in medicine. So I had done two years and had conversations about being a chief resident, which is a very prestigious thing at a place like UCSF. But I was addicted to the computer. And now you would never believe it, but the Bay Area was way behind in computing. Duke was way ahead. And in addition, Sharon was still -- you know, we'd been through quite a traumatic thing, and we wanted to be closer to family. So we came back, and I went right to work as a fellow and had a fabulous time.

Once again, two years into the fellowship, the Coronary Care Unit director, Eric Conn, went into practice in Chattanooga. And Joe Greenfield, the chief of Cardiology, called me in and he said, 'I think we need you to be the attending on the Coronary Care Unit while you finish your fellowship.' So, somehow that was managed. And that's actually what I did. I was on call for both Duke and what is now Duke Regional Hospital. It was Watts Hospital or Durham County at the time. So I was on call 12 out of 14 nights. That first year when I took over the...

Yeah. The first year was that time when the first coronary angiograms were done showing that what caused heart attacks was a blood clot. Hard to believe that I was taught as a medical student that blood clots did not cause heart attacks. It took some adventurous cardiologists doing acute angiograms to see that. But then the race was on. What do you do about it now? You know, the leading cause of death. I was losing 4 or 5 people a day on the Duke Coronary Care Unit, because we essentially had no treatment. And dissolving the blood clot was something that we knew could be done. So that set off a race. So, the 12 out of 14 nights were literally very often coming in to see a chronically ill person and put them on a protocol. And very few other institutions were doing this kind of work. So it was very high-stakes and high-profile.