The field of infectious diseases is continually evolving, and our ability to research and treat existing bugs, combat antimicrobial resistance and respond to global pandemics all comes down to dedicated ID and HIV professionals. These researchers and clinicians act as detectives, collaborating across all areas of medicine to investigate emerging diseases and find innovative solutions to deliver the best patient care. This commitment is evidenced by ID specialists like IDSA Foundation supporter Steven Schnittman, MD, and his son Samuel “Sam” Schnittman, MD.
From a fellowship at the National Institutes of Health (NIH) Laboratory of Immunoregulation under Anthony Fauci, MD, to starting his own biopharmaceutical consulting business, Dr. Steven Schnittman is passionate about research, innovation and mentorship. With a career that’s developed in tandem with the HIV/AIDS pandemic, his experience intersects several critical moments in HIV research and development, including researching immunopathogenesis of HIV infection and helping develop the first collaborative study groups for HIV in the world.
This interest in HIV medicine seems to run in the family. Now, his son Dr. Sam Schnittman is also pursuing a career in infectious diseases. As a StARR (Stimulating Access to Research in Residency) Research Fellow in the Department of Medicine at the University of California, San Francisco (UCSF) and a soon-to-be fellow in the combined Massachusetts General Hospital and Brigham and Women’s Hospital Infectious Diseases Fellowship Program, he is interested in studying the mechanisms that underlie immune activation and inflammation in HIV and their consequences leading to the development of non-AIDS-related comorbidities. His ultimate goal is to target therapeutic interventions at inflammatory pathways to reduce such clinical outcomes.
Their own unique experiences provide insights on how ID medicine has advanced and demonstrates that whether you’ve been practicing for years or are just beginning your career, the current and next generation of ID specialists have a critical role to play in reducing the burdens of infectious diseases worldwide. We spoke with the Schnittmans to learn more about their passion for the field and the need for mentorship and funding opportunities to support the ID specialty.
Why did you decide on a career in infectious diseases?
Steven: My decision to pursue a career in infectious diseases goes back to 1981 when I was a third-year medical student at NYU School of Medicine. I was doing my internal medicine rotation at Bellevue Hospital and had an amazing ward attending by the name of Michael Simberkoff, MD. He also happened to be the chief of ID at the Manhattan Campus of the VA NY Harbor Healthcare System. During that time, I was exposed to him several days a week. As residents, we would present to him, and I viewed his feedback and overall mentorship in a very positive light. It made me intrigued and interested to pursue ID further.
It was also then that I saw my first HIV/AIDS patients. They weren’t called AIDS patients at the time, but we were seeing young men, particularly gay young men, developing Pneumocystis pneumonia and Kaposi’s sarcoma. They were dying within days or months of arriving with a strange immunologic disease in which their immune system was severely debilitated.
I then stayed in New York for my residency at The New York Hospital from 1982 to 1985. By the end of my residency, I had probably seen about 1% of all AIDS patients in the U.S. In those days, it was horrible. The patients who were admitted had one opportunistic infection after another and did not live very long. The first therapies weren’t available until the mid to late 80s, and even they were impotent.
It was exposure to the problem solving involved in those unique patients and this new, evolving disease that further stimulated my interest in going into infectious diseases.
Sam: For me, it was an iterative process throughout medical school and residency that led me to understand a number of great features of the field. You get to work like a detective. You combine thinking about people’s history, their physical, their labs, their imaging. You get to collaborate and work with virtually every other subspecialty in the hospital, which is incredibly rare. As we’ve seen in the last year, your work is constantly evolving: there are emerging and re-emerging ID-related outbreaks, there’s antimicrobial resistance and then there’s all of these cool new tools and technologies—new medications, antibiotics, antivirals and the rapid development of new diagnostics and therapeutics in the face of a pandemic.
What ultimately brought me to HIV was a result of doing my residency training at UCSF in San Francisco. The first HIV clinic was at San Francisco General Hospital, so I think there’s an immense history and a lot of tremendous clinicians and researchers there who are dedicated and are great mentors. I had the fortune to interact with so many ID physicians early on in my training, and clinician educators like David Sears, MD, and Jennifer Babik, MD, PhD, and physician-scientists like Peter Hunt, MD, were the major impetuses behind my growth and interest in ID and HIV.
Whereas my father worked to keep people with HIV from dying, HIV today looks different in much of the U.S. When people take their antiretrovirals, they can remain virally suppressed, but there are other complications that we increasingly encounter, including cardiovascular disease, complications of weight gain and metabolic syndrome, and cancer. That’s what has interested me. Even with increasing rates of viral suppression, particularly in places like San Francisco, we are facing this new rampant epidemic of non-AIDS-related comorbidities. So while my father’s focus was to stop people from dying, my focus is more on assessing how we can help these people live longer and healthier.
All of those things combined with being part of a group that loves to do what they do – perhaps more so than any other subspecialty – I think makes the ID specialty very attractive.
Steven, what were your early career goals and your steps to achieve them?
Steven: At that time, unlike today, being exposed to research was unusual both in medical school and in residency. My initial goals were to try to get exposed to research as part of my fellowship as quickly and as intensely as possible. That is why I ranked the NIH as a place I wanted to do my ID training. There I would be exposed to some great minds in infectious diseases and related areas that would help me to set up a research program to pursue it further.
I wasn’t sure which lab I was going to wind up in at NIH or what my research was going to be. But in 1985, I was selected by Dr. Anthony Fauci and his laboratory of immunoregulation to join that lab and do my fellowship under him. My first few months were in the lab, and I was put on projects related to the immunopathogenesis of HIV/AIDS. We were looking at what cells are predominantly infected by HIV and to what extent.
Tony was an incredible guy, and I had the opportunity to work on a day-to-day basis with him. There were also some other great people at NIH who helped me quickly get up to speed. I was working on projects at a time when whatever you did in HIV pathogenesis was going to be noteworthy and newsworthy. The research was all novel and fascinating, and it was with Tony’s leadership that I was able to get a publication in SCIENCE. It was challenging to do something like that, but it was an exciting time.
It sounds like you were working alongside many great minds. Were there other mentors who helped guide you along your path?
Steven: I eventually moved from the NIH lab to their extramural program. At the time, the program was helping to create the first cooperative group to do clinical trials for HIV/AIDS. This was the AIDS Clinical Trials Group (ACTG) that still exists to this day. I worked on the government side and brought the ACTG and Community Programs for Clinical Research on AIDS (CPCRA) up to speed so we could do the first clinical trials of drugs like AZT.
This experience meant that I got to work closely with the greatest minds in ID and HIV who were leading this effort as investigators in the ACTG. This includes someone Sam now knows – Paul Volberding, MD, who was one of the founders of the ACTG at UCSF. I also encountered John Bartlett, MD, at Johns Hopkins who recently passed away. There were some really incredible minds who helped progress these efforts during that period.
How have past accomplishments in the field of ID and HIV influenced the specialty today?
Steven: During the height of the HIV/AIDS pandemic, people were bold. This was the first time we brought activists to the table. Activists sat on clinical research teams, helped contribute to the development of clinical protocols and devised what the strategy and agenda would be going forward. It was a novel risk to take, but it was ultimately critical to the success of the research partnership between the activists, government and academia.
The ID community played a huge part in bringing activists to the table, and this is now being mimicked by other therapeutic areas because we realize that the way to success is collaboration between the people impacted by the disease and those doing the research on it. This critical juncture in time has had valuable spillover effects. Huge gains were made by the investments the government made at that time, and it was well worth it.
Sam: It was also the ACTG infrastructure that allowed us to quickly create and adapt many of the COVID-19 randomized trials in the U.S. Something my father was involved in decades ago is what allowed us to respond so rapidly now.
What advice would you give to medical students considering a career in ID?
Steven: I think the ID profession is one of incredible potential flexibility. One could be a clinician or do basic, clinical or translational research. You can adapt or change across these different areas throughout your career. Your career could be in academia, the pharmaceutical industry or a government role, whether it’s the NIH, CDC or the FDA. There are infectious diseases specialists who are employed in all of those areas contributing in significant ways to move the field forward.
Considering the theme “building the future of ID,” how can the infectious diseases community recruit and support the next generation of ID specialists?
Sam: I think we’ve seen that there’s an increasing need for ID professionals across the country and the world. At the same time, there’s been decreasing interest in ID over the years for a variety of reasons. We can hope that will change naturally with the pandemic by seeing leadership from people like Dr. Fauci; Rochelle Walensky, MD, MPH, at the CDC; and others and by recognizing the importance of having a strong ID workforce and research fields.
People in the field have commented on the need for improved teaching and pedagogy, starting in medical school, which would involve moving away from strict memorization of microbiology and toward a larger focus on critical thinking, because that’s what’s so exciting about infectious diseases.
I also think there needs to be more exposure to faculty at institutions and conferences. There are tremendous ID mentors at every hospital and medical school, and medical students and residents don’t always get exposure to them. UCSF’s internal medicine residency seems to repeatedly match a relatively higher proportion of graduates into ID, and a part of this trend may be that we work with ID physicians and pharmacists very closely throughout our training. Beyond that, there needs to be increased financial support for academic pathways and overall for the field.
Steven: Mentorship is key. It’s critical that you spend the time to engage and interact with younger individuals in the field to keep them interested and excited in the work they do. It’s important to recognize talent, bring them into challenging roles and expose them to things so they can push themselves as far as they can.
This year is the IDSA Foundation’s 20th anniversary, and we’re thinking a lot about the organization’s past achievements and what we hope to achieve together over the next 20 years and beyond. What do you hope to see for the future of your career and for the field of infectious diseases?
Steven: I hope to continue to use my 35+ years of clinical development experience to advise new and novel programs. I opened a consulting organization to advise on how to develop new drugs for various diseases. Little did I know that a year and a half into it, there was going to be a pandemic. Demand for my advice increased, and it was having that experience in clinical development that enabled me to advise on COVID-19 trials and novel programs.
In the field of ID, I think we need to keep pushing for novel and innovative approaches for drug development beyond vaccines. We were forced to speed the development of the COVID-19 vaccines and to develop them in parallel rather than in sequence. That involved risk and financial cost, but we certainly saved an enormous amount of time in the long run. I think continuing to push for novel, innovative approaches will be key to the field over the next 20 years. Finding ways to accelerate development and making that development attractive to companies and organizations is going to be critical if we’re going to help save people from the bugs of the future.
Sam: I hope to see support for the next generation of physician-scientists. Within ID, it is challenging to start and maintain a career as a physician-scientist. My father didn’t step foot in a lab until he was in fellowship and still launched a successful basic and clinical research career, but it would be exceptionally difficult to do that today and be successful. There’s limited research training before and even during fellowship to develop the critical skills necessary for an academic career. There’s also incredibly scarce funding during the transition to NIH Career Development (K) Awards.
In terms of academic advancement and funding, there seem to be non-transparent hopes from funding sources, and there are so many complexities to wrestle with. What are the number of publications you need at each stage? What are your commitments to your mentor as you progress? What are the institute’s research priorities? How might funding shifts affect your ability to maintain funding and your career? For example, what will happen to HIV funding over the next five or 10 years, especially with so much current focus on COVID-19?
As you can see, the reproducibility of initial and continued funding success relies on a select number of unique circumstances all coalescing. I would love to see a way to make that less unique and more reproduceable across the country, because that’s how we were able to respond to this pandemic, and it is how we can help to maintain people in this pipeline.
The IDSA Foundation is committed to advancing the field of infectious diseases through research funding, grant opportunities and mentorship. Help us support the work ID heroes and ensure the next generation of ID specialists is equipped to handle the challenges of the future by making a gift today.