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Faculty Spotlight: Wolfgang Liedtke, MD, PhD

Friday, May 5, 2017

The work of Wolfgang Liedtke, MD, PhD, is focused on pain: helping patients cope with head and facial pain, researching how pain is communicated at the cellular level, and in organizing seminars and courses on pain for students and clinicians at Duke. In this Faculty Spotlight interview, Liedtke talks about this work, how the academic environments of the United States and his native Germany differ, and about his loves of travel, painting, and cooking outside of work.

What are your responsibilities within the Neurology Department? What does your average work day look like?
On Fridays I provide patient care at Morreene Road, patients with chronic “therapy-refractory” head-face pain, coming to see me from across the country, even international. There is significant work tied to provision of patient care which I am working on essentially every day. I also visit Morreene Road a few times a week to touch base with staff and sign scripts and other documents.

For the rest of my work, my focus is strongly on the lab where I interact with every lab member continuously. I also read the literature non-stop as it pertains to anything pain-related. My molecular focus is on the TRPV4 ion channel which was almost patented >10y ago, and on the KCC2 chloride-extruding transporter molecule which makes GABA function as the dominant inhibitory neurotransmitter in the healthy adult CNS.

We have lab-meetings biweekly. I assemble grant applications and refine them before submission, also surveying the information landscape for any emerging opportunities.I maintain communication with active stakeholders in clinical and basic science fields related to neural mechanisms of pain.

I am a member of the Duke Neurology APT committee. It is my job to mentor four faculty members so that they get everything lined up properly for their next round with the APT committee.

For teaching and CME, I invite speakers to grand rounds and special seminars, then organize these visits. Teaching myself, I also give grand rounds and other seminars from time to time. I am a co-director of the course “Neurobiology of Disease,” one of the most popular courses at Duke. I am a co-director of the monthly interdisciplinary Duke Pain Colloquium, together with Ru-rong Ji, PhD,  from Anesthesiology, supported by the Dean of the SoM now for almost five years, one of the most popular seminars on campus. I work a lot, both in my office, at home, and in the clinics, also on the road.

How did you first get interested in neurology and neuroscience?
I’ve been interested in these subjects since high school. Neural functioning stood out as something extraordinary and special amidst all bioscience. At the intersection of biology/medicine and humanities, it is clearly the human brain that makes us who we are.

As I learned more and more about the nervous system, I came to realize that we are very special, but in many respects are a descendant of earlier stages of us in evolution. Touch and mechanical aversion as an elementary form of pain behavior can be studied in worms, and we can learn enormously from these relatively simple creatures. I believe calling them “lowly worms” is insulting and an expression of human hubris.

I came into neurology sort-of by accident because my internship (between studying medicine at the university and residency) in Neurosurgery at the University of Zurich did not work out as planned. So I faced the choice - go home to Cologne (and do anesthesiology) vs stay in Zurich (which I liked a lot) and find something else to do. Fortunately, the Neurology department welcomed me, and I had a fantastic internship there.

What made you decide to focus on researching and treating pain in particular?

I first got the research  “bug” during my PhD in Medical Virology. I just love being in a life science lab. Then when interning in Neurology, it did not take long for me to see that the time a neurosurgeon spends in the OR, the neurologist better get busy in a lab so that we can understand and treat better diseases of the brain, spinal cord and nerves.

As to the focus on pain, by the time I was a resident I had already come in contact with patients suffering from pain, experiencing their misery, plus the shortcomings of medicine in this respect. I strongly believe that researching pain and treating patients with chronic pain is a mandate of the very first order for a clinical neuroscientist.

Your work tackles chronic pain from two very different angles, both in your research into how pain is felt and responded to,  at the personal level when treating patients dealing with chronic pain.What do you enjoy most about each of these two areas?

I know that I can conduct research that will make a difference, on a real scale. And that comes from what I can do, and also from my professional experience, having two real legs and moving forward on them.

My research makes a difference because I am very familiar with the current level of understanding of pain physiology and pathophysiology, in the context of the function of the central nervous system, and in an organismal context, and then I hear how people feel. Rehearsing symptoms and experiences together with patients gives me an understanding what patients suffer from, and also gives patients a sentiment that they are taken seriously, that their doctor's brain is working for them. All patients appreciate being listened to, and me offering a thorough understanding of their suffering.

Chronic pain, after all, also leads to discrimination, part of which comes from lack (or unwillingness) of understanding of the social surrounding of the patient.

But we intend not only to rehearse and be an empathetic sounding-board. We want to do things so that patients get better - going back to Hippocrates, "to alleviate pain."

And there my research-based understanding of physiology, pathophysiology and pharmacology comes in handy once again, selecting treatments, prioritizing treatment options customized for other diseases the patient suffers from, and optimized for the potential to make progress and to be safe, to do no harm to somebody already in pain. These choices that I advise patients to take are typically well-accepted. For an example, see this case.

As to how patients influence my research: I only want to focus on problems and open questions where I can see a promising road ahead, where there appears to be a robust path forward that will have a likelihood, at least a decent chance, of making non-incremental progress for patients.

Recently, I met a patient with a genetic mutation in an ion-channel gene that causes her to have a severe pain syndrome. We know the mutation in her case and will aim to deconstruct how this channel mutation causes the type of pain that she has.

The mutated gene has been involved in hereditary pain syndromes before, but we can do better on mechanistic elucidation. I do not know what we will find, but there is a chance that this one patient might teach us something about severe and incapacitating pain that we have not known before, and that is valid for pain in general beyond this ion channel mutation.

Our human imagination is poor, so we better gather our smarts and follow nature who might teach us. In case we hit the target with this approach, it can be incredibly powerful, and one is humbled, deeply humbled by the privilege to see something like this for the first time, namely a new mechanism of an ion channel mutation that - up to date SOMEHOW - causes bad pain in a patient.

How has our ability to treat chronic pain changed since you became a doctor?
We have more tools now. We have fantastic opportunities in the laboratory and with possible translation. To make those goals happen, we need more funding and also an improved organization of our interdisciplinary field.

What changes do you see coming in the next decade?
We’ll get a better handle on managing chronic pain conditions. We’ll get a better handle on headaches.We will raise the level of basic understanding, perhaps or at least in some areas, to astounding degrees, fueled by basic and translational science.

We will lay out ways to deal with the current opioid issue, and hopefully also realize them

We will see an increasing influence of immunology and biomedical engineering where it comes to the understanding and treatment of pain.

You completed your residency and earned your MD and PhD in Germany, but have also studied and worked in the U.S. for the past 20 years. What’s the biggest difference in the academic medical environment between these two countries?
The United States is a larger arena, and perhaps by default permits more diversity in regards to how different hypotheses how things go or function. It has more traditionally strong basic science funding and vivid connection basic science to clinical sciences. Red tape is equally counterproductive in both systems. Litigation and opioid-madness are unique to the U.S. However, traditional hierarchies are more problematic in Germany.

The U.S. has more diversity of ideas than Germany. In the U.S. you can survive better with a view and direction far off mainstream, and that, over time, gives an incredible advantage to us.

In neurology/neuroscience, there are for example areas where one could ask why critical breakthroughs were not (yet) delivered, and how our own counter-productive "politicizing" a research field, erection of hierarchical baboon-pyramids, has hampered progress, e.g. Alzheimer's Disease, experimental stroke research (a high number of highly successful approaches in laboratory models, NONE of which has been translated into clinical reality successfully), plus not to forget our ignorance.

In Germany descendants of certain "schools" in adhere to these schools of thought perhaps more rigidly, and maintain and enforce a more fierce loyalty, especially intellectually, to their schools and old professors. In Germany, it also appears to me that it is important to remain at a given institution, people are afraid/ not considering to move and rather stay at one particular place. Also, clearly, when discussing concepts, results and future direction, a stake-holder's impact is very much proportionate to their academic rank. A more junior (by rank) team member can make a very compelling argument, yet if her / his chairman is over-ruling them despite holding on to a more outdated view, chances are that the chair will prevail.

To my antenna this works in a more egalitarian way here in the U.S., overall for the better, but this is simply my own perspective which might no longer be on the mark. Maybe I'm the dinosaur now.

What passions or hobbies do you have outside of the Department?
Spending time with my wife and daughter, reading, painting, cooking and drinking wine, photography, working out, travel.

Liedtke with one of his paintings, named “Brexit III”, at home in Durham.