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B
The Endangered Physician-Scientist:
Opportunities for Revitalization Emerge
Leon E. Rosenberg
Professor, Department of Molecular Biology, Princeton University
and
Timothy J. I.ey
Alan A. and Edith L. Wolfe Professor
Department of Internal Medicine,
Washington University School of Medicine
_ ~ n 1979 Wyngaarden wrote that physician-investigators (now genera
ally called physician-scientists and defined as M.D.s or M.D./Ph.D.s
_ ~ whose principal professional activity is research) were an endangered
species (Wyngaarden, 1979~. This conclusion was based on an examina-
tion of trends at the NIH concerning postdoctoral research fellows, re-
search-career-development awardees, and research-project-grant-princi-
pal investigators. Only now, more than 20 years later, has this prescient
albeit unwelcome truth been widely accepted. No single publication or
lecture overcame the denial and dismissal of Wyngaarden's message.
Rather, it has taken work by several individuals (Ahrens, 1992; Gill, 1984;
Goldstein and Brown, 1997; Rosenberg, 1999, 2000; Schechter, 1998;
Thompson and Moskowitz, 1997; Williams et al., 1997) and an impressive
number of organizations, including the Institute of Medicine (Kelley and
Randolph, 1994), the NIH Director's Panel on Clinical Research (Nathan,
1998), the National Research Council's Committee on National Needs for
Biomedical and Behavioral Research (NRC, 2000), the American Medical
1A number of individuals generously provided us with information for this report: Marc
Horowitz, Ruth Kirschstein, Burton Shapiro, and Judith Vaitukaitis of the National Insti-
tutes of Health; Andrew Quon of American Association of Medical Colleges; Carl Rhodes
of the Howard Hughes Medical Institute; and Hui Wen Chan and Tamara Zemlo of the
Federation of American Societies for Experimental Biology.
60
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APPENDIX B
61
Association (AMA, 1996), the Association of American Medical Colleges
(AAMC, 1999), and the Federation of American Societies for Experimen-
tal Biology (Zemlo et al., 2000) to achieve consensus that a serious prob-
lem exists.
EVIDENCE FOR ENDANGERMENT
There are threats to the physician-scientist career path throughout its
length and breadth.
· During the 1990s there was a progressive, statistically significant
decline in the intention of matriculating and graduating medical students
to pursue a research career. This decline was noted at the most research-
intensive medical schools as well as those with less research activity. A
distinctly smaller fraction of female students, who now constitute about
49 percent of all medical students, expressed stronger research intentions
than did their male counterparts (Guelich et al., under review).
· During the 1990s progressively fewer M.D.s obtained postdoctoral
research training positions from NIH (Rosenberg, 1999~. This conclusion
was reached by summing all of NIH's training mechanisms for M.D.s
(T32, F32, K04, K08~.
· In the past several years there has been a decline in the number of
first-time M.D. applicants for research project grants, a trend not observed
for M.D./Ph.D.s or for Ph.D.s (Rosenberg, 1999~.
· M.D.s constitute a progressively smaller fraction of members of
chartered NIH review panels, a trend that has been ongoing for 20 years
(Zemlo et al., 2000~.
· There has been a progressive shift toward older age of M.D. princi-
pal investigators supported by NIH. In 1977, 56 percent of NIH principal
investigators with the M.D. degree were less than 45 years old. In 1997
this fraction had fallen to 44 percent (Zemlo et al., 2000~.
· Since the 1970s the number of Ph.D.s applying for NIH grants has
grown much faster than the number of M.D. applicants. Whereas M.D.s
and M.D./Ph.D.s made up 43 percent of NIH principal investigators in
1970, they account for less than 30 percent now, despite having a success
rate indistinguishable from that for Ph.D. applicants (Rosenberg, 1999;
Zemlo et al., 2000~.
· The total number of physicians engaged in research has declined
over the past 15 years, while the total number in practice has increased
dramatically; He percentage of all physicians engaged in research has,
therefore, decreased sharply over this period of time (Zemlo et al., 2000~.
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62
APPENDIX B
TWO GENERAL MECHANISMS
FOR BECOMING A PHYSICIAN-SCIENTIST
The historical pathway to becoming a physician-scientist is the post-
doctoral (or "late bloomer") one. These M.D.s become seriously interested
in research during their clinical residency (two to three years) and sub-
specialty years (two to three years). This interest is then pursued during
an additional three to six years devoted exclusively, or nearly so, to labo-
ratory, patient-oriented, or epidemiologic study. In contrast, the second
pathway starts at medical school matriculation, when candidates enroll in
combined M.D./Ph.D. programs leading to receipt of both degrees in
seven to eight years.
These pathways differ in many ways other than when the career
choice is made. First, the late-bloomer pool remains far larger than that of
the M.D./Ph.D.; M.D.s still account for about 70 percent of physician-
scientists serving as principal investigators on NIH research project
grants. Second, M.D./Ph.D.s generally complete their formal education
with a much smaller debt burden than do those with an M.D. degree only,
because M.D./Ph.D students usually receive tuition and stipend support
from the NIH or other agencies. Third, the kind of research these two
groups do tend to differ. M.D./Ph.D. students frequently perform their
thesis work in basic science departments, which are naturally focused on
basic research. Their initial research topic is often not influenced by clini-
cal experiences. M.D. postdoctoral candidates, on the other hand, gener-
ally select a research topic based on their own experience with sick people.
This results in a far higher fraction of late bloomers being engaged in
disease-oriented and/or patient-oriented research. Fourth, the number of
people seeking the M.D./Ph.D. route is growing, whereas the number of
late bloomers is declining, making this subset the truly endangered one.
WHY PHYSICIAN-SCIENTISTS MATTER
How important to the health of the public is this endangerment of
physician-scientists? What is the proof that they matter? A definitive an-
swer to these provocative questions could be obtained by permitting phy-
sician-scientists to disappear over the next generation and then assessing
the impact on health research, health care, and health status. We hope this
Swiftian knockout experiment will be rejected in favor of reasoned argu-
ments.
First, physician-scientists continue to make major contributions to
health research. If one takes the Nobel Prize in physiology or medicine as
the ultimate emblem of scientific distinction, M.D.s have done well, gar-
nering about 50 percent of all such awards during the past 50 years. Let us
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APPENDIX B
63
mention just a few of the discoveries these Nobelists and others have
made. Physician-scientists doing basic or disease-oriented research have
discovered oncogenes, the low-density lipoprotein receptor, priors, HIV,
pulmonary surfactant, and the genes responsible for cystic fibrosis and
Huntington's disease. Those doing patient-oriented or epidemiologic in-
vestigation have pioneered in the eradication of smallpox; the near eradi-
cation of polio; the cure of childhood leukemia, Hodgkin's disease, and
testicular cancer; the development of open heart surgery and of organ and
bone marrow transplantation; and the elucidation of means to decrease
mortality due to heart attacks and strokes. Based on this past performance
there is every reason to expect that physician-scientists will make equally
important contributions in the new millennium.
Second, whereas medical school education is not aimed at teaching
one how to obtain scientific answers, it is the ideal place to raise a wide
range of questions about health and disease that can be answered only
through basic or applied research. It is the questions that physician-scien-
tists ask because of their involvement with sick patients that distinguish
their approach to research, and that make them critical members of the
health research workforce. These questions should be even more robust
in the postgenomic era, and more capable of being answered.
Third, the bridge between bedside and bench depends on bidirec-
tional traffic and communication. Physician-scientists are in an ideal posi-
tion to communicate and collaborate with Ph.D. scientists on one side and
with health care providers on the other. They can make the strongest case
for the clinical relevance of basic research to legislators, advocates, and
health agencies. Without physician-scientists the bridge will weaken, per-
haps even collapse. This would have serious implications for the funding
of health and medical research because the public supports such invest-
ments in the hope of securing longer, healthier lives they want to see
science translated into cures. The public supports medical science not for
what it is, but what it is for.
REASONS FOR ENDANGERMENT
Why is the physician-scientist career path in decline just when scien-
tific opportunities to diagnose, treat, cure, and prevent disease have never
been greater? This paradox has many explanations, which affect all par-
ticipants in the pathway and all stages of development. College students
interested in medicine are too often advised that they can become either a
physician or a scientist but not both unless they are superstars who can be
accepted by the M.D./Ph.D. programs at medical school, which enroll
only about 2 percent of all medical students. Medical school admission
committees reinforce this view in that they tend neither to try to recruit
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64
APPENDIX B
students with experience or interest in research nor to indicate that it is
plausible and exciting to be a physician and a scientist. Thus most ma-
triculating medical students focus exclusively on becoming clinicians.
The opportunity for medical students to try their hand at research
varies widely. A few schools require all their students to conduct a re-
search project and to write a doctoral thesis. At such schools as many as
50 percent of medical students take a year out to do research, but these
patterns are the exception, not the rule. Most students at most medical
schools have no research experience. They graduate with a great deal of
information about sick people and a great deal of debt, now averaging
nearly $90,000. After graduation, exposure to research depends on the
specialty chosen and even more the subspecialty. These are the critical
years for the late bloomer. Such individuals require lengthy, rigorous
research experience equivalent to a Ph.D. in either laboratory, patient-
oriented, or epidemiologic research. Too often the subspecialty fellow-
ships provide scientific training that is too narrow, too abbreviated, and
too superficial to provide a foundation for a long research career. Too
often the stipends are insufficient to meet individual or family responsi-
bilities and repay enormous medical school loans.
For those intrepid enough to soldier on and achieve faculty status, the
challenges continue, and perhaps grow even larger. One must have pro-
tected time to establish an independent research program, usually at least
75 percent of effort in the first three to five years. Such protection is
required to obtain research grant funds and build a team. Such protection
is now very difficult to find in clinical departments, particularly in this era
of managed care with its resultant demands to see more patients so that
the clinical earrungs that most departments depend on will be maintained.
Once having risen to the status of an established investigator with ad-
vanced faculty status, it remains necessary to obtain and re-obtain exter-
nal funds from NIH or other sponsors in an environment that is extremely
competitive.
The emotional and structural barriers just described are daunting. If
we are to revitalize the physician-scientist career path and refill the hu-
man pipeline, these barriers must be lowered or better still, removed, so
that the decisions made by would-be physician-scientists will be tilted
toward the great excitement they can have doing science in the name of
health.
EMERGING OPPORTUNITIES
We are encouraged by a series of recent developments aimed at offer-
ing incentives and removing disincentives.
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APPENDIX B
65
· The Clinical Research Enhancement Act, signed into federal law in
2000, finds that "clinical research is critical to the advancement of scien-
tific knowledge and to the development of cures and improved treatment
for disease." It provides for "increasing the involvement of the NIH in
clinical research." Among its many provisions the Act directs the NIH to
establish a broad extramural loan repayment program (LRP) for M.D.s
engaged in training in clinical research. This program was initiated in
2002, and will provide a maximum of $35,000 per year of loan repayment
plus the taxes on this "income" for up to three years of training. Clinical
research is defined broadly so that a large number of M.D.s with identifi-
able NIH support will be eligible for funding through competitive re-
view. The total number of awards in the first year was 250, growing to at
least 500 in later years.
· Two other extramural loan repayment programs was initiated in
2002, as well. One is for individuals engaged in basic or clinical pediatric
research. The other is for members of disadvantaged minorities engaged
in minority health disparities research. The financial terms of these pro-
grams will be identical to that of the Clinical Research Enhancement Act
loan repayment programs. The number of individuals to be recruited has
not yet been set (M. Horowitz, personal communication, 2001~.
· The NIH also supports focused loan repayment programs for train-
ees in the intramural program working in any of four areas of special
need: AIDS; underrepresented minorities doing clinical research; contra-
ceptive and infertility research; and general research. There are currently
152 individuals in these programs. The financial terms of these awards
are identical to those described above ~ M. Horowitz, personal communi-
cation, 2001~.
· In response to recommendations of the Director's Panel on Clinical
Research and the Clinical Research Enhancement Act the NIH has estab-
lished three new mechanisms aimed at enhancing the career development
of physician-scientists doing patient-oriented research. The Mentored
Patient-Oriented Research Career Development Award (K23) provides
five years of salary and research support to a current total of 279 awarders.
It is aimed at young investigators in transition from fellowship to junior
faculty. The Mid-Career Investigator in Patient-Oriented Research Award
(K24) provides "protected research time to . . . clinical investigators by
relieving them of patient care and administrative responsibilities." It is a
five-year award currently held by 158 people. The Institutional Curricu-
lum Award (K30) aims "to provide didactic multidisciplinary training in
the fundamentals of clinical research." There are currently 55 such pro-
grams supported, and new ones are being considered a Vaitukaitis, per-
sonal communication, 2001~.
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66
.
APPENDIX B
The Medical Scientist Training program (MSTP) of the NIH has
slowly increased in size. In 1996 the program supported 833 M.D. /Ph.D.
students at 33 medical schools. In 2001, 927 students were supported at 39
schools (B. Shapiro, personal communication, 2001~.
· The NIH has been authorized by the FY2001 appropriation to in-
crease He salary cap on its research grants from $141,000 to $157,000.
· In 2001 He Howard Hughes Medical Institute appointed 5 to 10
new investigators who conducted patient-oriented research. Nominees at
He assistant, associate, or full investigator levels were considered from
medical schools, hospitals, and schools of public health. Most of those
appointed held the M.D. or the M.D./Ph.D. degrees (C. Rhodes, personal
communication, 2001~.
· A growing list of not-for-profit agencies, now numbering at least
12, provide support for the training and career development of physician-
scientists (Chan and Zemlo, 2001~(see Table B.1) in three categories:
fellowships; awards to junior faculty; and awards to senior faculty. The
newest sponsors on this roster are the Doris Duke Charitable Trust and
He Damon Runyon Fund.
· A growing number of academic institutions (e.g., Duke, Harvard,
Johns Hopkins, Yale, UCLA, and Washington University) have devel-
TABLE B.1 Nonprofit Organizations Supporting Training and Career
Development of Physician-Scientists
Stage of Support Offered
Fellow Junior Senior
Organization Faculty Faculty
American Cancer Society
American Federation for Aging Research X
American Gastroenterologic Association
American Lung Association
American Society of Hematology
Berlex Foundation
Burroughs Wellcome Fund
Damon Runyon Fund
Doris Duke Charitable Trust
Leukemia and Lymphoma Society
National Foundation for Infectious Diseases
Rockefeller Brothers Fund
X
X
X
X
X
X
X
X
X
X
X
X
X
X X
X
X
SOURCE: Modified from Chan and Zemlo (2001). The list should be seen as illustrative
rather than comprehensive.
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APPENDIX B
67
aped degree-granting postdoctoral programs in clinical research for
M.D.s. Some of these programs offer a Ph.D. in clinical science; others
offer master's degrees. These multiyear programs combine didactic and
mentored research experience.
· The Association for Patient-Oriented Research was established in
1999 and has already had two annual meetings at which research directly
involving patients has been presented by investigators from departments
of medicine, surgery, pediatrics, and psychiatry. This association now has
more than 300 members from the United States and abroad.
RECOMMENDATIONS
This list of opportunities demonstrates that some of the key players in
the health research enterprise recogruze the imperative to revitalize the
physician-scientist career pathway. These steps are good ones and we
hope will catalyze other actions by these and other participants. But much
more must be done. For example, doubling the number of students in the
MSTP program (as recommended by the Federation of American Societ-
ies for Experimental Biology) is justified by the large applicant pool and
the positive outcome of those so trained. But this action alone will not
solve the problem of M.D.s doing clinical research with patients.
A larger and broader NIH loan repayment program for M.D. post-
doctorals in both the intramural and extramural programs of the NIH
would further mitigate this key economic disincentive. Such a program
should support M.D.s training in basic as well as applied research, be-
cause such diversity of training will enhance the contributions made by
future physician-scientists. In like fashion, tuition relief for medical stu-
dents taking a full year out of medical school to do research would be an
inducement for more students to get this early kind of exposure.
Nonmonetary efforts are also important for revitalizing the pathway.
Medical schools can take steps to make it clear that an interest in research
is one of the qualities sought in their applicants and can strive to reduce
the gender gap in research intentions between male and female medical
students. Successful academic physician-scientists must make it an ongo-
ing priority to talk with students and residents about the excitement and
gratification they have experienced doing research. The NIH and the Na-
tional Research Council should define national goals for the number of
physician-scientists needed in the long term and develop a national data-
base to continuously monitor key trends concerning physician-scientists.
It has taken a generation for the endangerment of physician-scientists
to be acknowledged. It will take at least another generation to restore the
physician-scientist cadre to its rightful size and diversity. Just as medical
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68
APPENDIX B
research is viewed as a national priority that offers hope to sick people,
revitalizing the physician-scientists career paw should be viewed as a
national priority Mat offers hope for the continued success of medical
research.
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Representative terms from entire chapter:
loan repayment
