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1
Office of Public Affairs, Federation of American Societies for Experimental Biology, Bethesda, Maryland 20814, USA;
* Department of Pharmacological and Physiological Sciences, Saint Louis University, St. Louis, Missouri 63104-1078, USA; and
Washington University School of Medicine, St. Louis, Missouri 63110-1092, USA
1Correspondence: Division of Bone Marrow Transplantation and Stem cell Biology, Washington University, School of Medicine, 660 S. Euclid, St. Louis, MO 63110-1092, USA.
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BACKGROUND |
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 TOP BACKGROUND WHO ARE PHYSICIAN-SCIENTISTS?PERCEPTIONS: THE IMPORTANCE OF...THE DATAEXPANDING RESEARCH OPPORTUNITYDESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...THE IMPACT OF THE...FUTURE OF THE PHYSICIAN...RECOMMENDATIONSREFERENCES |
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. While
apprehension about the survival of physician-scientists had been
expressed previously (2
3
4)
, there are a number of
indications that this problem is becoming more severe. Anecdotal
evidence of the difficulties in recruiting and retaining medical school
faculty has been growing. Increasingly, prominent leaders in the
research community are calling attention to this issue (5
, 6)
. External forces, leading to changes in the finances of
academic health centers, are raising new obstacles to research and
training (7)
. Nominations of physician-scientists age 45
or younger to honorary societies such as the American Society for
Clinical Investigation have declined by almost 30% over the past
decade, suggesting that the pool of talented young investigators is
shrinking. The implications of this situation for the progress of medical research made the question relevant to the mission of the Federation of American Societies for Experimental Biology (FASEB): To enhance the ability of biomedical and life scientists to improve, through their research, the health, well-being, and productivity of all people. At its December 1998 meeting, the FASEB Board voted to initiate an investigation of physician-scientists and career opportunities for biomedical research.
Responsibility for this study was given to the Career Opportunities Subcommittee of the Science Policy Committee, under the leadership of Nicola Partridge. The subcommittee collected and analyzed data on training and research activities from the Association of American Medical Colleges (AAMC), the American Medical Association (AMA), and the National Institutes of Health (NIH). In addition, the subcommittee organized a conference2 to address the following questions:
• Are physician-scientists critical to the success of the biomedical research enterprise?
• What evidence exists that there is a decline in physician-scientists?
• If there is a decline, how might it be reversed or alleviated?
Delegates from the FASEB societies held a closed session at the conclusion of the conference in order to review the data and the panelists’ testimony and to formulate recommendations. Through ongoing communication with the delegates, the Career Opportunities Subcommittee has endeavored to present, along with the data and conclusions from the conference, the consensus-based recommendations of the FASEB society delegates.
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WHO ARE PHYSICIAN-SCIENTISTS? |
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TOPBACKGROUNDWHO ARE PHYSICIAN-SCIENTISTS?PERCEPTIONS: THE IMPORTANCE OF...THE DATAEXPANDING RESEARCH OPPORTUNITYDESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...THE IMPACT OF THE...FUTURE OF THE PHYSICIAN...RECOMMENDATIONSREFERENCES |
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PERCEPTIONS: THE IMPORTANCE OF PHYSICIAN-SCIENTISTS |
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TOPBACKGROUNDWHO ARE PHYSICIAN-SCIENTISTS?PERCEPTIONS: THE IMPORTANCE OF...THE DATAEXPANDING RESEARCH OPPORTUNITYDESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...THE IMPACT OF THE...FUTURE OF THE PHYSICIAN...RECOMMENDATIONSREFERENCES |
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As we enter the post-genomic era, physician-scientists will have the specialized perspectives required to lead evolving fields such as genetic medicine, pharmacogenetics, and bioinformatics. As this research is translated into patient treatment protocols, it is physician-scientists who will have the necessary training and skills to ensure that these protocols are designed and evaluated in ethical and rigorous clinical trials.
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THE DATA |
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EXPANDING RESEARCH OPPORTUNITY |
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TOPBACKGROUNDWHO ARE PHYSICIAN-SCIENTISTS?PERCEPTIONS: THE IMPORTANCE OF...THE DATAEXPANDING RESEARCH OPPORTUNITYDESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...THE IMPACT OF THE...FUTURE OF THE PHYSICIAN...RECOMMENDATIONSREFERENCES |
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DESCRIPTION OF THE PROBLEM: THE CAREER PATHWAY |
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). The number of physicians reporting research as their primary career
activity fell by 6% over the last 17 years, from 15,377 in 1980 to
14,434 in 1997. During the same period, there has been almost a
doubling of those reporting patient care as their principal career
activity for the same period: 376,512 in 1980 to 620,472 in 1997. The
number of M.D. faculty members in basic science departments of medical
schools has also declined from 2381 M.D.’s in 1982 to 2195 in 1996
(Fig. 2A
). Of these individuals, the number who were active in research, as
measured by principal investigator status (PI) on an NIH grant,
declined from 481 in 1982 to 348 in 1997 (Fig. 3A
). In these departments, the decrease in the number of M.D. faculty
members with NIH awards was even greater than the total reduction in
the number of M.D. faculty members: 28% as compared to 8%.
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Even though there has been a large increase in the number of M.D.’s in
clinical departments of the medical schools (Fig. 2B
), there
is a much slower growth in the number of physician-scientists in these
institutions compared to researchers with Ph.D. degrees. For example,
the number of M.D. faculty in clinical departments who were PIs on NIH
grants has risen 26% from 2470 in 1982 to 3103 in 1997 (Fig. 3B
). During this same period, the number of Ph.D. faculty in
clinical departments who were PIs on NIH grants increased 105%, from
1121 to 2296 (Fig. 3B
). As a result, the fraction of NIH
funded researchers in clinical departments who are physician-scientists
has declined. This is further illustrated by the fact that the percentage of the
total M.D. faculty in clinical departments with NIH grants remained
stable from 1982 to 1997 at ~6%, whereas the percentage of the Ph.D.
faculty in similar departments with NIH awards rose from 15% to 23%.
Another measure of the degree of participation of physician-scientists
in the NIH research community, and a reflection of their influence in
the field of biomedicine, is the number of M.D. appointments to
chartered NIH review panels. At both the Center for Scientific Review
(CSR) and the various institutes, there has been a decrease in the
percentage of M.D.’s on chartered review panels. In 1980, M.D.’s made
up 32% of CSR chartered review panels and Ph.D.’s made up 62%; in
1995 these percentages were 19% and 74%,
respectively4
(Fig. 4A
). This decline was even larger for
institute-specific chartered review panels (Fig. 4B
). The 1980 percentage for M.D.’s was 45%, decreasing to
28% in 1995. For Ph.D.’s, the percentage increased from 39% to 55%
over the same period. M.D./Ph.D. percentages for both types of
chartered review panels remained unchanged at around 6%.
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DESCRIPTION OF THE PROBLEM: MEDICAL SCHOOL TRAINING |
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TOPBACKGROUNDWHO ARE PHYSICIAN-SCIENTISTS?PERCEPTIONS: THE IMPORTANCE OF...THE DATAEXPANDING RESEARCH OPPORTUNITYDESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...DESCRIPTION OF THE PROBLEM:...THE IMPACT OF THE...FUTURE OF THE PHYSICIAN...RECOMMENDATIONSREFERENCES |
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). This downward trend is still evident when students graduate from
medical school (Fig. 5)
.
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One explanation for students electing not to pursue a career in
research is the tremendous debt that they incur during medical school.
This financial burden has increased substantially since the middle of
the 1980s. In 1985, only 3% of medical school graduates had debt
greater than $75,000. But in 1998, approximately half of all the
graduates owed more than
$75,000. Since the number of medical school graduates has remained relatively
constant over this time period—15,000 to 16,000 per year—an
increasing fraction of students are graduating from medical school
deeply indebted. This is made more notable by the relatively low
inflation of this period. In fact, the median level of debt for medical
school graduates, after adjusting for inflation, has doubled since 1985
(Fig. 6
).
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Several recent studies have demonstrated that the time spent in
preparation for a research career has lengthened. Although this problem
exists for both M.D. and Ph.D. scientists, its effect on
physician-scientists (with their alternative career opportunities) is
likely to be more career limiting. A committee established by the
National Research Council (chaired by Shirley Tilghman and Torsten
Wiesel) found that the number of young Ph.D. scientists (under age 36)
applying for research grants was declining (8)
. This
finding can be explained by the increasing length of time needed to
prepare young scientists for the transition from student status to that
of independent investigator (9)
.
There has also been a steady shift in the age profile of
physician-scientists with NIH support. In 1977, 56% of all NIH PIs
with an M.D. degree were less than 45 years old, but this percentage
fell to 44% in 1997 (Fig. 7
and Fig. 8A
). Conversely, 44% of all NIH PIs with an M.D. degree were
over 45 years old, and this percentage rose to 56% in 1997 (Fig. 7
and
Fig. 8B
). A similar trend is evident for NIH PIs with an
M.D./Ph.D. degree. In 1977, 54% of this population was less than 45
years old, and this percentage decreased to 41% in 1997 (Fig. 9
and Fig. 8A
). As seen with M.D. NIH PIs over 45 years of
age, 46% of the M.D./Ph.D. NIH PIs were over 45 years old in 1977, and
this percentage increased to 59% in 1997 (Fig. 8B
and Fig. 9
).
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These demographic data of NIH PIs with M.D. and M.D./Ph.D. degrees capture only one-third of the M.D.’s who report research as their primary professional activity to the AMA. While this fraction represents a minority of all physician-scientists, we hypothesize that its age profile reflects the general population of physician-scientists.5 Furthermore, since NIH contributes ~80% of the federal funds budgeted for health research,6 this subset of physician-scientists is vital to the national biomedical research enterprise and represents a critical segment of the physician-scientist workforce.
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DESCRIPTION OF THE PROBLEM: TRANSITION FROM TRAINING TO SCIENTIFIC INDEPENDENCE |
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), and the number of individual M.D. postdoctoral fellows (always
smaller than the number of institutional trainees) declined 43% from
314 in 1985 to 180 in 1997.
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For aspiring physician-scientists, NIH provides mentored training
opportunities that offer higher stipends than traditional fellowships.
One such program, the Mentored Clinical Scientist Development Award
(K08), has seen an increasing number of applications and an average
success rate of 50% (Fig. 11
). Since the inception of the program in the early 1970s, the number of
K08 awards per year has increased steadily to slightly more than 300 in
1998. This program has succeeded in preparing many young
physician-scientists for a career in research (10)
, but it
has not compensated for the absolute decrease in M.D.’s supported by
T32 and F32 fellowships between 1990 and 1997.
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The ability of the K series of awards to promote independent research careers may be impeded by their relatively low salary compared to clinical practice. For the Mentored Patient-Oriented Research Career Development Award (K23), some NIH institutes and centers often have a salary cap of $75,000. Given the substantial debt that many M.D.’s incur during medical school, 3–5 years of K23 support could limit their ability to fulfill their financial obligations and thus deter them from a research-focused career.
One critical objective for all research training programs is the
preparation of young scientists for the transition from trainees to
independent researchers. A hallmark of this progression is the
submission of an NIH Research Project Grant (RPG) application. By
reviewing the number of first-time applicants for RPGs by professional
degree types, one can estimate the overall success in achieving this
goal. For M.D.’s, there appears to be no net growth in the number of
first-time applicants since 1978 to 1998 (average of 825 applicants per
year) (Fig. 12
). The number of first-time Ph.D.
applicants has fluctuated over this same period (average of 2400
applicants per year); however, it is currently in an upward cycle (Fig. 12
). In contrast, the number of first-time M.D./Ph.D. applicants has risen
steadily over the past 15 years, and in fact has more than doubled
since 1984 (Fig. 12)
.
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When physician-scientists do apply for independent awards, the
possibilities for receiving funding are promising. Both M.D.’s and
M.D./Ph.D.’s have similar success rates to Ph.D.’s for NIH
RPGs. The average success rate for unfunded applicants from 1986 to 1995 was
21% for M.D.’s, 22% for M.D./Ph.D.’s, and 22% for
Ph.D.’s (Fig. 13A
). Over those 10 years,
the average success rate for previously funded applicants by degree was
34% for M.D.’s, 31% for M.D./Ph.D.’s, and 33% for Ph.D.’s (Fig. 13B
).
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The parity of M.D. and Ph.D. success rates, however, stands in contrast
to a major differential in application rates. Since the 1970s, the
number of Ph.D.’s applying for NIH grants has grown faster than the
number of M.D. applicants (Fig. 14
). In 1970, ~6000 Ph.D. scientists and 3000 M.D. scientists applied
for RPGs. By 1998, the number of Ph.D. applicants had almost tripled
and the growth in M.D. applicants had approximately doubled. As a
result of this differential rate of growth in applications, the
fraction of the RPGs going to Ph.D.’s rose while the fraction of
grants awarded to M.D.’s declined. Today, just over 70% of the RPGs
are awarded to Ph.D. scientists, with the remaining 30% awarded to
M.D. or M.D./Ph.D. scientists.
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THE IMPACT OF THE MEDICAL SCIENTIST TRAINING PROGRAM |
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. The authors found
that MSTP graduates performed well across a series of outcome measures,
including future academic appointments, grants, and publications. The
review concludes that MSTP graduates have been very successful in
establishing productive research careers. The effect of this
specialized training program on increasing the productivity of
physician-scientists is significant: M.D./Ph.D.’s make up ~2.5% of
the medical school graduates each year, yet they hold about a third of
the NIH grants going to physician-scientists. Of the 38 NIH-funded MSTPs in 1999, one of the best documented is at Washington University School of Medicine in St. Louis, Missouri. Established in 1968, it currently has 153 participating students. According to Stuart Kornfeld, the school’s former MSTP director, there has been a total of 276 graduates. Approximately 5% of the graduates have gone directly into postdoctoral research fellowships; the other 95% have entered residency-training programs.
Graduates of the Washington University School of Medicine’s MSTP illustrate the program’s potential: most of its graduates hold academic positions (74%), with the rest being somewhat equally divided among positions at NIH, industry, and private practice. Of the MSTP graduates from Washington University holding academic positions, 85% are involved principally in basic or disease-oriented research, 8% conduct patient-oriented research, 3% perform a mixture of both basic and clinical research, and 3% are not engaged in research. At the same time, the majority of Washington University MSTP graduates still devote some time to clinical activities (Stuart Kornfeld, M.D., personal communication).
Although the Washington University program and other MSTPs have clearly promoted the training and career development of physician-scientists, these programs cannot be the only means by which to increase the number of physician-scientists. Since the majority of MSTP graduates perform primarily basic research or disease-oriented research, other programs are needed to assist those individuals who are more interested in doing patient-oriented research. Moreover, MSTPs almost exclusively capture students who decide to become researchers before they begin medical school. Additional measures will be necessary to identify and train students who become inspired to pursue research careers at later times in their medical education.
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FUTURE OF THE PHYSICIAN–SCIENTIST: CONCLUSIONS |
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Special training and the good possibility of funding, however, do not appear to have increased the traffic along the career pathway. There has been a decrease in the number of M.D.’s in basic science departments of medical schools holding NIH research grants, and less growth of NIH-funded M.D.’s in the clinical sciences, as compared to Ph.D.’s and M.D./Ph.D.’s. These facts, together with a decreasing proportion of NIH award holders under 45 years old, indicate that there are a declining number of successful young physician-scientists.
Anecdotal evidence suggests that the financial constraints brought on
by managed care and other external financial pressures on academic
health centers are forcing many physician-scientists to abandon
research. Data suggest that there is a correlation between the market
penetration of managed care and a decline in NIH awards to academic
health centers (12)
. Specifically, for those
physician-scientists who are also involved in patient care, increasing
clinical demands can sometimes lead to less time for research and grant
writing. As a result, these physician-scientists are at risk of
becoming less competitive. Another deterrent is that
physician-scientists usually earn less money than they could in private
practice. Consequently, if current trends continue, the scientific
contributions of physician-scientists and their mentoring of future
medical researchers will be threatened.
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RECOMMENDATIONS |
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The underlying principle guiding the practice of medicine is the scientific method. The practice of medicine should be evidentiary, based on scientific facts, and guided by ongoing research. The training physicians receive must prepare them for the post-genomic era, so that they will be able to use this information effectively in caring for their patients. The importance of research and scientific training for all physicians (not only physician-scientists) should be a bedrock principle in the curricula of medical schools. FASEB society members teaching undergraduate students should emphasize these principles, and undergraduate faculty advisors should be aware of opportunities for physician-scientists. Medical school admissions committees should value exposure to research. In medical school, scientific methods and research should be appropriately emphasized, and mechanisms should be in place for students to receive research training as part of their medical school experience, if they so desire. Physician-scientists must serve as role models for medical students by participating actively in the classroom, the laboratory, and the clinic.
2) Choosing the Career: A national program for medical school debt forgiveness should be established for physicians who receive rigorous research training and pursue research careers.
The large debt facing most medical school graduates is a disincentive for the prospective physician-scientist. For this reason, FASEB favors a national program that would reduce the indebtedness of medical school graduates who train to become physician-scientists and pursue research careers. Such a program would most likely capture late bloomers, whose interest in science develops directly out of experiences in medical school or through postgraduate clinical training. For these individuals, the large medical school debt burden represents a very real impediment to choosing this career since stipends paid during research training are substantially less than can be earned in clinical practice. Models for a debt reduction program have been proposed, and some have been used on a limited scale within selected target areas. FASEB recommends that an experimental program, sponsoring at least 100 M.D.’s per year, be initiated within 2 years. This program would include analytic features that would allow for an evaluation of its effectiveness. The Federation will immediately begin to work with appropriate agencies to design and implement such a program.
3) Stabilizing the Early Career: The NIH and other appropriate foundations should substantially expand the support for the training and mentoring of physician-scientists.
The support for M.D./Ph.D. programs and early career mentored
programs should be expanded substantially within the next several
years. Currently, there are at least 400 M.D./Ph.D. graduates annually
in the United States (13)
. FASEB recommends that the size
of these programs be doubled over 5 years, so that a substantial
increase in the pool of entry-level physician-scientists will be
realized in ~10 years. However, the expansion of M.D./Ph.D. programs
alone will not adequately meet the need for physician-scientists. There
must be additional support for postgraduate research training, for
physician-scientists who are undergoing mentored training, and for
physician-scientists who have just become independent researchers.
Disincentives to careers in research (e.g., low salary caps and salary
restrictions for the PIs of mentored K series awards) should be
removed.
4) Stabilizing the Established Career: Favorable institutional cultures must be developed in academia to support physician-scientists throughout their careers.
Because of the increasing financial constraints placed on academic medical centers by managed care and other external forces, physician-scientists are being asked to assume more clinical responsibilities. This problem is now causing many physician-scientists to choose between research or clinical practice, a choice that prevents them from maximizing contributions to research and medicine. Leaders of academic medical centers should acknowledge the uniqueness of this career and develop specific measures at their institutions to protect this role. Reasonable clinical workloads must be maintained for physician-scientists. Teaching and reviewing responsibilities of physician-scientists must be valued in the same manner as clinical responsibilities. The NIH, in cooperation with academic medical centers, can help support physician-scientists by facilitating beneficial collaborations among M.D. and Ph.D. scientists (e.g., by allowing true coinvestigator status for M.D.’s and Ph.D.’s on grants) and using the special skills of physician-scientists on peer review panels. As medical school departments become more diverse, establishing a research culture that supports interactions among faculty of different disciplines and training will be critical for maintaining the competitiveness of their scientists and thus, their institutions.
5) Tracking the Career: Additional information must be collected to define the problem further and to monitor the outcomes of corrective efforts.
Although FASEB and other organizations have identified problems in the supply of physician-scientists, there are inadequate data to develop precise national goals. Moreover, there is insufficient information to determine why young physician-scientists are turning away from this career. This lack of information impairs the ability of planning organizations to make timely recommendations for corrective measures. FASEB suggests that organizations like NIH, the National Academy of Sciences, AAMC, and others should continuously monitor the physician-scientist issue as solutions are proposed. These data will help to identify trends early, evaluate corrective measures, and ensure that this crucial scientific and health care resource is not irreversibly depleted.
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ACKNOWLEDGMENTS |
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Abul Abbas, M.D., The American Association of Immunologists
Peter Aronson, M.D., The American Physiological Society
William Balke, M.D., Biophysical Society
Ross Feldman, M.D., American Society for Pharmacology and Experimental Therapeutics
Myron Genel, M.D., The Endocrine Society
David Korn, M.D., American Society for Investigative Pathology
Albert Mildvan, M.D., American Society for Biochemistry and Molecular Biology
Eric Orwoll, M.D., The American Society for Bone and Mineral Research
Henry Ralston, M.D., American Association of Anatomists
Samuel Silverstein, M.D., The American Society for Cell Biology
Michael Sitrin, M.D., American Society for Nutritional Sciences
Jerome F. Strauss III, M.D., Ph.D., Society for the Study of Reproduction
Michael Welsh, M.D., American Society for Clinical Investigation
In addition, the authors are grateful to all the speakers at the FASEB conference on Physician-Scientists and Career Opportunities for Biomedical Research:
Franklin Adkinson, M.D., Johns Hopkins University School of Medicine
Irwin Arias, M.D., Tufts University School of Medicine
Roger Bulger, M.D., Association of Academic Health Centers
Franklin Bunn, M.D., Brigham and Women’s Hospital
Setsuko Chambers, M.D., Yale University School of Medicine
Daniel Foster, M.D., University of Texas Southwestern Medical Center
David G. Kaufman, M.D., Ph.D., University of North Carolina, FASEB President
David Kipnis, M.D., Washington University School of Medicine
Ruth Kirschstein, M.D., National Institutes of Health
Stuart Kornfeld, M.D., Washington University School of Medicine
Joseph Martin, M.D., Harvard University School of Medicine
Leon Rosenberg, M.D., Princeton University
Kenneth Shine, M.D., National Academy of Sciences
James Wyngaarden, M.D., Duke University (Emeritus)
The authors extend a special thanks to Leon Rosenberg for his assistance with conference organizing, manuscript preparation, and review; Stuart Kornfeld for thoughtful discussions and critical input; and Michael Brown, Alan Schechter, and Lawrence Shulman for their advice on conference planning. The authors would also like to express their gratitude to Robert Moore, Walter Schafer, and Ronald Geller for help with the collection and interpretation of data; Mike Stephens for technical comments and counsel; Sandy Drury, Rosemarie Soulen, Bonnie Litch, and David Stephens for their contributions in the development of the conference; FASEB Career Opportunities Subcommittee members, Thomas Knudsen and Edward Benz; and Christopher White for helping prepare the figures.
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FOOTNOTES |
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3 Major professional activity is defined by the AMA as the activity in which a physician engages for the greatest fraction of the average number of hours worked per typical week.
4 A small fraction of members had other degrees.
5 The authors are not aware of any databases that track the age demographics of non-NIH funded physician-scientists.
6 http://www4.od.nih.gov/ofm/PRIMER97/page6.stm.
7 Postdoctoral fellows are also supported as research associates on NIH research grants. There are no comprehensive data, however, on the characteristics of individuals supported in this way.
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REFERENCES |
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