For 2 decades now, leaders in academic medicine have been sounding the warning that physician-scientists are in diminishing supply and that researchparticularly patient-oriented researchwill suffer as a result.
The problem is apparent at every stage of the medical career pathway: Fewer medical students express interest in research, few are able to take time for intensive postgraduate research training, and once they are full-fledged physicians, few find academic positions attractive. (The latter problem appears particularly acute in oncology; see sidebar, next page.)
The federal government has begun to address these concerns through National Institutes of Health grant programs and other incentives to draw doctors into research, and experts say these are a good start toward a turnaround. But they warn that the problem has deep and widespread roots in the structure and culture of U.S. health care, and these systemic problems will need to be addressed if new generations of physician-scientists are to flourish.
The Medical Science Training Program at NIH sponsors joint M.D.-Ph.D. programs at universities across the nation. Yet "remarkably few" students enroll, said Leon E. Rosenberg, M.D., of Princeton University in New Jersey. Nationally, only about 500 medical students each year graduate with dual degrees, meaning that most physician-scientists get their research training after completing a traditional M.D. degree.
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"You dont become a physician-scientist by taking a cardiology fellowship and spending 6 months out of 2 years doing research ... it doesnt work that way," Rosenberg said. "The science related to medicine has become much more complicated, and whether youre doing laboratory research or patient-oriented research, you have to have a good idea and you have to know how to test it rigorously."
A survey of internal medicine subspecialty training programs, published in the Nov. 21, 2000, Annals of Internal Medicine, found that most programs did not allow fellows sufficient research training to meet requirements of the "research pathway" certification recently set out by the American Board of Internal Medicine.
Medical doctors have increasingly lost out in the competition for NIH funds and hence, so has patient-oriented research. In a 1997 study published in the Journal of the American Medical Association, Gordon Williams, M.D., of Brigham and Womens Hospital and Harvard Medical School, Boston, and co-authors reported that patient-oriented research proposals were less likely to be funded by NIH than laboratory research proposals.
Specifically, patient-oriented proposals had a poor chance of success when reviewed by study sections that reviewed few such proposals. They were more likely to succeed when reviewed by study sections that reviewed at least 50% patient-oriented proposalssections that probably had greater representation from scientists who were expert in patient-oriented research.
Salary Expectations
The economic realities of both medical education and health care present further daunting obstacles to research careers for physicians.
"When medical students graduate with an average debt of $90,000, they have to think not once or twice, but many times, before theyre willing to commit those additional years to something as uncertain as a career as a physician-scientist," Rosenberg said.
NIH and academic medical institutions have begun taking steps to lower some of these barriers. The Clinical Research Enhancement Act, signed into law November 13, 2000, calls on NIH to establish new awards for graduate training in clinical investigation, career development for patient-oriented researchers, and development and support of core curriculum programs for training clinical investigators and medical students and to expand the agencys loan repayment program for clinical researchers to include extramural investigators.
Career Opportunities
But perhaps the biggest challenge, sources said, will be to change the institutional culture that regards research as an expensive drain on physicians revenue-producing clinical activities. A report on physician-scientists and career opportunities by the Federation of American Societies for Experimental Biology, published in the February 2000 FASEB Journal, noted that "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."
Completing a vicious circle, medical students and new graduates witness the pressures their teachers and mentors face in pursuing research careersand most, not surprisingly, choose to steer clear of these in starting their own careers.
"What the students and residents hear is [that] you can be a scientist or a physician, but not both in any meaningful sense," Daniel W. Foster, M.D., of the University of Texas Southwestern Medical School, Dallas, wrote in the August 1999 FASEB Newsletter. "And if the students/residents think they have to give up medicine, they will generally walk away. I believe that the fear of having to leave medicine is a powerful and under-recognized negative force in the decrease in physician-scientists. I think we should be saying exactly the opposite: you can be a scientist and still be a physician. You may, in the long term, be a better physician because of your research."
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