Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 107
TRAINING OF PHYSICIAN/SCIENTISTS
Lloyd H. Smith, Jr. *
This memorandum is directed to certain topics relating to
the role of physician/scientists in the conduct of the nation's
biomedical research program and how national policy should be
shaped to ensure that a sufficient number of physician/scientists
are available to play that role in the future. The memorandum
does not concern itself with the training and supply of Ph.D.
scientists, although this is clearly an increasingly convergent
problem. Nevertheless, many of the points raised here may have
more universal applicability to all scientists who direct their
attention to biomedical investigation. The following questions
are addressed briefly:
1. Is there a need for physician/scientists as opposed to
or in addition to basic scientists in the conduct of
biomedical science, both in our academic health science
centers and wherever else that form of science is
conducted?
Are there deficiencies in number or quality in the
current and projected supply of physician/scientists?
3. How many physician/scientists should be trained?
4. What are the best methods for recruitment and training
of physician/scientists?
How can the effectiveness of training programs be
evaluated?
Other questions could be formulated. If answers to the above
five questions could be approximated with a reasonable degree of
accuracy, however, they might serve as a basis for a rational
national policy.
SPECIAL ROLE OF THE PHYSICIAN/SCIENTIST
A generation ago "medical research" was carried out largely
by physicians, most of whom had relatively little formal training
-
* The opinions expressed in this paper are the author's and do
not necessarily reflect those of either the Committee on
Biomedical and Behavioral Research Personnel or the National
Research Council.
OCR for page 108
in science beyond that offered in the medical school curriculum.
Probe ems were identified in clinical medicine and then pursued to
whatever depth the investigator was able to penetrate from
previous experience or from techniques acquired for that specific
purpose. Few physicians sought rigorous training in biological
science per se paralleling the demanding schedules required for
obtaining and maintaining clinical competence. The science
taught in specialty divisions of departments of medicine,
pediatrics, neurology, and so on tended to be both goal-oriented
and superficial. For a few clinical investigators of genius,
this approach to medical research could be highly productive, but
most medical investigators were poorly prepared for sustained
scholarship. For some, NTH offered both a sanctuary and a
postgraduate school for learning science in depth, and the
success of that experience is evident everywhere today
in American academic medicine. The "doctor's draft" of the past
brought with it, almost as a gratuitous byproduct, a great
improvement in the quality of medical research in the United
States.
During the last 30 years, the scope, scale, and
sophistication of research into human (and eukaryotic) biology
have been enhanced enormously. As a result, it has become the
domain of the professional scientist rather than of the inspired
amateur. The study of human biology in the broadest sense has
spread far beyond hospitals and even medical schools and is being
pursued intensively and successfully in universities and
institutes with no direct commitment to medical care (e.g., MIT,
Cal Tech, Harvard College, and University of California-BerkeJey)
and by individuals who have not been trained in medicine. These
trends are clearly evident and can be documented easily by
analyses of the flow of NIH and NSF funds.
What do these trends mean for the application of current
revolutionary advances in biology to the prevention and treatment
of human diseases? This, after all, is the basic concern of the
citizens who support this science. In partial answer, several
points are worthy of emphasis:
1. The remarkable progress in basic biology brings with it
parallel new opportunities for human application in
"clinical investigation." The seminal retrospective
studies of Cumroe and Dripps (1976), for example,
showed quite cd early that technical advances directly
applicable to the care of patients with cardiovascular
and respiratory diseases depended heavily on basic
research (about 40 percent in their arbitrary
definition). In effect, there is no real discontinuity
between the most fundamental basic biological science
and the technology of modern medicine.
108
OCR for page 109
2. Clinical research is not simply that which is performed
by a physician. Many basic scientists carry out
excellent clinical research, and some of the research
done by physicians is clearly basic science. It is
difficult to supply an unambiguous definition of
clinical research. As a beginning r one can say that it
is research directed toward the elucidation and,
therefore, the control of a human disease either
directly or with a reasonable degree of intellectual
continuity.
3.
4.
_ ~
The physician/scientist is more likely to tilt in the
direction of clinical research, as defined above, than
is the basic scientist. This is stated as an article
of faith, based on the following driving forces:
a. He or she is more likely to be aware of the
existing problems in human health and disease and
also what is important to do and what is feasible
to do. This awareness is not only the product of
medical education but also of the imperatives of
daily experience.
b. He or she. is more likely to have a primary
commitment to this type of applied research
because of intrinsic interest and also because of
the reward systems in the environment in which he
or she pursues a profession (department, school of
medicine, national peer network, and societies).
The physician/scientist is of particular importance in
medical schools in order to translate the current role
and future potential of basic science during the
education of future practitioners. Those currently in
medical school and in postdoctoral training will have
their main professional experiences in the twenty-
first century. That fact implies enormous changes in
the technological basis of medical practice in ways
that cannot now be foreseen. Only those educated in
the spirit of scientific inquiry can hope to remain
abreast of this continuously changing frontier.
Uniquely in medicine, the university is involved
directly in operating a major industry--that of health
care. In all other disciplines the university is
divorced from the direct practical application of what
it learns and what it teaches. In this type of
"industrial setting'' that exists in the clinical
departments of all medical schools, it is of particular
importance to have those who can serve on the interface
between what is best in science (the university role)
and what is best in medical practice (the industrial
109
OCR for page 110
role). This can best be done by those who have
authentic credentials in both domains.
For all of these reasons, and perhaps others as well, it is
very important to maintain a strong contingent of physician/
scientists in American medicine, recognizing that they may have
to compromise somewhat in both areas of activity. They are
unlikely to be the best clinicians in their respective hospitals
because clinical skills are not honed in the laboratory, and they
may not be the most productive scientists because they will need
to commit extra time for maintaining basic clinical competency.
Uniess some are successful in such an amphoteric existence,
however, medical schools will fragment into "two societies," as
C. P. Snow described in another context some years ago.
SUPPLY OF PHYSICIAN/SCIENTIST8
Do we have a
the present time?
although this is
First of all, the
Perhaps we should
which to attempt
effectiveness of
competition for
greater concern
committee that
scientists for
sufficient number of physician/scientists at
The general consensus is that we do not,
an area in which it is difficult to obtain data.
physician/scientist is not a standard unit.
invent a new scale of "competency units" in
such measurements. The diminishing
the physician (in comparison to the Ph.D.) in
NIH support has been well-publicized. Perhaps of
is the difficulty encountered by every search
seriously attempts to identify physician/
academic appointments within even our most
prestigious, research-intensive medical schools. Within given
disciplines (e.g., cardiology, gastroenterology, etc.), the
number of physician/scientists who have attained some clinical
competence and who could also meet the stringent criteria for
scholarship for appointment in a basic science department is
incredibly small. It is widely perceived that the paucity of
such individuals who are competent in modern science and some
phase of clinical medicine is the main limitation in our ability
to move ahead quickly in modern clinical research. This is the
most valid reason for the current move to create institutes or
departments of "molecular medicine," or some variation on that
theme, in order to obtain the climate in which such work can
prosper. But the number of currently available physician/
scientists who can do distinguished work in these areas is
limiting. In summary, we may have a reasonable number of
physicians who have participated in some form of research, but we
do not have enough who have undergone rigorous preparation for
scientific careers.
HOW MANY PHYSICIAN/SCIENTISTS SHOULD BE TRAINED?
An excess. This is not a facetious answer. Scientific
ability does not parallel intelligence and hard work. Some very
bright people are relatively ineffective as working scientists;
110
OCR for page 111
others less intellectually gifted are highly competent as
scientists. Creativity in science cannot be predicted with any
confidence; it can only be demonstrated over time. The cost of
scientific training is comparatively modest when balanced against
projected expenditures during a career in science. For all of
these reasons, it is a better strategy to train an "excess'' of
scientists and then to continue to support only the best for
subsequent research. The basic purpose of science policy, after
all, is not to employ scientists but to ensure that the nation's
goals in research and education be met. Therefore, the focus
should be on the results obtained rather than on the number of
scientists employed. There are many secondary gains for expanded
training of physician/scientists, even for those who do not
remain in this arena of activity. For science itself they
furnish useful workers who contribute to the completion of the
investigative projects in which they are being trained. Of equal
importance, the individual benefits from learning further about
scientific method and thereby is better prepared to evaluate
medical progress and to learn to adapt to a career in the
practice of medicine for the twenty-first century. Extra
scientific training for the physician should not, therefore, be
considered as a waste of resources.
The ability of our nation to predict future work force needs
has not been impressive in science or in medicine. It is
patently impossible to predict with any degree of precision the
needs for a system that is undergoing vast fluctuations. Because
of this, it is generally more prudent to overshoot rather than
undershoot, particularly in view of the fact that the process of
training a physician/scientist is a very long one, perhaps eight
to ten years. This process is, therefore, inherently sluggish in
its response to market forces or attempted social engineering.
Even if it were possible to predict with some precision the
number of future available positions for physician/scientists in
academia, industry, public service, and other venues, this figure
would not furnish a rational basis for the number to be trained.
As noted previously, investigators vary widely in productivity
and creativity and therefore do not represent a standard product.
There is probably a finite pool of candidates who are capable of
the highest level of sustained creativity. The real challenge in
scientific work force policy is to identify the candidates and to
bring them to fruition as scientists, realizing that this can be
done only by training many and choosing the best from among them.
Methods for Recruiting and Training Physician/Scientists
Current Barriers
It might be useful first to consider briefly the current
barriers to attracting the best young physicians into scientific
careers. Since there are few useful data concerning this
theories abound. Some are as follows:
111
OCR for page 112
5-
1. The deterrent effects of personal indebtedness. Here
data are available concerning the increasing
indebtedness of medical school graduates (about
$30,000-$40,000 for public schools and about $40,000-
$60,000 for private schools, with wide ranges beyond
these averages). Such debts clearly reduce the ability
of the student to electively undertake yet further
training at low compensation directed toward a career
with modest long-term fiscal rewards.
2. The increasing stretch in trying to maintain competency
in both science and medicine as both become more
demanding. This creates continuing tensions for the
individual who attempts a career that bridges both
domains.
The perceived insecurities of academic life based on
the vagaries of short-term extramural funding for
research. Current investigators transmit these
insecurities to those who are considering similar
careers.
The current "industrial turmoil" in clinical
departments as they contend with the demands for health
care delivery and financial viability in a time of
change. The resulting harassment is not lost upon the
young.
Possibly changing levels of expectation. More students
are married or have other elective obligations than in
the past and may be less willing to undergo the longer
periods of relative privation to prepare for a research
career.
The attractiveness of medical practice. Some of this
attractiveness relates to the immediacy of personal
gratification in helping other human beings as opposed
to the qualitatively different and often deferred
rewards of medical research.
There are many other factors as well, including the absence
or paucity of suitable role models, jam-packed medical school
curricula based on fact engorgement rather than on problem
solving, and the end of the doctor's draft. Obviously, all of
these deterrents will occur in a different silhouette for each
student.
General Principles of Training
There is no single best method of training the physician/
scientist (i.e., best for each individual and for every setting).
312
OCR for page 113
It is noted that most scientists tend to recommend the type of
pathway that guided their own careers. This topic can be
considered usefully under four headings:
1. Entrapment of the young: Ideally, there should be a
period of research prior to or during medical school in
order for the student to decide whether he or she
enjoys this activity and is good at it (the two factors
generally coexist). Time should be made available for
this in the medical school curriculum or in
arrangements for summer laboratory experiences. It is
important for every student to learn something in
depth--to penetrate to the frontier of knowledge,
however narrow the subject may be. For some the
intense trial period for research may be extended
usefully for up to a year. Such a period is necessary
in order for both the student and the sponsoring agency
or department to decide whether a more extensive
investment of time and money is warranted in his or her
· ~
. ralnlng.
2. Training in depth : It is imperative that the serious
physician/scientist receive training in depth in a
scientific discipline relevant to medicine. It is both
inaccurate and arrogant to assume that the intensive
professional training of a physician prepares him or
her to compete in modern biological science with a
scientist who has undertaken the rigorous discipline of
a Ph.D. degree. Rarely can this type of training in
science be achieved in a specialty division of a
clinical department (although there are some exceptions
here). Whether this training fulfills the formal
requirements for a Ph.D. degree probably is immaterial,
but it should be comparable to such a program in rigor
and scope. During this time, the physician should not
attempt to carry out parallel clinical duties, which
will only serve as a diversion from his or her critical
opportunity to become a serious scientist (or to
demonstrate to himself or herself and to others that
such a career is not his metier).
3.
Coordination of scientific and clinical training: The
coordination of clinical and scientific training is a
vexing problem that defies an easy solution. This
simply presages, however, the future problems that the
physician/scientist will have throughout his or her
subsequent career in coordinating a role as both a
physician and a scientist. In general, there are two
approaches, each with some advantages and
disadvantages:
113
OCR for page 114
a. Pre-M. D. scientific training: The prototype here
is the M.D./Ph.D. program. The advantages are an
earlier commitment to science in depth and
continuity with the standard basic science of the
medical school curriculum. Another advantage is
that the individual has this extra scientific
competency at his or her command during the
intensive clinical experiences of the senior year
of medical school and the years of residency
training. The obvious disadvantage is the
enforced hiatus (usually at least three years)
between the completion of thesis work and the
chance to return to full-time science. Many of
these same considerations would hold for more
extensive non-Ph.D.-directed scientific experience
during medical school or for the individual who
has obtained a Ph.D. prior to entering medical
school.
b. Post-M. D. scientific training: The prototype here
is NIH or NIH-equivalent experience that many
current investigators obtained in the past. The
advantages are that at this stage of maturity the
individual is perhaps more likely to know his or
her future plans and also that the work can
continue without serious interruption following
the training period. A theoretical disadvantage
is that the individual may by now have firmly
decided upon a clinical career without having had
a serious look at the alternative of research. In
addition, accumulated debts may by this time have
diminished the feasibility of investing the
necessary additional years for research training.
Either model can be effective as demonstrated by
those in academic medicine today. In this brief
outline above, little consideration was given to
the financial implications of these alternatives,
since these would vary depending on the existing
means of support--for example, the full support
provisions of the federally sponsored MD/POD
program.
4. Launching a career: The beginning years of a career as
a physician/scientist are of vital importance as the
individual attempts to establish an independent program
as a scholar. During this transitional period, such
individuals require protected time and should not be
required to participate as heavily in departmental
activities (patient care, teaching, and university
service) as do those who are not making a similar
effort to bridge basic science and medical research.
114
OCR for page 115
This topic is directly pertinent to the future supply
and viability of physician/scientists in clinical
departments, but it is not discussed here further.
MODELS FOR TRAINING IN DEPTH
As noted previously, there are many possible models for
training for research for the physician/scientist. Individuals
with exceptional motivation and talent can develop successful
scientific careers through any one of these or other pathways.
1. M.D./Ph.D. programs: In the M.D./Ph.D. programs the
student pursues a regular Ph.D. degree, usually after
the second year of the standard medical school
curriculum, in one of the basic science departments of
his or her institution. The Ph.D. training often can
be somewhat truncated (three years) because of the
student's previous course in science, but it is usually
not shaped specifically for the physician-to-be. These
programs have been judged to be highly successful as
judged by the number of participants who have remained
active in science and who have achieved independent
research funding through peer review mechanisms. The
pros and cons of this mode of training for research
have been listed previously. Data concerning the
outcome of NIH programs are readily available. It is
the general opinion that this pathway should be
retained and expanded. Not least of the positive
features is that the trainee usually is able to avoid
or attenuate the burden of personal debt. Since these
programs are well-defined and have been analyzed
thoroughly, the M.D./Ph.D. pathway is not considered
further here. It seems clear that such programs should
continue to receive high national priority.
2. Postdoctoral fellowships for the physician/"cientist:
At least three years of rigorous training in modern
biological science usually is necessary for most
individuals, however gifted, to arrive at a stage of
independence as an investigator (Goldstein, 1986~. In
fact, the period of time may be longer and require the
equivalent of the "post-doe" experience that is now de
rigueur for Ph.D. recipients. For those who are
training for a career in research, this time should not
be diluted with simultaneous clinical responsibilities,
which inevitably serve to divert attention and energies
elsewhere. Preferably, this experience should be in an
active basic science laboratory that is on the cutting
edge of some discipline that is ultimately applicable
to medical research and that is in the usual
predoctoral, postdoctoral climate of competitive ideas
and productivity. Since the boundaries of modern
115
OCR for page 116
biological science are pervious, it is not particularly
important whether the nomenclature of the department is
that of cell biology, molecular biology, biochemistry,
or microbiology. The same powerful methodologies of
working with peptides, proteins, receptors, DNA, RNA,
monoclonal antibodies, and so on can be acquired and
will have ultimate applicability to virtually any
problem relating to the pathogenesis and treatment of
human disease. Beyond the methodologies--and even more
vital--the nascent physician/scientist will be honed in
the rigors of defining problems and learning how they
can be approached rationally. The physician in
training to become a physician/scientist should not be
concerned that the problems being pursued seem
excessively fundamental and far from human biology. It
is always easier to move from that which is very basic
to that which is applicable than to try to learn
selective elements of experimental biology as the need
arises in clinical investigation.
One approach has been to establish a program of
national fellowships for the postdoctoral training of
the physician/scientist. It is useful to analyze the
current program of the Markey Foundation (which is
scheduled to be phased out over the next few years).
In this program provision is also made for some
assistance for the physician/scientist at the entry
level of beginning faculty membership. Similarly, the
Physician/Scientist Award program of NIH has endorsed
this approach over the past five years, so that
experience is beginning to accumulate about its
effectiveness.
3. Postdoctoral training programs for the physician/
scientist: The M.D./Ph.D. program and the individual
fellowship program for training in science were
described briefly above. In general, there has been
considerable experience with both modes of training.
Formalized training programs for physicians usually
have been established as appendages to specially
divisions of clinical departments (e.g., in
gastroenterology, cardiology, endocrinology, etc.~.
The scientific training that such divisions can supply
rarely approaches that available in basic science
departments. Also, it is diluted frequently by
simultaneous training in the parent medical discipline.
It is not surprising, therefore, that many of the
physicians so trained quickly leave investigative
careers to enter the practice of their respective
specialties. Although this process has continued to
ensure a supply of scientifically trained clinicians,
teachers, and clinical investigators, it has not
116
OCR for page 117
sufficed to develop physicians who are sufficiently
well-grounded in the fundamental sciences for sustained
scholarship.
These considerations have led to proposals for new
forms of institutional postdoctoral training programs
that would be shaped more specifically for the
production of physician/scientists. Such a successful
program should contain the following elements:
a. It should represent a true consortium between the
clinical and preclinical departments of the
institution with equal responsibility for the
design and administration of the program.
b. Selection of the trainees should be made during
the senior year of medical school, based on
evidence of some previous experience in research
and overall promise. Selection and planning then
can be coordinated for both basic clinical
training and subsequent scientific training. It
would be advantageous to have the basic science
departments participate in the selection process
in order to ensure their commitment to those who
enter the coordinated program.
c.
Formal course work in the physical and biochemical
sciences should be an integral part of any such
program so that its graduates command a
theoretical background comparable to that obtained
by those with graduate degrees in the biological
sciences. The extent of the required course work
can be individualized based upon the level of
prior training, but it should be rigorous and at
the graduate level in the relevant disciplines
(biochemistry, genetics, molecular biology, cell
biology, etc.~.
The training program should be for not less than
three years, of which most will be invested in
direct research experience under the supervision
of a mentor.
At the completion of this training period, which
often may be extended beyond the formal three-
year program, most of the physician/scientists
will rejoin their respective clinical departments
for subspecialty clinical training in their chosen
disciplines. Some will elect to remain in basic
science and will enrich those disciplines with
their breadth of training and interest in human
biology.
117
OCR for page 118
EVALUATTON OF PROGRAMS
Science is what scientists do. The logical approach would
be to evaluate the scientific achievements of those who have
completed a given type of training. Obviously, this is much more
difficult to do than it seems at first. It is usual, therefore,
to use as a surrogate a number of indirect indices, such as the
number who remain in an academic environment, those who have
successfully attained an RO-1 grant, or those who have remained
active in research (as judged usually by grant activity) after
some arbitrary period of time. None of these measures is very
satisfactory since the quality of science is not appraised, other
than its success at securing competitive funding. In a sense,
the appraisal has been transferred to the respective study
sections.
One can use other indices of peer recognition, such as
election to elitist scientific societies, or one can use citation
criteria or arbitrary assignments of value to publication in
certain of the more stringently reviewed journals. Ultimately,
most evaluations are highly subjective. Furthermore, they cannot
be readily made except over extended periods of time in view of
the natural history of a scientific career.
There must, therefore, be an element of faith. A program
that enhances the exposure of students to science as a creative
process (rather than a repository of inert facts) and that
encourages and supports those who wish to pursue rigorous
scientific training in depth must be assumed to increase the
chance that those who are most qualified will more likely pursue
careers as physician/scientists. Intuitively it seems so. NIH
experience of the years of the doctors draft seems to support
this supposition. It is not a rigorous method of assessment, but
it may have to suffice. Further-more, as noted previously, those
who fall out of the system, that is, do not have sustained
careers as productive physician/scientists--cannot be judged
flatly as failures since they may well be more capable of
adapting to the complexities of the practice of medicine in the
twenty-first century.
SUMMARY
In a sense, this brief position paper is in itself a summary
of an opinion without formal documentation. Several points seem
worthy of emphasis in future policy concerning the training of
physician/scientists:
1. There is a special need for physician/scientists in the
conduct of the nation's biomedical research. The
increasing interest and involvement of Ph.D. scientists
in medical investigation are of great importance and
118
OCR for page 119
benefit, but this does not replace the need for
physician/scientists.
2. The number of wel1-qualified physician/scientists is in
short supply now and will continue to be limiting in
current projections. As a result, there are missed
opportunities for the rapid application of modern
biology to medical problems.
3. Our ability to predict work force needs is inexact,
based on past record, and the responsiveness of the
production system is sluggish inherently because of the
long pipeline and other variables. Therefore, it is
wiser to overshoot rather than undershoot in
projections of work force needs.
The physician/scientist is not a unit of scientific
competency and productivity. The nation should be less
interested in the exact number of FTEs employed than in
the pace of scientific progress. A wise policy
therefore would be as follows:
a.
to train larger numbers of physician/scientists
but retain only the best in scientific careers;
and
b. to accept the fact that this investment in
training gives value received even for those who
do not remain in science:
5.
o The cost of training is low in comparison
with the ultimate investment in the
scientific work of those supported; hence,
pays to allow for the choice of the best,
based on performance in research.
The "trainees" are, in fact, modestly
reimbursed laboratory workers who contribute
great value to the direct conduct of research
during their so-called training periods.
O Those who leave science return to medicine
better prepared to apply more critically the
science of the future in their respective
professional careers.
Four phases of training that can be defined
arbitrarily:
a. Entrapment : Early research experience for the
medical student will help to define those who have
interest and competency in research.
119
OCR for page 120
b. Training in depth : This requirement is noted
below.
c.
Coordination with clinical training: The
physician/scientist must balance proficiency in
both domains.
. Launching of an independent scientific career:
The early years of a scientific career require
special consideration and protection.
6. Training in depth usually requires at least three years
of experience in some phase of basic biological
science. This is absolutely necessary if the physician
is going to be able to serve effectively on the
frontier between the best in science and the realm of
medical research. Rarely can this be achieved in a
clinical department as they are now constituted.
A number of pathways have been successful in offering
to physicians this kind of training for proficiency in
science. All of these models, which were described
briefly here, can offer training in depth and should be
continued in a balanced national program for training
physician/scientists:
a. the M.D./Ph.D. programs;
b. national fellowship programs; and
c. postdoctoraI training programs for
physician/scientists.
The last category of specific training programs
probably warrants the most attention, since such
programs currently are less well-defined.
REFERENCES
Cunroe Jr., J. H., and R. D. Dripps. 1976. Scientific basis for
the support of biomedical science. Science 192 : 105-111.
Goldstein, J. L. 1986. On the origin and prevention of PAIDS
(Paralyzed Academic Investigator's Disease Syndrome):
Presidential address delivered before the 78th annual
meeting of the American Society for Clinical Investigation,
Washington, D.C., May 3, 1986. Journa 7 of C7inica 7
Investigation 78:848-854.
120
Representative terms from entire chapter:
biological science
