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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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