Congratulations to Colleen Shaddox for a very interesting and timely article in the Autumn 2011 edition [“Is the physician-scientist an endangered species?”]. I published an article in Yale Medicine: Alumni Bulletin of the School of Medicine in the spring of 1972, titled “Sicklemia: The Doctor Bird Visits a Political Arena.” As a student advocate I helped to form the Sickle Cell Committee of South Central Connecticut between the community of New Haven and the School of Medicine. Then I graduated from the School of Medicine in 1973 and have been practicing internal medicine ever since. I’m proud to have left a contribution to the community. It’s important to be able to think outside the box if physicians are to contribute to science or their local communities.
Robert E. Galloway, M.D. ’73, M.P.H., M.B.A.
Concern is expressed in the Autumn 2011 issue about the future of the physician-scientist. Clearly the benefits that medical research has bestowed upon humanity are remarkable, thanks to the efforts and perseverance of research physicians’ inquisitiveness and their relentless pursuit of answers. But do medical researchers necessarily have to be M.D./Ph.D.s?
Almost 100 years ago, Sir William Osler, a respected clinician, author of a widely read medical textbook, and one of the founders of the Johns Hopkins University School of Medicine, believed that medical researchers should confine their labors to research institutes and that physicians should be trained by community-based physicians in private practice. He thought that the separation would be beneficial because it would lead to the training of more practical-minded physicians. Osler also believed that physicians living in the community would bring a practical and humanistic viewpoint to the medical wards that research scientists who are focused on the purely scientific components of illness are incapable of.
But Abraham Flexner—who was an educator, not a physician—held the contrary position. He believed that physician-scientists should be trained in the university and that full-time professors of medicine should train physicians. With the backing of the Carnegie Foundation and the Rockefeller Foundation, Flexner prevailed. The orientation of American medicine has been research-based ever since. Some believe that the lack of primary care physicians is partly due to the disproportionate attention to medical research compared to primary care. The effects of Flexner’s influence on medical education are now being questioned by some medical educators.
The point is that medical research is absolutely necessary for medicine to advance. How much research and what kind, however, are questions that need to be addressed. Osler’s idea of separating physician-clinicians and physician-scientists, as heretical as it may sound today, may have merit. Perhaps fewer M.D./Ph.D.s will not have a generally negative effect on medical progress. Maybe more Ph.D.s working in research institutes and collaborating with physician-clinicians is a model that should be studied.
It would lessen the focus on medical research and place more emphasis on the training of primary care physicians. Is that necessarily a bad thing?
Edward J. Volpintesta, M.D.
In “Is the physician-scientist an endangered species?,” Colleen Shaddox outlines the School of Medicine’s noble efforts to encourage young people to become the medical researchers of the future. The major threat to the developing physician who undertakes basic science research is that this species is a financial liability in most academic departments.
When faculty members are told by their chairs that they must “cover their salary,” they encounter a conflict. On the one hand, a physician-scientist typically needs two NIH R01 grants to pay a significant portion of salary and cover the expenses of doing research. And it is hard to see how one could successfully run such a lab without at least 90 percent effort. To cover the remainder of his or her salary typically means generating income through clinical work. When one considers the costs of seeing patients (malpractice, room rental, administrative support, etc.), however, the break-even time point is typically about 40 percent effort. In the current academic department business model, there simply is not enough time to be an effective basic science researcher and see enough patients to cover the remaining salary costs. The exception to this situation occurs in wealthy departments—either surgical departments or those with profit-generating procedures. To the extent that departments must keep their financial house in order, there is a major disincentive to carry physicians who undertake basic science research. Departments and medical schools must find intrinsic merit in physician-scientist faculty members and support them accordingly, or the physician-scientist will go the way of the dodo bird.
Robert G. Kalb, M.D., HS ’87, FW ’90
Perelman School of Medicine
University of Pennsylvania