Is the physician-scientist an endangered species?

One of the challenges of interviewing Danny Balkin is that he keeps asking the questions—about the writing process, the state of journalism, and the quality of frozen yogurt purveyors in New Haven. If there is such a thing as a born investigator, Balkin is one. The M.D./Ph.D. student’s face widens into a kid-in-a-candy-store smile as he talks about the possibility of harnessing his laboratory’s basic research to benefit families whose sons have Lowe syndrome—a rare X-linked genetic disorder that causes mental retardation, kidney disease, and cataracts in boys.

Balkin works in the lab of Pietro De Camilli, M.D., Eugene Higgins Professor of Cell Biology and professor of neurobiology, on research intended to illuminate the mechanisms of Lowe syndrome. That connection to real-life patients is critical for Balkin, as it has been for generations of physician-scientists who tailored their investigations to solve clinical problems. Yet voices in the medical and research communities have warned of a looming shortage of physician-scientists since the 1970s. From 1983 to 1998, according to a 2002 article in The New England Journal of Medicine, the percentage of physician-scientists in the United States dropped from 4 percent of the total number of doctors to 2 percent.

Still, much of the evidence surrounding the issue remains anecdotal. Moreover, as Ann C. Bonham, Ph.D., chief scientific officer of the Association of American Medical Colleges (AAMC), asks, just what is a physician-scientist? Bonham believes that the definition goes beyond simply physicians with dual degrees. “Having a broad definition of physician-scientists is very important,” she said. “We have come to think about it as physicians who are engaged in some form of science—whether it’s basic science, clinical research, health outcomes research, community-based participatory research, or prevention research.”

However the group is defined, the importance of the physician-scientist in medicine is more than just academic. This dual role brings an important perspective to research. “The thing that’s so irreplaceable about physicians is that they approach research questions differently because they are inspired by their personal experience taking care of patients,” explained Andrew I. Schafer, M.D., chair of the department of medicine at Weill Cornell Medical College. In 2009 Schafer edited The Vanishing Physician-Scientist?, a collection of essays by academic physicians and physician-scientists from more than a dozen institutions. For the record, the question mark in the title is significant. “I actually think that they are not going to vanish,” he said, but shoring up the vocation of physician-scientist will take a lot of work. “We, the community of academic medicine, are going to have to make some major, major changes.”

“We’re at risk of having two separate worlds that don’t interact—the research world and the clinical world,” warned Dean Robert J. Alpern, M.D., Ensign Professor of Medicine. The physician-scientist is an effective bridge between those worlds, he said, adding that any drive to increase the numbers of physician-scientists is “going to have to come from schools like Yale.”

Barriers to physician-scientists

A Yale committee chaired by Peter S. Aronson, M.D., FW ’77, the C.N.H. Long Professor of Medicine and professor of cellular and molecular physiology, spent much of 2010 devising strategies to promote student interest in the physician-scientist career track at Yale. To be sure, the medical school already offers students opportunities in research. Medical students must write a thesis based on original research in order to graduate. Each year the school also admits about a dozen M.D./Ph.D. candidates. In 2006 the school began offering a master’s degree in health science (M.H.S.) to students who engage in full-time research for at least two years, meet coursework requirements, and complete either a laboratory-based or clinical thesis project. Since then, eligibility for the M.H.S. degree has been extended to participants in the Robert Wood Johnson Clinical Scholars Program, the YCCI/CTSA Scholars Program, and the Department of Surgery Residency Program. Other clinical departments are also seeking approval to enroll interested residents and fellows.

Yet the Aronson committee’s final report, issued in September 2010, identified a number of barriers to those wishing to pursue dual careers: extra years spent in training at lower pay; the burden of medical school debt; the under-representation of physician-scientists on medical school admissions committees; a dearth of physician-scientists on bedside teaching rounds; and a disproportionate tendency for women—who represent half of M.D. and M.D./Ph.D. students—to leave research at all stages of their careers. (Schafer also notes that as young scientists and doctors of both genders strive for “work/life balance,” traditional career paths must be reevaluated.)

The report made a number of recommendations, including tracking the careers of medical school alumni. “There should be systematic collection and analysis of data on careers of Yale graduates with respect to measures of success as physician-scientists (e.g. grants, academic positions, citations),” the document says. “It is also important to compile easily accessible data on student demographics and experiences while at Yale (e.g. time in research, type of research, funding of mentor, advanced degree programs, elective courses, etc.) so that these variables can be correlated with career outcomes.”

At the heart of the report were recommendations for encouraging physician-scientist careers while students are still at the medical school. Because of Yale’s thesis requirement, research is already a part of student life—the Office of Student Research matches students with faculty investigators and helps them find funding for research projects. More than half of Yale medical students opt to spend a fifth year on research—but John N. Forrest Jr., M.D., HS ’67, professor of medicine, director of the Office of Student Research, and a member of the Aronson committee, worries that the extra year is becoming a necessity as research time within the four-year curriculum is shrinking. “It’s fallen because good things have been put in the curriculum,” he said, noting that summer clerkships are now available to students who might otherwise have spent those months doing research. Over the past 20 years, according to the committee’s report, the time available for research over four years has decreased from 11 months to 6 months.

The group’s recommendations include calls for more guaranteed time for research throughout the four-year curriculum, loan forgiveness for medical school graduates who meet such career benchmarks as a K08 or K23 award from the NIH, elective courses relevant to basic and clinical research, an enhanced advisory system for students interested in physician-scientist careers, and greater integration of faculty who are physician-scientists into clinical teaching programs.

The report also proposed the creation of “Summer Zero,” a six-week program before medical students begin their first year at Yale. The program, to be called start@Yale (Summer To Advance Research Training at Yale), would come with a stipend and would feature a hands-on research experience. It would also include lectures and discussions of topics in laboratory and clinical research, with an emphasis on the importance of research in advancing patient care. “It is a great concept and means that the students’ first exposure at the School of Medicine would be in hands-on research” Forrest said.

Growing the M.D./Ph.D. program

The dean’s office is still considering the specifics of the committee’s recommendations. “If I had an infinite amount of money,” Alpern said, “I’d probably do everything in the report.”

“All of this stuff costs money,” sighed James D. Jamieson, M.D., Ph.D., professor of cell biology, director of the M.D./Ph.D. program, and a member of Aronson’s committee. The committee suggested an expansion of the M.D./Ph.D. program, which provides full support for its students. A majority of them go on to faculty positions and obtain research grants.

“We are committed to helping the M.D./Ph.D. program grow,” said Carolyn W. Slayman, Ph.D., Sterling Professor of Genetics, professor of cellular and molecular physiology, and deputy dean for academic and scientific affairs. There’s a consensus among chairs, she said, that it would be ideal to expand the program from about 12 percent to between 15 and 20 percent of each class. “It’s something that Yale does very well,” she said.

Part of that success comes from choosing the right type of student from the start, said Jamieson. “These are people who ask questions and have the best interests of their patients at heart,” he said. He’s a zealous advocate for weighing research experience heavily at admission and for rigorous science throughout the curriculum. “You’re teaching people how to bloody well think—not to memorize facts!” But Jamieson admits that flat government funding is a hurdle for young physician-scientists, and not one that individual medical schools can easily move aside. Without a nationwide investment in research, he predicts that the best and brightest investigators will pursue careers overseas.

The AAMC’s Bonham sees some bright spots on the horizon for up-and-coming physician-scientists. The health care reform bill passed in 2010 created the Patient-Centered Outcomes Research Institute, charged with setting priorities for comparative effectiveness research. “That kind of research will need physicians and physician-scientists, and there is dedicated funding,” Bonham said, adding that this field of research also creates new collaborative niches outside the traditional bounds of laboratory or clinical research. “There will be opportunities for engaging medical students, fellows, and junior faculty in comparative effectiveness research,” she said. “That necessarily implies teams with health outcomes researchers, clinicians, nurses, social scientists, and implementation scientists.”

Yale does have several programs in place to aid junior faculty in establishing themselves as researchers who’ll be competitive for NIH funding. Getting started, warned one leading researcher, can be daunting. “You need about four or five years of concentrated investigation in your field of interest,” said Robert S. Sherwin, M.D., FW ’74, C.N.H. Long Professor of Medicine and director of the Yale Center for Clinical Investigation (YCCI). YCCI Scholars are early-career scientists in clinical or translational research who receive salary support as well as mentorship and access to resources in such areas as biostatistics and bioinformatics or study coordination and recruitment. YCCI also houses the Investigative Medicine Program, which supports physicians seeking a Ph.D. to pursue patient-oriented research. The School of Medicine has several other named Scholars slots elsewhere that support early-career scientists.

The time it takes to establish a research career is in part a reflection of a rapidly expanding body of knowledge. “Many of the things I learned in medical school are of little value today,” Sherwin said with a smile. “Our knowledge of the biological basis of disease has expanded dramatically and become much more complex than it was when I started.”

Although Aronson considers medical school “the broadest biological training you can have,” the financial implications of getting dual degrees discourage some young people. The Ph.D. route offers a faster track to a job in academia than pursuing two degrees, followed by completing a residency and possibly a fellowship, Aronson explained.

But there are great rewards to be had, said Aronson. He takes pride in the accomplishments of his “scientific grandchildren,” the students of his students. And, of course, there are the potential advances in medicine. “My father and most of his family died in their 50s,” said Aronson. “Thanks to the discovery of statins, I have had the chance for a longer life than the previous generation.”

Aronson’s committee came up with a proposal, which they caution is preliminary, to streamline the M.D./Ph.D. program and the path to establishing independence as a researcher. The objective is to shorten the time spent in training. Currently, says David A. Hafler, M.D., M.Sc., chair and Gilbert H. Glaser Professor of Neurology, scientists starting out often write their first R01 and establish their laboratories quite late in their careers. Hafler suggested a novel program that combines the M.D./Ph.D. and residency into one program. Students would apply for admission to the M.D./Ph.D. program in their third year, be interviewed to stay at Yale for their residency, and begin graduate coursework in their fourth and fifth years. The existing option—in which students apply to the program when entering medical school—would still be available. Students on the new track would do a two-year clinical residency and specialty fellowship followed by three more years of intensive research. The proposal saves about three years compared with the more traditional path.

Exposing students to research

Complexity and time pressures keep many physician-scientists off the wards—the place they are most likely to inspire medical students, said Alpern. To be competitive for NIH grants requires the average academic physician to spend a majority of his or her time on research. Some maintain clinical skills by becoming “very subspecialized,” he said. But most will have little contact with students. “The role model for the students is the clinician,” he said.

Not all four faculty tracks at the medical school lend themselves equally to contact with students. Most physician-scientists enter the Traditional track, a path to tenure in which faculty spend most of their time in research, with some time devoted to teaching. The Clinician-Scholar track was added in the 1980s to allow faculty to spend more time in practice without impeding their advancement. The Investigator track is designed for faculty who spend most of their time in research.

Students are most likely to be supervised in their third and fourth years by Clinician-Educators, a role created in the 1990s as the school sought to expand and develop more areas of excellence within its clinical practice. Yale was more willing to support the medical school’s expansion with Clinician-Educators, who are not eligible for tenure and would not lock the university into the kind of long-term financial commitment associated with employing tenured faculty, Slayman explained. She cautioned, however, against a simplistic understanding of the tracks. Many Clinician-Educators, who have grown in number from 135 in 2001 to 278 today, are not only great clinicians but also boast impressive research achievements. Nevertheless, she said, medical students spend more time on the wards with people who think of themselves primarily as clinicians.

To get more physician-scientists on the wards, some medical schools use a system of co-attendings. Physician-scientists and clinicians form a partnership that offers students a taste of the investigatory approach while a clinically current doctor is involved with every patient, said Aronson. “Many of us do teach medical students,” said Aronson, a role he said he enjoys. But with the decrease in residents’ work hours, the role of the attending has become more critical. “It makes it more difficult to do part time and do efficiently,” he said.

To give students more exposure to physician-scientists, the Department of Pediatrics offers a “Bedside to Bench” elective seminar that pairs students with a physician-scientist mentor. The student and mentor select a pediatric patient as a focus—the student makes a presentation on that patient to the group and reviews what’s known about his or her disease. Then the heart of the students’ work begins—figuring out the most important unanswered questions about the biological basis of the disease and outlining a program of research that would provide answers.

“We encourage them to think creatively,” said Clifford W. Bogue, M.D., FW ’93, interim chair of pediatrics and one of the seminar directors. The seminar presents “an opportunity to expose them to what it means to be a physician-scientist.” Originally for M.D./Ph.D. students only, the seminar is now open to all first-year medical students and typically draws 50 to 60 a year, he said. Part of the attraction may be a taste of clinical contact in the first year. “They’re dying for some sort of clinical relevance,” said Bogue.

The bulk of clinical time typically comes in the latter half of medical school. Clinical practice is “the last thing they are seeing,” said Balkin, the M.D./Ph.D. student, who reflected that timing alone could contribute to a choice to pursue clinical practice over investigation.

Balkin is a regular at the Leadership in Biomedicine Lecture Series sponsored by the Office of Student Research. Top investigators talk not only about their research but also about the paths that led them to it. Balkin recalled Richard P. Lifton, M.D., Ph.D., chair and Sterling Professor of Genetics, telling about a reviewer who deemed “impossible” a study that Lifton had proposed in 1988 as a resident in Boston. That only made the young investigator absolutely determined to soldier on. The proposal outlined what would become Lifton’s landmark research in hypertension. Balkin said those talks help him see what’s possible and spur him on his path.

“We need to make the students aware of what an exciting lifestyle it is to be a physician-scientist,” said Alpern. “To have the NIH give you a million dollars a year to play in your lab is really fun.”

Being committed to the career path is half the battle, according to Schafer. He throws in a trick question when interviewing potential fellows, asking them what they’d do if they absolutely could not get funding for their research. About 90 percent reply that they’d devote themselves to clinical practice. A select few say the idea of not combining medicine with basic science is “inconceivable.” Those applicants get the job.

Balkin feels much the same. “The problems are the problems,” he said. “But if you want to do research, you will find a way to make it work.” YM