Physician-scientist training programs that offer the opportunity to conduct cutting-edge research are at the heart of academic medicine. Through training that allows individuals to study various forms of disease in both the clinic and the lab, these programs help them acquire the tools they need to blossom into field-leading physicians who take what they observe during patient care to the lab, and then apply what they learn there to treating patients.
This back-and-forth is essential to developing treatment advances. Nationally, the number of physician-scientists is declining, but developing new physician-scientists is a priority at Yale School of Medicine (YSM), where many clinical departments offer the chance to work with top experts in their field.
After residency, individuals may choose to pursue a fellowship so that they can further specialize in their fields of interest. Individuals in physician-scientist programs are typically MD-PhD graduates who declared themselves interested in this pathway as they interviewed for their fellowships. Because this trajectory requires three years of research training, the clinical training portion of the fellowship is reduced by a year. Following their time in the hospital, fellows move into the lab for the research-intensive portion of their training.
Entering these programs presents numerous challenges at institutions across the country, and postdoctoral researchers often have to make sacrifices in pursuit of their research. In particular, many enter these programs at fundamental moments in their own lives—such as having young children or when they’re planning to start a family. And the changing financial packages that come with being a fellow can be daunting. Yale School of Medicine has recognized these challenges, and is pioneering ways to rectify the difficulties they cause.
Typically, after transitioning to university labs for the research portion of their training, fellows are considered trainees at their university, so they receive stipend status, and their new pay scale is typically lower than the hospital pay scale. The transition also has consequences in terms of their own health coverage: An individual might be eligible to see one doctor while employed by the hospital, but may have to change providers after moving to the university.
“If you have children, or if you’re pregnant, you may have to change providers at time when it’s really inconvenient,” says Keith Choate, MD, PhD, associate dean for physician-scientist development and professor of dermatology, of pathology, and of genetics.
Furthermore, although the monthly premium cost of health insurance is incorporated into the stipend, because the dollar amount fellows receive is taxed, it’s not enough to cover both their living expenses and the full cost of their benefits.
Another significant challenge presented by the transition relates to the federal loan repayment program—an income-based program that forgives loans after 10 years of employment. Because fellows have a stipend, they have a non-employed status, and these years of research at the university are not counted toward this program. Therefore, it takes them longer to reach that 10-year mark.
"Many persist in science because of the idea that what we do here at Yale not only changes the lives of individual patients, but also potentially the face of medicine,” says Choate. “We need to ensure that fellows have a fair deal as they’re starting their fellowship so that they don’t feel like they’re making a sacrifice when they first step into the laboratory.”
Choate says that Yale is now looking to overhaul physician-scientist development procedures, with a series of initiatives to smooth the pathway. The dean’s office, for example, has chipped in to provide trainees an additional stipend to fully cover the cost of health insurance. To address the difference in pay scales between the hospital and university, he and his colleagues have also asked that research departments pay their trainees equivalent compensation. To his knowledge, Choate says, no other institution has been able to come up with an ideal solution for accommodating physician-scientists, and the innovative approaches that Yale is taking have not been tried anywhere else.
“This is a national issue,” says Brian Rebeschi, executive director of finance and administration for the School of Medicine. “We’ve made some real changes, but at the same time, there’s more work to do.”
While Yale can provide equivalent health insurance coverage as fellows transition from the hospital to the lab, they still can’t keep their same insurance plans. In the future, Rebeschi and his colleagues hope to explore creative options to transport funding from the university to the hospital so that fellows don’t have to change their employer status and can maintain their benefits. Other initiatives will require advocating for policy change at a national level, such as having the federal government count research time as employment when it calculates loan forgiveness. Rebeschi and his colleagues have also been working with grant directors at the National Institutes of Health to try and identify ways to lobby for changes in the way grant rules are written.
“There is an ongoing commitment to continuously be working to address these issues,” says Stephen Huot, MD, PhD, professor of medicine (nephrology) and senior associate dean for graduate medical education. “We want to attract the best and the brightest. While fellows are devoting so much time and energy into launching an academic research career, we should be providing as much infrastructure as we possibly can for their success.”
Huot hopes that these initiatives will also promote a more inclusive workplace. At academic medical centers around the country, there are disproportionately low numbers of faculty members from underserved communities. The more successful Yale can be in creating a learning environment that is supportive of diverse learners, the more successful it will be at hiring faculty from underrepresented groups.
“Our fellows are the next generation of academic leaders,” he says. “Their success is our success.”