Their research builds on the lived experience of patients and the ethical issues created by patient care in a complex, highly technological medical system. What is needed to save them? Andrew. L. Shafer, Vanishing Physician-Scientist? (Cornell University Press, 2009
Are physicians integral to discovery in medicine? Do they bring a unique perspective, drawn from their scientific training and their experience of caring for patients, that illuminates avenues for research blocked off to other scientists? Are physicians uniquely required to perform the translation of bench-science discoveries into clinical practice through clinical trials? Are, indeed, physician-scientists a vanishing breed threatened with extinction? The answers to these questions are explored in an edited volume of essays drawn together by Dr. Andrew Schafer, E. Hugh Luckey Distinguished Professor of Medicine and chair of the Department of Medicine at Weill Cornell Medical College and Physician-in-Chief of the New York Presbyterian Hospital-Weill Cornell Medical Center.
The essays in this book are the result of an initiative that he led on behalf of the Association of Professors of Medicine, which convened a national conference called “Revitalizing the Nation’s Physician-Scientist Work Force” in November 2007, from which many of these essays derive. The book contains 15 chapters plus an epilogue and an introduction by Dr. Schafer. It covers the history of physician-scientists from the dawn of the scientific era of medicine. It examines the demographics of the physician-scientist work force and looks at the role of the physician-scientist in translational research. Most important, the book has essays devoted to women as physician-scientists and to Generation X and the millennials, so it examines the important demographic transition in the physician-scientist work force. It also discusses how to engage undergraduate students in biomedical and clinical research.
There are chapters examining such institutions as academic medical centres and medical schools, the relationship between physicians and PhD scientists and medical research, the role of mentoring in developing scientists, as well as looking at the attrition of young physician-scientists and how to restore and invigorate this endangered species. The book, therefore, presents a comprehensive overview of the current state of physician-scientists in the U.S. research milieu.
The book has a decidedly American focus. The author of each chapter is a renowned physician holding important senior position in one of the many of the top medical schools in the U. S. The chapters they have written cover the topics comprehensively and draw exhaustively from the literature and data to support the authors’ claims.
The book picks up a theme identified initially in 1979, when James Wyngaarden warned that physicians who specialized in research were becoming an endangered species. What has been happening was that physicians were increasingly devoting their time to patient care, so education and research were becoming increasingly the purview of dedicated PhD scientists. The physician-scientist is defined as person holding an MD degree, or an MD degree and other advanced degrees, who devotes much of her or his career to seeking new knowledge about health and disease through research. The nature of research a physician-scientist can engage in covers a broad range, from basic science studies in a laboratory to translational and patient-oriented clinical research, extending into the application to the health of the population through health services research or population health and epidemiology. The difficulties of maintaining a creative and productive research career at the same time as engaging in clinical responsibilities is becoming increasingly a challenge and is dissuading a large cohort of potential academic researchers from research.
The data presented in this book seem to support this contention. Dr. Schafer notes that “the percentage of physicians engaged in research as their major professional activity in the United States decreased from a peak of 4.6% in 1985 to 1.8% in 2003. At the same time the absolute number of physician-scientists dropped from a peak of about 23,000 in 1985 to 14,000 in 1995.” The essays in the book point out the barriers facing someone who wants to be a successful physician-scientist. First, the number of years it takes to acquire appropriate training is in the order 12-14 years (medical school, postgraduate training, and fellowship training in a specialty). After several years of postdoctoral placement are required before one gets a junior academic position. The result is considerable financial hardship and accrued debt as the income provided by a research career is considerably less than what is offered in clinical practice. (It must be noted, however, that money is not the chief driver behind the desire to become a physician-scientist. Inquisitiveness and having mentors and role models seems a better predictor of willingness to follow a physician-scientist career than income does.)
However, another major barrier is the vicissitudes of peer-reviewed funding. Junior researchers often face considerable obstacles in building a fundable research career. Several rejections of grant proposals are the rule rather than the exception. In the chapter entitled “The Attrition of Young Physician-Scientists: Problems and Potential Solutions”, Mark Donowitz, James Anderson, Fabio Cominelli, and Greg Germino note
“[T]he reality, as well as the perception for young-scientists, watching their more established role models attempt to continue in careers as physician-scientists is that most will fail. If one fears that he or she is more likely than not to fail, why take on the additional financial risks as well? The perception that one is likely to fail may also contribute to the high attrition rate of investigators already in the pipeline. Negative reviews of a submitted grant or paper may be viewed of a sign of things to come, triggering a decision to leave the career path prematurely.”
Thus the combination of long gestation period, high indebtedness, and low success rate leads to what the authors call “a flawed business plan for the production of physician-scientists.”
They perceptively note that running a research lab is like running a small business. A busy lab depends on consistent cash flow (from grants) to pay for laboratory space, hire people, buy equipment, attract postgraduate fellows and graduate students and technicians.. Available funding in the U. S. and Canada is finite – in the U. S. it consists of the National Institutes of Health primarily and, in Canada, the Canadian Institutes of Health Research. Funding from various foundations particularly the disease-oriented, is e available – as well as money from private enterprise – but these are competitively funded, and success rates are often less than one in five of the grants submitted. Indeed, almost every researcher, both in Canada and the U. S., is dependent on continuous success in winning grants in order to maintain momentum and functioning lab teams – since researchers cannot develop the reserves needed to carry them through downturns or the vicissitudes of funding cycles. In fact, most research teams are so dependent they risk being able to function should they have one simple grant request turned down.
Though the book is generally devoted to an American reading audience, the chapters are instructive to anybody interested in the fate of the physician-scientist in Canada. Three chapters are noteworthy: “The Ecology of Physician-Scientists in Academic Medicine” by David Corn and Stephen Heining; “Women as Physician-Scientists” by Rushma Jagsi and Nancy J. Tarbel; and the aforementioned “Attrition of Young Physician-Scientists: Problems and Potential Solutions.” The structural forces identified by these writers exist in Canada. Developing new models of career funding that recognize the various life-cycle stresses faced by beginning scientists should be a priority such as proactive programmes permitting women scientists to enter the research stream, which would be a way of preventing what is clearly, according to the data, a higher attrition rate in female physician-researchers than male. Supportive work environment should be contemplated, and academic institutions, such as universities, can play a proactive role in redressing these gender biases.
The strengths of this book are the overwhelmingly data-rich portrayal of the physician-scientist human resource situation in the U. S. While this is one of the book’s strengths, it is also a limitation, for a Canadian reader. What is the situation in Canada? I am unaware of any data with the depth and scope that is presented in this volume. However, the situation and plight of physician-scientists in Canada is much worse than in the U. S. Part of this has to do with the funding mechanisms and the way salary support is generated for individuals who wish to devote a considerable part of their time to research. There is a crucial difference between the National Institutes of Health and the Canadian Institutes of Health Research. Whereas the National Institutes of Health permits investigators to write a salary for the principal investigator and co-investigator into the grants, such is not the case at the Canadian Institutes for Health Research. That is, there is no provision for salary support from operating grants given to the principal investigator. Thus, physician-scientists are at a disadvantage by virtue of the fact that their salaries are often completely underwritten by clinical billings. Thus, time devoted to research is often time taken away from patient care, and such researchers are often looked at askance by their departments and their local clinical practices as they are seen not to be contributing to the general welfare of the department.
There are a limited number of salary support awards available. Most of these come in the form of new investigator awards, which cover five years of 75 per cent protected time. However, the dollar values of these prestigious awards do not come close to replacing the clinical billings that a physician-scientist would bring into a department. Other opportunities for salary support, such as endowed chairs, are few and far between. Thus, the very model in place in Canada militates against the recruitment and retention of physician-scientists as there is no adequate salary support that would give protected time to physician-scientists to devote to research work. Nonetheless, I am aware of large numbers of physicians who are devoted to generating knowledge in their field, often doing research in the off-hours and hoping to contribute new knowledge to improve patient care and outcomes.
Does it matter that we have physician-scientists? Should we not leave the generation of new knowledge to cadres of trained doctorates? I tend to agree with the authors of this book that physician-scientists are uniquely poised to generate new ideas into health from their close experience with patients. I also agree that they are in an ideal position to effect translations from bench science into clinical practice. However, the ambit of physician research extends well beyond basic sciences and, indeed, the notion of a physician-scientist does orient one into the more scientific aspects of medicine. As a physician-scholar privileged to hold a Canada Research Chair, much of my research builds on the lived experience of patients and the ethical issues created by the care of patients in a modern, complex, technological, medical system. As much as this book focuses on the physician-scientist using a model from the National Institutes of Health oriented towards the quantitative biological sciences, there is a rich vein to be explored by physician-scholars rooted in the humanities and social sciences as well. Thus, I think it is important that the physician-scholar, as I will call them, not become a vanishing breed. I believe that their status as an endangered species is much greater in Canada than the U. S., and it is probably time to rethink how we can support, sustain, and attract a new generation of physician-scientists in Canada. I think they would make immense contributions to the global knowledge economy, and Canada, with its long tradition of scientific discovery and excellence in physician research, is well suited to build on this legacy.
Physician Ross Upshur is director of the University of Toronto’s Joint Centre for Bioethics and a Canada Research Chair in primary care research. At the University of Toronto he is a professor in the Department of Family and Community Medicine and the Department of Public Health Science.