When Leon Rosenberg, M.D., began a 6-year research stint at the National Institutes of Health in 1959, NIH had just built the monolithic clinical research facility known as Building 10. The new center offered established and promising clinical scientists the opportunity to work in state-of-the-art labs adjoining comfortable patient wards. "We were all eager to prove we had the right stuff," Rosenberg recalled at a recent lecture at NIH.
But the physician-scientist--that species of M.D. who also conducts research--has since fallen on hard times. Rosenberg, now a professor of molecular biology at Princeton University and president of Funding First, documents and decries the decline in physician-scientists in this week's issue of Science [ 15 Jan 1999, pp. 331 - 332].
According to Rosenberg's analysis, M.D.s are applying for and receiving NIH research grants in progressively smaller numbers compared to Ph.D.s, with the trend more pronounced in young investigators. If the trend continues, "there would be no first-time M.D. applicants for NIH research project grants by 2003," he says.
The data-gathering began almost 4 years ago when Rosenberg agreed to sit on a panel convened by NIH director Harold Varmus to review the status of clinical research. Two and a half years later, the committee issued its pronouncement: NIH needs to support more patient-oriented research.
But the "concerns were not stated as strongly as they needed to be," Rosenberg said in a recent interview. Although the decline of physician-researchers is not a new phenomenon (20 years ago, former NIH director James Wyngaarden wrote a paper entitled "The clinical investigator as an endangered species"), more recent discussions have focused on the decline in patient-oriented research rather than on the decline of the type of person doing the research. The physician-scientist as a whole is in trouble, not just those conducting patient-oriented research, Rosenberg asserts.
Rosenberg compares the situation to that of the spotted owl. We've been so focused on the spotted owl (physician-scientists conducting patient-oriented research) that we haven't noticed that all owls are endangered (all physician-scientists, whether they investigates basic, disease-oriented, patient-oriented, population-oriented, or prevention-oriented research).
But why bemoan the lack of M.D.s conducting research when there are more than enough Ph.D.s? Rosenberg argues that physicians add a unique dimension to research. If the physician-scientist becomes extinct, he predicts that the proverbial bench-to-bedside bridge "will weaken, perhaps even collapse."
Mary Lake Polan, a physician-scientist heading up gynecology and obstetrics at the Stanford University School of Medicine, echoes these sentiments. "Personal interactions--talking to, caring for, operating on patients--give clinicians an instinctive feel for what's important." The young M.D.s who join her research staff tend to have a great advantage over the Ph.D.s, Polan says. Translational research doesn't just move from the bench to the bedside; it works the other way around as well, she adds.
Even Scott Basinger, a Ph.D.-trained scientist whose lab is located in a clinical department, agrees that there is no substitute for medical school training. "The reason a cohort of Ph.D.s has never stepped up to fill the clinical research gap ... is because Ph.D.s don't have the passion for patient-oriented research that M.D.s get from working with patients," says Basinger, assistant dean at Baylor College of Medicine's Graduate School of Biomedical Sciences in Houston.
Rosenberg cites numerous causes for the decline in physician-researchers, including heavier debt load of medical graduates, the financial lure of medical specialties, a perceived decrease in research training programs, the instability of federal research grant support, and the demands placed by managed care. These factors contribute to an increased demand on the time that clinical investigators must devote to delivering health services rather than to research.
The threat of extinction "can be averted only by bold, concerted action on the part of all," Rosenberg writes. He recommends that Congress appoint a national panel to study and implement solutions (see sidebar).
But even if Rosenberg's congressional panel succeeds in luring more M.D.s into the research pipeline, will the country be able to absorb them all? "No one knows the answer," says Polan, who studied the career outcomes of physician-clinicians for the NIH panel. "It's a chicken-and-egg problem." If more clinicians are trained to be researchers, she says, at least there's a fighting chance that they themselves will create and expand research opportunities. "I don't think you can lose by training more physicians conversant with the research literature and scientific methodology."
Those with a combined M.D./Ph.D. degree have the best career options of all, Basinger says. "If my wife and I had a carful of kids, and they asked me what they should be when they grow up ... I'd tell them to get an M.D./Ph.D. and become physician-scientists."