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During the late 1960s and early '70s, there was increasing concern in both the United States and Canada regarding the need to create a leadership corps of clinician-scientists to sustain academic medicine. The U.S. National Institutes of Health (NIH) took the lead in establishing the highly competitive Medical Scientist Training Program (MSTP) in 1968 to fund MD/PhD Programs at various U.S. medical schools, but in Canada there was little interest in adopting this innovation. By the early 1980s however, it became clear that these dual-degree programs were flourishing, producing a steady stream of outstanding medical scientists who were leading the agenda in both basic and clinical research. It was obviously time for the Canadian medical schools to think seriously about adopting this 'U.S. import' as a model for clinician-scientist training.

In 1984, the University of Toronto became the first Canadian medical school to offer an MD/PhD program, but the model has grown in popularity to the point where there are now eight Canadian medical schools with MD/PhD programs and a national enrolment of approximately 100. As the largest program of its kind in Canada with 38 students in 2003-04, the University of Toronto (U of T) has assumed a leadership role; U of T successfully lobbied the Medical Research Council of Canada, now the Canadian Institutes of Health Research (CIHR), to develop a nationally funded MD/PhD Studentship Program. Such a program has been in existence since 1995. Dr. Mel Silverman, director of the U of T program since its inception, was also responsible for organizing the Young Investigators Forum at the annual Canadian Society for Clinical Investigation/Royal College of Physicians and Surgeons of Canada meeting to provide an opportunity for MD/PhD students from across Canada to meet and present their research. Growing from a small meeting in 1997, this year's forum, held in September in Halifax, featured 49 abstracts covering diverse areas including clinical medicine, integrative biology, and basic science.

MD/PhD Programs in Canada, while at a younger gestational age than those of the U.S., bear a striking resemblance in overall structure. Generally, students are accepted into these programs following their undergraduate experience and proceed to complete all of the requirements for medical school and a PhD degree in approximately 8 years. There are minor variations in curriculum design, but in most programs, students undertake the preclinical years of medicine, take a break to do the PhD, and then return to complete the clinical aspects of medical school. Where the Canadian programs differ dramatically from their U.S. counterparts is in how their students are supported financially.

In the U.S., NIH funds MSTP to support MD/PhD programs on a competitive basis nationwide. The award is made in the form of a block grant to the best medical schools, which are then able to offer their students full funding throughout the MD/PhD program. The award covers tuition and incidental fees, plus a stipend for living expenses.

Postsecondary education in Canada does not have the same tradition of recruiting students through tuition scholarships, and this carries over to MD/PhD programs. Although some very small programs, which admit only one or two students per year, have committed university funds to provide tuition relief, a majority of Canadian MD/PhD students receive only CA$20,000 per year for 6 years, either through CIHR's MD/PhD studentship program, the Alberta Heritage Foundation, other granting agencies, or university endowments. This is clearly insufficient, given that the average length of the dual-degree programs is 8 years, and that medical school tuition at U of T is now over CA$16,000 per year.

Another distinction in clinician-scientist training in Canada, as compared to U.S. programs, is the opportunities for research during postdoctoral residency programs. The U.S. offers a Clinician Investigator Stream in internal medicine, medical subspecialties, and some surgical specialties that allow for 3 years of research in a 6-year residency; no such track exists within the Royal College of Physicians and Surgeons framework. Some medical residencies offer 1 year of research, but this is hardly sufficient for a meaningful postdoctoral experience.

Despite these differences, this model of training clinician-scientists has been recognized for its potential to attract some of the best and brightest; the competition for positions remains fierce, and the number of clinician-scientists produced is insufficient. With only about 100 students currently enrolled in MD/PhD programs at Canadian medical schools, and the average program lasting 8 years, Canada is producing approximately 10 graduates per year--a number insufficient to sustain Canadian academic medicine at the highest level. A more reasonable target would be two to three times larger, achievable by expansion within the existing programs.

Limited follow-up data--on the programs that have been in place long enough to have graduates who have completed all of their residency training--indicate that the overwhelming majority are taking up positions in academic medicine in Canada, the U.S., and internationally. Although it is too early to measure the impact of these programs and their graduates on the state of clinical science in Canada, follow-up data on U.S. graduates are extensive and confirm that more than 80% of program graduates are in academic medicine in both clinical and basic science departments, are successful in obtaining external research awards, and are publishing their research in excellent journals. We have every expectation that our Canadian graduates will pursue similar paths, and that MD/PhD programs will emerge as a critical piece of Canada's biomedical research training infrastructure.