When someone asks for a doctor, on an airplane, on the subway, or at church, I used to race right in there, eager to help. These days I hang back a little, to see if some younger physician will answer the call.

I still practice medicine. I get my Advanced Cardiac Life Support certificate updated every 2 years. I still carry an American Board of Internal Medicine certification in Medicine and Cardiology. But since finishing residency and fellowship clinical training, I have spent the majority of my working hours in the lab and the office, practicing science rather than medicine. Like most MD/PhD dual-degree-program graduates who are practicing physician-scientists, I have had to narrow the focus of my clinical practice. With all the time taken up by my science career, I just don't have time to stay current in a wide range of medical practice.

I graduated in 1991, then went on to an internship and residency in internal medicine, followed by cardiology fellowship training. My decisions and choices were driven by a desire to find a clinical niche and a research niche that interleave, and develop into a true physician-scientist. I chose cardiology, and specifically heart failure, because I wanted to work in a subspecialty where I could care for a group of patients over time, in my case patients with chronic heart disease. I like the long-term contact; I often think that if I had not gone into research and academic medicine, I would have become a family practitioner in some town where everyone knows each other by their first name. Probably too much TV as a kid. ...

I decided to narrow the focus of my clinical work in order to find time to develop my research career. There is a huge volume of information streaming at us--and by us--these days, in both the clinical and research worlds. Narrowing the scope of practice limits the volume of information I need to manage to stay current. This was a tough choice. When you subspecialize, you lose more general competency. Things that came easily to me at the end of residency now require a consult, referral, or some reading time. I'm still getting used to the disappointed look on my mother's face when I respond to her question about an ache or pain with "You should go see a doctor."

Like many MD/PhD graduates, as well as MD graduates with a strong interest in science, I am striving for a 20%/80% physician/scientist balance. This was the model that motivated the formation of dual-degree programs in the first place, and the career I aspired to from the beginning of medical school. I was fortunate during my medical school and postgraduate training to be exposed to successful and (sometimes) happy physician-scientists. I say fortunate because many training programs do not seem to support career development along this path, despite a stated interest in training physician-scientists.

Many MD/PhD graduates learn too late that from the moment you apply to residency you have to search for evidence that a particular program values and supports this path. Every institution is different. Even within a single institution the chances of launching a successful career as a doctor-doctor vary widely between departments. The presence of leadership that follows that model--physician-scientist deans, departmental directors, division chiefs, etc.--is a good indicator. The presence on the faculty of successful, true physician-scientists is an even better indicator.

Even at a supportive institution, establishing a research career requires discipline. A job in academia is unlike grad school or your postdoc years with unlimited hours in the lab. I've found that the so-called "protected research time" is only as protected as I make it. Managing the "clinical vacuum" is a huge challenge for clinician-scientists. Caring for patients is more than a full-time job. The unpredictable elements of patient care can keep you in the hospital or clinic much longer than you expect. Working as a good citizen as part of a group practice requires covering for others when they have conflicts. Some physician-scientists--including me--solve this piece of the puzzle by focusing their clinical work on a skill or procedure that clearly delineates their responsibilities--e.g., echocardiography or colonoscopy. If you are like me and want to spend your clinical time in direct patient care, you have to accept the jeopardy this creates for your research time.

Besides clinical responsibilities, teaching, lectures, committees, and administrative tasks are a constant threat to time at the bench. Academic promotion depends not only on your contributions to science but also on your local contributions to the university.

Down the road, perhaps, institutions will find ways to reward physician-scientists who manage to spend time moving between bench and bedside, without regard for the number of grant dollars and publications that this effort is able to generate. To date, however, practicing science and medicine together, bridging the gap, is not itself recognized as a contribution. This is surely part of the reason that bench-to-bedside physician-scientists are still in short supply, despite the increasing size of the MD/PhD graduating class.

A couple of weeks ago a PhD colleague used the word "tribe" to describe the departmental structures inherent to academic institutions. Listening to this colleague talk made me realize what an awkward position those of us working as clinician-scientists are in. As in any organization, tribal loyalty is important. By definition, we belong to multiple "tribes" within the medical center, and so must express multiple loyalties. This is an awkward situation. Given that every academic institution is under constant pressure due to limited time and money, our loyalty to any particular tribe is always compromised.

Issues such as these, along with the need to balance work life with family life, forces some of us to make a choice between tribes, giving up the "physician" or the "scientist" headdress. At a national level, though, we continue to hear the cry: "Doctor-doctor, come quick! We need you!" Every year new programs are created to motivate medical school graduates to take up this calling. For me, it is satisfying to answer that call and be part of our society's effort to improve health through basic and translational research. I hope that in time we can improve organizational structures to increase the chances that other MD/PhD graduates will follow this path.