If scientific discoveries are going to lead to treatments for patients, physicians trained to understand and do research must play a central role. After many years of decline, the number of physician-scientists available to do that work has begun to recover thanks to several new programs for recruiting and retaining talented students, according to an article published in the July issue of Academic Medicine.

But can young physician-scientists succeed in building and sustaining the research careers that they hope for during their lengthy training? The difficulties they face are so severe that many abandon the effort, says an article by four experienced physician-investigators published in the February issue of Gastroenterology. The departure of so much young talent constitutes nothing less than "the burning of American intellectual capital," lead author Mark Donowitz of Johns Hopkins University in Baltimore, Maryland, told Science Careers in an interview.

A losing investment

The nearly 500 students enrolled in M.D./Ph.D. programs at 15 universities who answered a survey about their experiences and plans for the Academic Medicine article have a strong interest in becoming researchers. The majority anticipates careers primarily devoted to basic research, with many of the rest intending to focus on clinical or epidemiological research. More than 90% of the respondents want to work at academic centers.

But Donowitz and his co-authors have serious doubts about their chance of succeeding. The article bemoans "a significant drop-out rate for physicians who have set out on this career path ... with many of the potentially most creative physician-scientists abandoning science. ... A huge national investment in intellectual capital is being wasted, while physician-scientists are themselves investing many years in training that does not deliver satisfying careers, despite the fact that this is a time of increased scientific opportunity."

The foursome giving that warning "are all old people," tenured professors, and established researchers, says Donowitz, who did his medical training in the late 1960s. He and two of his co-authors belong to a working group of the American Gastroenterological Association's policy committee and the fourth co-author is a former councilor of the American Society for Clinical Investigation. "But the way things are going," Donowitz continues, "we might be the young ones. The more you knock off the young people, the people who are the youngest are no longer young." It's a "crisis" in medical research when "the 'young investigators' turn out to be quite established people."

Progress depends on young people with "new techniques and new ideas and new enthusiasm," he says. But he and his colleagues have seen a "definite downturn" in the numbers of young physicians committed to basic science research. "Something is very, very wrong. The best and the brightest seem not to be going into science as much as they did in the past." And those who do opt for research careers "seem to be dropping out at a very high rate."

Taking care of (small) business

The problem, he believes, stems from the fact that every lab chief "essentially is running a small business." Like all businesses, "you have to pay your bills." Lab chiefs, however, can only get the money they need by winning grants, which today's tight funding and intense competition make unpredictable and unreliable. "You get them for a few years, then you lose them for a year, then you get them again. Consequently, people are continually essentially going bankrupt," Donowitz says.

But unlike ordinary businesses that can use capital reserves to keep the doors open through hard times, government-funded researchers cannot save up for lean years. The rules decree that "at the end of the year, you can't carry over more than 25% of what they give you. The grants are quite small, so you cannot weather a downturn," Donowitz continues.

Unlike Ph.D. researchers, medical doctors can always make a living by hanging out their shingles. "But that's not what this group of people wants to do," Donowitz says. The substantial earnings gap separating research and practice is not an important factor in young physician-scientists' decisions to leave the lab, he believes. "There are a bunch of us who are not interested in making this extra money but are turned on by the thought process of doing science. ... The money is really, I'm convinced, not the major issue at all."

Instead, "lack of security" drives physician-scientists from research, he says. "You're always at risk of going bankrupt"--not personally, he emphasizes, but as a productive investigator. Anxiety and uncertainty produce "a very difficult life." As proof that stress and discouragement, not lack of love for science, lead physicians to quit, Donowitz notes that "the people who drop out of science generally don't leave the academic center. They become the clinician-teachers."

Looking for solutions

Donowitz hails the rising cadres of young physicians being trained specifically for translational research as a "very positive" development, but he fears trouble ahead. "When this group of young people have to go through the [National Institutes of Health] funding system, I predict that they will tolerate it less and drop out even more" than physician-scientists doing basic research. Translational researchers "take somebody's basic science and apply it to patient care and disease," he explains. "When you're a basic scientist, you're working with your own ideas that you have created and have been living with." Without this personal connection to the basic science, "I don't think [translational researchers] are going to be as devoted" to research when difficulties mount. Donowitz emphasizes, however, "that's a hypothesis. It hasn't been proven."

In former times, physicians who did research--many tinkering in their off hours-- supported the work from their own earnings and savings, from hospital funds, or, often, from family fortunes, Donowitz says: "When I first got to Hopkins, the famous scientists had streets named after their families." But as hospital budgets have tightened, the cost of doing science has risen, laboratories have grown in size, and research has become a more-than–full-time job, physician-scientists have become ever more dependent on competitive grants from the federal government.

And that, Donowitz and his co-authors believe, places squarely on Congress and the medical schools that administer federal grants the responsibility to change policies to assure that more of the small businesses that produce American scientific progress can keep going when times get tough. First, Congress needs to remove the "flaw" in the law that prevents labs from carrying over enough money to survive between grants, he says. Second, medical schools hiring faculty "should realize there's an obligation" to use their funds to help productive scientists get through funding droughts.

"We are not suggesting that there should be some kind of social security or safety net for M.D./Ph.D.s" to assure that none fail. Rather, they are calling for a "partnership" in which universities will help sustain researchers doing high-caliber work who find themselves in temporary distress due to extremely tight funding. "It's the obligation of the medical schools to judge" which labs are doing work worthy of such support, he adds.

Only improvements that remove boom-or-bust uncertainty, Donowitz says, will permit today's talented and highly educated young people to produce a return on the national investment in their training and fulfill their promise as the productive physician-scientists that the nation needs.

Beryl Lieff Benderly writes from Washington, D.C.

10.1126/science.caredit.a0700126