Physician-scientists have always brought a unique perspective to biomedical research that is inspired by their personal experience in caring for patients. Indeed, throughout history, physicians have played a central role in advancing the science of medicine as the "translators" of medical research. Yet there has been growing concern over the past 3 decades that the workforce of physician-scientists, at least in the form we have come to know them in previous generations, may be vanishing.
We have a problem
There is ample evidence to support this worrisome trend. Although the numbers of National Institutes of Health (NIH) grant applications and applicants over the past 15 years has more than doubled, those numbers have been essentially flat for M.D.-only physician-scientist applicants. During the 5-year period from 1998 to 2003, during which the NIH budget doubled, there was a 43% increase in first-time R01 applicants with Ph.D.s as principal investigators (PIs) and a 104% increase in applications with M.D.-Ph.D. PIs -- a very small percentage of the total pool of applicants. In contrast, applications from those with M.D. degrees declined by 4%.
Perhaps even more disconcerting are data about the recent attrition of NIH-funded physician-scientists. As reported by Theodore Kotchen et al. and Howard Dickler et al. in The Journal of the American Medical Association in 2004 and 2007, respectively, about 40% of M.D.s with K08 (mentored clinical scientist development) awards do not even apply for a subsequent first independent (R01) grant. Furthermore, unsuccessful first-time M.D. applicants for an R01 grant are consistently less persistent than their Ph.D. counterparts in reapplying after an initial failed attempt. And M.D. applicants who do have an R01 grant are less likely than Ph.D. applicants to apply for a subsequent R01 grant. So in recent years, at every point in the early life cycle of NIH funding, physician-scientists have been more likely than Ph.D. scientists to leave the NIH grant-applicant pool.
These numbers suggest that, however serious the problem of insufficient numbers entering the physician-scientist workforce, there's an even more important factor: The pipeline is broken, or at least leaking badly.
How did this problem happen?
What are some of the fundamental causes for the decline in the physician-scientist workforce? At the core of it, I think, is the reality that the arenas of basic biomedical research (on one side) and the clinical practice of medicine (on the other) have progressively and dramatically separated. This widening chasm has created a rapidly increasing language barrier between basic biomedical scientists and practicing clinicians. It is a two-way barrier: Midcareer clinicians today are unable to understand even the basic vocabulary of molecular biology and genetics, and biomedical investigators (even those with M.D. degrees) are increasingly losing track of rapid advances in clinical medicine, which is always increasing in technologic complexity.
In addition to its linguistic aspects, the chasm between basic science and clinical practice is also both scientific and cultural. The scientific chasm was created largely by the reductionism in medical research in the early years of the molecular biology and genetics revolution throughout much of the second half of the 20th century. This reductionist approach to medical science dictated that complex systems can be understood only by first reducing them into the study of their smallest, individual, analyzable parts. Reductionism moved medical research further and further away from the whole patient. More recently, reductionism has been counterbalanced by the emergence of "systems biology," which I expect to reanimate the crucial link between basic science, clinical research, and medical practice.
The cultural chasm between science and clinical practice involves the very distinct mentalities required to practice clinical medicine and to do basic biomedical research. Barry Coller insightfully described this chasm in The Vanishing Physician-Scientist?:
- Clinicians are motivated by the need for immediate action (sometimes to even save a life), whereas scientists are conditioned to avoid rushing to judgment; - Clinicians are taught to adhere to standards and guidelines of practice, whereas scientists are encouraged to challenge existing paradigms; - Clinicians traditionally respect hierarchy and expert authority, whereas scientists tend to critique and challenge accepted wisdom; - For clinicians, errors are potentially mortal threats, whereas for scientists, errors are inevitable manifestations of the creative process; - Clinicians focus on the unique, whereas scientists look for generalizable principles.
- Clinicians are motivated by the need for immediate action (sometimes to even save a life), whereas scientists are conditioned to avoid rushing to judgment;
- Clinicians are taught to adhere to standards and guidelines of practice, whereas scientists are encouraged to challenge existing paradigms;
- Clinicians traditionally respect hierarchy and expert authority, whereas scientists tend to critique and challenge accepted wisdom;
- For clinicians, errors are potentially mortal threats, whereas for scientists, errors are inevitable manifestations of the creative process;
- Clinicians focus on the unique, whereas scientists look for generalizable principles.
In addition to the scientific and cultural chasms, contemporary forces are now contributing to the weakened physician-scientist career pipeline. The number of women graduating from medical school today equals the number of men. The dramatic change in medical student gender demographics has not been accompanied, however, by a proportionate increase of women in senior faculty ranks and leadership positions, even after the expected time lag. It has been noted that women tend to find physician-scientist careers less attractive than men do for a number of reasons: They (1) are concerned that it will be impossible to combine a successful medical research career with childbearing and family life; (2) feel that they have to be better than their male counterparts to be considered equal; (3) receive little encouragement to become physician-scientists; and (4) lack compelling role models.
Entry and retention in physician-scientist careers also appears to be impeded today by a generation gap in expectations. The current generation of medical school graduates, regardless of gender, has very different priorities. They attach much more importance to work-life balance and controllable lifestyles that they believe, perhaps erroneously, to be incompatible with serious research careers. Finally, at least partly as a function of these new forces, there has been serious erosion in the quantity and quality of effective mentoring in its traditional dyadic, "mentor mentee" format.
So, are physician-scientists marked for extinction?
And yet, as I have concluded in The Vanishing Physician-Scientist?, I believe that physician-scientists should be considered "endangered" today only in their current state, not in the sense of permanent extinction. What is vanishing -- if it ever really existed -- is a mass of physician-scientists matching an earlier generation's idealized concept of the "triple threat" who could, as a solitary clinical investigator, move effortlessly between bedside and bench, managing a busy clinical practice and a productive research laboratory while devoting significant time to teaching and mentoring.
How can I make it?
So how can young physician-scientists realistically flourish under these circumstances? First, you must recognize that the current structure of medical schools and universities, with their anachronistic, rigid "up or out" promotion and tenure systems, were designed to accommodate the male physician-scientist of earlier generations whose career ambitions were supported by stay-at-home wives who assumed all household and child-rearing responsibilities. It will take some time for academic systems to catch up to the contemporary realities of being a successful physician-scientist today. During this period of transition, I would offer the following advice.
1. Be proactive in carving out your own physician-scientist career path. In the past, young physicians with a passion and aptitude for research were nourished and incubated in highly supportive environments. They could assume that their paths to independence as investigators would be carefully groomed and personally guided by readily available, experienced, dedicated, and influential mentors who would also create for them the personal connections they need for collaborations. If you are in such an environment now, consider yourself extraordinarily fortunate. The great majority of young physician-scientists today will not have the luxury of being the passive recipients of such spoon-fed career development. So, be proactive, resourceful, and aggressive in searching for and engaging the guidance you will need.
2. Along these lines, seek and cultivate mentors. Of course, above all, you must have strong scientific mentoring. But you must also have role models, confidants, champions, and experienced and influential people who can provide you with connections and show you the ropes (people whom I refer to as academic "godfathers" or "godmothers"). These characteristics are rarely found all rolled into one individual, so assemble your own personal mentoring circle. In many cases, you will find them outside your own department and even outside your institution. Work to recruit them to your mentoring team and then cultivate them by reciprocating as a "good mentee" -- someone who accepts criticism well, keeps an open mind, frequently gives credit to the mentor, and can bring real value to the mentor-mentee relationship.
3. Navigate the diverse missions of academic medicine with self-discipline. You should learn great time-management skills. These are mostly hard-earned, self-taught, acquired skills, not innate abilities, so don't just say, "I don't have good time-management skills" and leave it at that. Try very hard to organize your calendar to enable you to devote large blocks of uninterrupted time to each of your core professional activities -- at least several hours in any given day, preferably whole days or even several consecutive days. This means learning to be able to say "no" -- or "not now" -- in a gracious and disarming way. For example, when asked to give a lecture when you are engaged in writing a grant application, offer a different time when you can do it, after the grant deadline.
4. Learn that medical research today is a team sport. During this generation, the breathtaking pace and scope of progress in both the science and the practice of medicine has vastly outstripped the capacity of any individual physician-scientist to maintain even a semblance of currency in both arenas. The key to success is your ability to thoughtfully surround yourself with partners, particularly Ph.D. scientists, who offer complementary expertise. And for each project, you and your collaborators should try to agree in advance what each scientist's role will be and who will be the "driver." Insisting on being the sole principal investigator on every project, or even most projects, will prove to be counterproductive. Can you be a team player and still be a star? Yes. Remember that the greatest sports stars have been the ones who were able to elevate their teams to win championships.
Without a doubt, this is a difficult period to become a physician-scientist because academic structures and reward systems are lagging well behind the contemporary realities that constrain traditional physician-scientist careers. It is a particularly challenging period for young women physician-scientists. Rather than railing against the system, you should be a constructive, even outspoken, catalyst for change in your home institution. Do not allow systemic adversities to defeat you: The same amazing intellectual rewards that physician-scientists of previous generations enjoyed are most certainly available for the current and future generations.
N. C. Andrews, "The other physician-scientist problem: Where have all the young girls gone?" Nature Medicine 8, 439 (2002).
H. B. Dickler et al., "New Physician-Investigators Receiving National Institutes of Health Research Project Grants: A Historical Perspective on the 'Endangered Species.' " The Journal of the American Medical Association 297, 2496 (2007).
T. A. Kotchen et al , "NIH Peer Review of Grant Applications for Clinical Research." The Journal of the American Medical Association 291, 836 (2004).
T. J. Ley and B. H. Hamilton, "The Gender Gap in NIH Grant Applications." Science 322, 1472 (2008).
T. J. Ley and L. E. Rosenberg, "The Physician-Scientist Career Pipeline in 2005: Build It, and They Will Come." The Journal of the American Medical Association 294, 1343 (2005).
A. I. Schafer, Ed., The Vanishing Physician-Scientist? Ithaca, New York: Cornell University Press. (2009).
Andrew I. Schafer is chair of the Department of Medicine and the E. Hugh Luckey Distinguished Professor of Medicine at Weill Cornell Medical College, and physician-in-chief at New York-Presbyterian Hospital/Weill Cornell Medical Center. He is the editor of The Vanishing Physician-Scientist?, published by Cornell University Press.