Most people are content to follow one career trajectory, yet there are many qualified medical doctors who yield to the lure of research and choose to take up positions as clinical scientists. Dividing your time between the lab and the hospital may seem like the ideal way to satisfy both intellectual and vocational desires, but juggling both careers brings a unique set of challenges and rewards.
What it takes to train as a medic and a researcher ...
Zubin Bhagwagar trained as a doctor in India before coming to Oxford to gain his membership of the Royal College of Psychiatrists (MRCPsych) in 1998. A clinical lecturer in psychiatry, he currently spends 3 days at the University of Oxford running outpatient clinics in adult psychiatry and working in a busy community mental health team. The rest of the week, Bhagwagar is wearing a very different kind of hat: the one of a final-year DPhil student at Hammersmith Hospital, London. There he is conducting PET scan research, investigating the neurobiological relationships involved in vulnerability to mood disorders. His DPhil, due for submission later this year, was partly supported by a clinical training fellowship from the Medical Research Council (MRC).
To Bhagwagar, the rewards of pursuing research alongside your clinical training are obvious. "It is interesting; you can ask questions and also realise how little we know!" he enthuses. "It also keeps me interested in clinical work. Research helps me to function at a 'cerebral' as well as just a 'spinal' level." The chance to travel and meet the global research community is also a bonus. "You get to see the bigger picture--what the world thinks about disease--in addition to focusing on local services and patient issues." It is also a great advantage to have the fallback of returning to the wards if research funding becomes scarce. "Clinical researchers are lucky in this respect, as we always have the option of going back into full-time clinical work."
However, all this comes at a price. Bhagwagar had to struggle with the inflexibility of clinical training. "I believe that there needs to be a clearer training structure for clinicians involved in research," says Bhagwagar. "The introduction of new schemes following the Saville Report  is a start. However, training bodies also need to provide better help, support, and advice for academic trainees and I believe that the situation is far from perfect at present." Bhagwagar feels that in this context it is important you ensure continuity between your two careers. "If you switch from research to the clinic and back again there is a tapering off of your knowledge and skills which will have to be regained when you go back into research, and vice versa," he says.
Another major issue is the lack of career structure for trainee clinicians involved in research. Traditionally, doctors spend 3 years working as a specialist registrar after becoming members of the Royal College of Psychiatrists and then go on to be consultants. But by the time he fully qualifies, Bhagwagar will have spent 6 years at the specialist registrar level. This means he has to contend with the harsh reality of juniors being promoted ahead of him, he says, but he also points out that this becomes immaterial when you have motivations that differ from someone with a 'normal' medical career.
Personal satisfaction is Bhagwagar's prime motivator. Ultimately he hopes to enjoy the best of both worlds as long as the funding permits. But even if you are not sure about pursuing both careers, there is much to be gained from the dual training. "Clinicians come into research for a variety of reasons and not everyone fancies academic research as a full-time career," he says. "But one is able to pick up some extremely useful skills in a research job which stand you in good stead as a clinician."
Getting the funding to pursue both careers ...
A few steps up the career ladder, Richard Festenstein, consultant in neurogenetics at the National Hospital for Neurology and reader in molecular medicine at the MRC Clinical Sciences Centre, London, spends 1 day a week taking a neurology clinic and runs his lab the rest of the time. He enjoys the balance between answering mechanistic, fundamental questions and attempting to relate these to disease situations.
After gaining his medical degree in 1984, Festenstein pursued a clinical career in neurology. Believing that science and medicine are inextricably linked, he decided to do a PhD at the MRC Mill Hill laboratories and investigated the role of regulatory elements in controlling gene expression, graduating in 1996. He explains that he "was attracted by the idea of using mouse models to answer human questions" and "could also see the possibility of applying the results in the form of gene therapy" for thalassemia patients. While working for his PhD he also acted as a clinical assistant at the National Hospital for Neurology "to keep my feet on the ground and continue my training."
If funding is a common issue for researchers, the problem is two-fold for those wanting to pursue their clinical interest. Festenstein estimates himself fortunate, for the MRC  has always supported his research--initially in the form of a training fellowship, then a clinical scientist fellowship and finally a senior fellowship. "There is a perception that in order to get funding you have to be working on projects that directly demonstrate a medical slant, yet basic science is at the root of medical problems--something the MRC fortunately recognises," he comments. He acknowledges though that if the MRC has helped greatly by offering him a solid career infrastructure, the positions are not easy to get. Back in the clinic, doctors are confronted with the issue of resources again, with many of them feeling that the chronic underfunding of the National Health Service gives them less and less time to spend with patients.
Festenstein believes the scientific component of medical training needs to be increased. "It is time that medicine becomes much more scientific," he says. However, the relative inflexibility of the new Kalman training system for medics makes the implementation of the reforms that would be necessary difficult. "This highly structured system leads to earlier specialisation and fixed time-frames for training, producing an environment which fails to integrate academic training successfully," Festenstein explains. With the need for "quick fix" medical solutions, there is little space for doctors to get to the scientific root of their patients' diseases once their training is over. Vice versa, "although science informs medicine, diseases can also inform us of basic mechanisms which ultimately lead to new therapies," says Festenstein. "We need both science and medicine to progress as a society."
To medics considering a dual career in science, Festenstein would advise to try and get into the Wellcome Trust  or MRC training schemes. He also recommends doing a PhD rather than the shorter MD. "The PhD training is much more rigorous, scientifically, though there is certainly room for both to co-exist," he explains. The nature itself of the project you pick is really important. "You must be convinced that the project is good science, either addressing fundamental questions or with a clear-cut human benefit," he continues. "There are lots of mediocre projects which will get you a PhD but won't advance you after that."
Reflection on the medical and scientific landscape ...
As someone who has successfully negotiated both the medical and scientific career ladders to the top, David Edwards, professor of neonatal medicine at Imperial College of Science, Medicine and Technology, London, is in a good position to view the landscape that current clinical scientists are tackling. He currently maintains clinical paediatric work at the Hammersmith Hospital while devoting the rest of his time to research and the inevitable administrative load that comes with it. Yet for him, paper-pushing has not been the major pressure. He finds that for clinicians involved in research, simply finding time to pursue their ideas is a problematic issue. "Very heavy clinical workloads do not help researchers, though recent implementation of the European Working Time directive in hospitals and appointment of more doctors has gone some way to solving this," he says.
He also acknowledges that right from the start clinical researchers don't have it easy. "The structure of the system militates against young doctors going into clinical research and this is a severe problem for both them and the country," he says. "There are problems at every level, from rigidity in training within the Royal Colleges to lack of recognition via merit awards."
Yet Edwards is delighted that there are still talented people who want to have both a clinical career and undertake research. He strongly encourages them: "Go for it--it's great fun and there are lots of career openings for properly trained clinical researchers."
So it seems that in spite of the training frustrations, time pressures, and lack of research funding, the personal rewards of a dual clinical and research career far outweigh the costs. One can hope that as more medics join the research ranks they will gain greater recognition and assistance from both the academic and clinical institutions responsible for supporting them.