Up until the last 10 years or so, the path for training clinician-scientists in Canada was largely the traditional approach of encouraging fellows to pursue research. This method has met with limited success in terms of numbers of clinicians combining academic research and practice. As a result, two other models were introduced that achieve the same goal of a dual career in research and clinical practice. The first model combines MD training with a PhD program in an integrated program, attaining both degrees simultaneously. In the second model, trainees seek out intensive research training after the MD, either in a formal degree-granting program or as a postdoctoral fellowship, in combination with residency or specialty fellowship training.
Currently, nine Canadian Institutes of Health Research (CIHR) accredited and funded MD/PhD studentship programs exist (see sidebar). In addition, there are several rapidly growing clinician-investigator programs based at many of the same universities. Over the past several years, funding and general support for these training programs has increased with the realization that there is a marked shortage of clinician-scientists in Canada. With the rapid advances being made in several areas, such as genetics, proteomics, and neurobiology, the need for individuals who can understand and contribute to mechanistic research and facilitate clinical applications has never been greater.
For those medical school applicants who know they want to combine research and a career in medicine, the MD/PhD program offers the opportunity to integrate training as clinician and scientist from the start. With a combined program, trainees begin to acquire early on the multitasking and organizational skills necessary for a successful dual career. The MD/PhD program at the University of British Columbia (UBC) is ideally suited for building these skills, since training in research and clinical medicine are interwoven throughout the 7-year program. Of the two available models, a dual-degree program is probably the best approach for students interested in basic science, because the choices available for research training are likely to be wider and include more opportunities for basic science and bench research into molecular mechanisms, compared to graduate programs or postdoctoral fellowships linked to post-MD clinical training; the latter is more likely to be focused more on clinic-based studies.
Students in the UBC program engage in a wide range of research: molecular mechanisms underlying cell proliferation in cancer or cell death in stroke; relating gene mutations to disease mechanisms; the social factors that determine access to health care for women living on the street. Although more time is spent prior to attaining the MD degree, graduates of the MD/PhD program have the necessary skills to carry out research (either bench-based or clinical), publish well, and compete well for funding, so the time between the degree and an independent position as a clinician-scientist tends to be shorter. These students can also take advantage of post-MD clinical training programs that offer time and opportunity for research. As well, their publication records make it easier to obtain salary support (i.e., from programs such as the CIHR-sponsored Clinician Scientist Award) during postdoctoral research training, further easing the transition to an independent position. Such awards offset the loss of clinical income during a stage when it is critical to spend maximal time in research in order to establish an independent career.
Adding the research focus
But students who decide to pursue a career in research at a later point in their MD or post-MD training still have options, in the form of combined residency/fellowship/research-training programs such as UBC's Clinician Investigator Program (CIP). UBC established CIP just 8 years ago, and the program is growing rapidly in popularity. It is part of a Canada-wide initiative by the Royal College of Physicians and Surgeons to increase opportunities for research training during the residency years. In this program, the trainee spends additional year(s) pursuing a master's or PhD degree, or concentrated time training in a lab or with a clinical researcher.
The research program is integrated with clinical residency or fellowship training. Salary support during research training is available through government money allocated to residency programs, together with departmental resources and/or funding from subspecialty societies. Unfortunately, this funding is piecemeal and not as stable as that available for MD/PhD programs. Because of their more mature level of clinical experience, CIP trainees tend to be highly motivated to push the frontiers of research toward clinical applications. Many examples exist of highly successful clinician-scientists who are products of each of these two pathways. There is no "right" path to follow for becoming a clinician-scientist.
What happens after training?
How does one become a competitive researcher and super clinician at the same time? There are a few important points to keep in mind. First, it is helpful to focus clinical practice sharply; not only to a subspecialty, but on an even narrower niche where one is the expert in only certain diseases within that subspecialty; by narrowing the scope, clinician-scientists find it easier stay on top of the rapid advances in both clinical and research fields. Second, it is important to decide whether to emphasize research-related activities or the clinic. To compete as a bench researcher usually requires at least a 75% time commitment. In the current climate of high competition for research funding, it is difficult to be successful with a 50:50 split.
On the other hand, if the research is tied closely to or directly derives from clinical practice, such an equal split may be realistic. In fact, it is critical for physician-scientists to link their bench research to their clinical practice. If the two are unrelated, it is much more difficult to compete for publication and funding with PhD scientists who spend all their time on research. But if it's done right, it can be an advantage: Lab time spent investigating molecular mechanisms underlying pathogenesis of the diseases seen in clinical practice will provide an advantage over the straight-PhD researchers; clinician-scientists will bring a broader perspective and insight into the disease, as well as access to patient material that is not readily available to PhD scientists.
The continued success of the clinician-scientist model requires that salary support continue to be available on a competitive basis well past the training years. There are many examples of gifted clinician-investigators who obtain salary support through the early years of their first faculty position, only to find that support is unavailable at mid-career. As a result, these clinician-scientists must place a larger emphasis on clinical practice, leading to diminished productivity and success in research. This last point is one that has yet to be addressed; the retention of clinician-scientists is one of the key issues currently under scrutiny by a task force initiated and overseen by CIHR (see the CIHR Web site  for more details), with a mandate to design programs and infrastructure that will optimize opportunities and facilitate excellent clinical research.
In summary, the move to foster a healthy environment for the clinician-scientists is rapidly gaining momentum and will likely pay off in the near future, for British Columbia and the rest of Canada.