Revival abroad, beginning at home: A case for the Indian clinician-scientist

A single flame gives both light and warmth. We measure them separately, in lumens and calories, yet they are one fire named twice. So, it is with medicine and research: Research is the light that makes disease visible, and medicine the warmth that brings that knowledge to a suffering body as relief. Healing and discovery are not separate acts, but one divided by habit. Over time, that habit became a rigid division. The laboratory followed disease into molecules, genomes, and data, while the clinic encountered it as signs, symptoms, and outcomes. This divergence arose not from indifference, but from immensity: Medicine grew too large for one mind to hold. As both domains expanded, they came to be learned in divergent ways. Medicine divided into organs and systems, yet every clinician still begins with the whole body. The cardiologist, ophthalmologist, and nephrologist all pass through the same anatomy, physiology, and pathology before narrowing to a specialty. Research fragmented differently. It did not divide by anatomy, but by method: molecular biology, genetics, bioinformatics, epidemiology, artificial intelligence, imaging, clinical trials, and countless other disciplines, each demanding years of apprenticeship. Yet no stage of clinical training opens that landscape the same way. Most clinicians meet only fragments of it, late, informally, and by chance. They are taught the whole body before choosing a part of it; they are rarely taught the architecture of discovery before being asked to contribute to it. This asymmetry matters. The clinician may recognize the question but not know the tools capable of answering it. Yet the clinician’s vantage is indispensable. At the bedside, disease is not a mechanism alone but burden, prognosis, and outcome, and that nearness gives it direction. It helps decide which questions are worth asking, what kind of answer would matter, and whether discovery has truly returned to the patient. Still, nearness alone cannot turn observation into knowledge. Between seeing what matters and proving what helps lies a gap where too many clinical questions vanish. Patterns remain anecdotes. Failures become memory. Uncertainties travel from one bedside to the next without becoming evidence. The clinician-scientist, a clinician who devotes a substantial part of professional life to rigorous research while remaining grounded in patient care, is trained to close that gap.1 In one person, the clinician who treats disease and the scientist who studies it are not two identities stitched together, but one vocation restored to its full shape. But this figure is not born. It is built. Modern science did not make the clinician-scientist unnecessary; it made one harder to produce. Questions arise naturally at the bedside; the ability to answer them does not. It requires training, mentorship, infrastructure, and institutions deliberately designed to create and sustain these human bridges between the clinic and the laboratory. The West, particularly the United States, recognized this challenge more than a century ago and responded by building institutions around it. At the beginning of the twentieth century, American medical education was recast around a simple proposition: Clinical skill and scientific training had to be part of the same curriculum.2 In the 1950s, the United States began to give that idea institutional form through the National Institutes of Health (NIH), recognizing that clinician-scientists could not be left to emerge by accident.3 Deliberate pathways followed, first through research training for physicians and then through combined MD-PhD programs and, from 1964, the NIH-supported Medical Scientist Training Program.4,5 The return was immense, and it registers two ways: in what physician-scientists have built, and in what their thinning now costs. Although they have never made up more than about 4% to 5% of the medical workforce, they have contributed to discovery far out of proportion to their number, accounting for between a third and a half of Nobel laureates in Physiology or Medicine over the past century.6 Yet their ranks have steadily thinned: The share of clinicians primarily engaged in research has fallen from around 4.5% in the 1980s to near 1.5% today, and the MD share of NIH research grants from 43% to 25%.7,8 Major reports now argue that this erosion is felt at both the bedside and the bench, weakening clinical-trial leadership and slowing translation, and have prompted a revival agenda built on protected time, dedicated funding pathways, and structured clinician-scientist programs across the United States and Europe.9,10 India’s case is not that clinician-scientists were forgotten; it is that, for decades, they were crowded out by necessity. A country short of doctors, hospitals, specialists, and access had to make service its first priority. Practice overtook research because practice was the emergency. But that old sequence, first capacity, then discovery, is no longer adequate because India is reaching a rare junction: Its capacity to build clinician-scientists is rising at the very moment its need for them is becoming impossible to ignore. The capacity is visible, and so is the lacuna. Medical education in India has expanded dramatically, to over 800 medical colleges and about 130,000 MBBS seats, the whole system having more than doubled in a decade.11 Formal clinician-scientist training, in contrast, remains vanishingly small. North America graduates around 600 clinician-scientists a year, about 3% of its medical students, and sustains on the order of a thousand funded MD-PhD seats at any one time; India has only a handful of integrated medical-PhD programs, often a single seat per specialty per year, its national intake counted in tens, not hundreds.4,12,13 Research infrastructure, too, is no longer the emptiness it once was: National investment and shared instrumentation have strengthened core facilities across institutions.14 So the question is changing. India is no longer asking only how to make more places where disease can be treated; it must ask how those same places can become sites where disease is understood. The need is just as urgent because the next era of medicine will be both molecular and local.15–17 Precision care cannot be imported whole from populations, hospitals, and markets unlike our own; evidence has to be tested against Indian realities: ancestry and diet, infection and environment, the cost a family can bear, and the system that must deliver it. The recurrent CEP290 variant targeted by two landmark treatments, an antisense drug and the first CRISPR therapy placed inside a human eye, accounts for a large share of CEP290-associated Leber congenital amaurosis in Western cohorts but was nearly absent in Indian children.18,19 This holds well beyond genomics, across diagnostics and trials and the daily work of getting care to a patient at all. Knowledge made elsewhere can guide India; it cannot stand in for knowledge made where Indian patients live and seek care. The responsibility is larger than India alone. Many of the conditions that crowd an Indian clinic are the same ones that shape life across the low- and middle-income world, yet they remain underserved by global research agendas and by markets that chase profit elsewhere. Fungal keratitis is the case in point: It blinds roughly six hundred thousand eyes a year, most of them young agricultural workers, yet draws a fraction of the science spent on macular degeneration, the blinding disease in the affluent world.20 If India builds clinician-scientists, it will not only answer its own questions. It can make the evidence, the tools, and the models for much of the global South, where the same diseases are common, the same constraints are real, and the same questions have waited far too long. To meet this moment, India needs clinician-scientists. Without them, expanding capacity will treat more disease but leave too many questions unasked, untested, and unanswered. With them, Indian hospitals and health-care institutions can become engines of discovery, generating knowledge not only for their own patients but also for other countries whose realities, burdens, and constraints global science has too often ignored.About the authorSiddharth Narendran Siddharth Narendran is a clinician-scientist at the Dr. P. Namperumalsamy Regional Research Center, Aravind Eye Hospital, Coimbatore. He completed his postgraduate training in ophthalmology at Aravind Eye Hospital, Madurai and subsequently undertook a postdoctoral fellowship from 2018 to 2020 at the Center for Advanced Vision Science, University of Virginia, under the mentorship of Prof. Jayakrishna Ambati. His work spans inherited retinal disease, age-related macular degeneration, CRISPR-based diagnostics for ocular infection, and the biological basis of sex and geographical disparities in eye disease.