Training and Sustaining Physician Scientists: What is Success?

Perspectives Viewpoints•Physician-scientists, MDs or MD-PhDs, are very important contributors to the advancement of biomedical science.•The current process for developing and sustaining physician-scientists is not working well.•Three programs substantially enhance physician-scientist development: MD-PhD programs, Internal Medicine Research Residencies, and National Institutes of Health (NIH)-supported K-award programs.•For even the best-trained physician-scientist, chances of receiving an independent NIH grant are declining.•Additional measures of success for an investigator should be considered. •Physician-scientists, MDs or MD-PhDs, are very important contributors to the advancement of biomedical science.•The current process for developing and sustaining physician-scientists is not working well.•Three programs substantially enhance physician-scientist development: MD-PhD programs, Internal Medicine Research Residencies, and National Institutes of Health (NIH)-supported K-award programs.•For even the best-trained physician-scientist, chances of receiving an independent NIH grant are declining.•Additional measures of success for an investigator should be considered. Physician-scientists—MDs or MD-PhDs who are trained and function as scientists in the broad sense—are viewed as key contributors to the advancement of biomedical science, translation of discovery, and improvement in health and health care.1Schafer A.I. The Vanishing Physician Scientist. Cornell University Press, Ithaca, NY2009Google Scholar Much has been written about the critical role of physician-scientists, how difficult they are to develop and to sustain, and their decline in number and impact over the past 20 years. Leaders of academic medicine agree that current processes for developing and supporting physician-scientists are not working well and need improvement. A comprehensive report on this topic has recently been issued by the National Institutes of Health (NIH).2U.S. Department of Health 86: 1071-1072Crossref PubMed Scopus (9) Google Scholar, 5Goldstein M.J. Kohrt H.E. What happened to the concept of the physician-scientist?.Acad Med. 2012; 87: 132-133Crossref PubMed Scopus (11) Google Scholar To further enhance the development of physician-scientists, several elements are foundational:1.Understand current processes, including strengths and successes, limitations, and failures.2.Agree on what success of a physician-scientist development and support program looks and feels like.3.Reasonably measure success. In 2015, we have some information available on the process of development and sustenance of physician scientists;6Todd III, R.F. Salata R.A. Klotman M.E. et al.Career outcomes of the graduates of the American Board of Internal Medicine Research Pathway, 1995-2007.Acad Med. 2013; 88: 1747-1753Crossref PubMed Scopus (19) Google Scholar, 7Jeffe D.B. Andriole D.A. Wathington H.D. Tai R.H. Educational outcomes for students enrolled in MD-PhD programs at medical school matriculation, 1995-2000: a national cohort study.Acad Med. 2014; 89: 84-93Crossref PubMed Scopus (46) Google Scholar however, we have little agreement on broad definitions of success for physician-scientist development and relatively poor measures of success for physician-scientists. Determining what success is, as well as how to measure it, is crucial to improve programs for physician-scientist development and support. At present, there are partial definitions of success, often rather parochial, and limited outcomes measures.8Jagsi R. Motomura A.R. Griffith K.A. Rangarajan S. Ubel P.A. Sex differences in attainment of independent funding by career development awardees.Ann Intern Med. 2009; 151: 804-811Crossref PubMed Google Scholar Medical schools, teaching hospitals, and biomedical science program leaders need more information to develop and sustain physician-scientists. There are at least 3 major well-developed pathways for physician-scientist development, as well as a traditional amorphous apprenticeship system. Often, the pathways are intertwined in a way that appears to produce synergies, each unquestionably contributing to physician-scientist career development. Pathways include MD-PhD programs; the American Board of Internal Medicine (ABIM) research residency pathway; and a series of mentored career development award programs supported by the National Institutes of Health (NIH; K awards), the Veterans Administration, private foundations (Doris Duke Charitable Foundation, American Heart Association, Sarnoff Foundation, and others),9Escobar-Alvarez S.N. Myers E.R. The Doris Duke Clinical Scientist Development Award: implications for early-career physician scientists.Acad Med. 2013; 88: 1740-1746Crossref PubMed Scopus (10) Google Scholar and certain professional societies. This analysis will focus on the 3 larger pathways: MD-PhD, ABIM research residency, and the NIH K award programs. The Medical Scientist Training Program (MSTP) funded by NIH supports learners at 44 medical schools. Additionally, in 2011, of 131 medical schools, 111 offered MD-PhD programs. Jeffe et al7Jeffe D.B. Andriole D.A. Wathington H.D. Tai R.H. Educational outcomes for students enrolled in MD-PhD programs at medical school matriculation, 1995-2000: a national cohort study.Acad Med. 2014; 89: 84-93Crossref PubMed Scopus (46) Google Scholar analyzed data from a survey of a cohort of MD-PhD candidates who matriculated in 1995-2000. The survey of 2582 matriculants indicated a success rate for receiving a PhD degree as MSTP program 80%, non-MSTP programs 60%, and overall 72%. Jeffe et al7Jeffe D.B. Andriole D.A. Wathington H.D. Tai R.H. Educational outcomes for students enrolled in MD-PhD programs at medical school matriculation, 1995-2000: a national cohort study.Acad Med. 2014; 89: 84-93Crossref PubMed Scopus (46) Google Scholar developed a multivariate regression model to find predictors of success in receiving a PhD degree. Important predictors of not completing a PhD include studying at a non-MSTP-supported institution, age > 23 years at entry into the program, and having a Medical College Admission Test score lower than 34. Factors without predictive value include sex, ethnicity, and student debt. MD-PhD programs are growing. From 2002 to 2013, the enrollment in MD-PhD programs nationally has increased from approximately 3600 to 5100, a 41% increase.10Association of American Medical Colleges. Table 36: Total active M.D.-Ph.D. enrollment by U.S. medical school and sex, 2009-2013. Available at: https://www.aamc.org/download/321554/data. Updated February 2, 2014. Accessed May 14, 2014.Google Scholar, 11Association of American Medical Colleges. Table 36: Total active MD/PhD enrollment by U.S. medical school and sex, 2002-2009. Available at: https://www.aamc.org/download/85968/data/table36-md-phd-enroll-sch-sex.pdf.pdf. Updated December 7, 2009. Accessed May 14, 2014.Google Scholar, 12Bonham A.C. MD-PhD training: looking back and looking forward.Acad Med. 2014; 89: 21-23Crossref PubMed Scopus (22) Google Scholar In 2013, approximately 520 potential physician-scientists received the combined MD-PhD degree. NIH leadership is developing methods to track success of graduates of MD-PhD programs.12Bonham A.C. MD-PhD training: looking back and looking forward.Acad Med. 2014; 89: 21-23Crossref PubMed Scopus (22) Google Scholar With the goal of fostering the careers of physician-scientists, ABIM permits internal medicine residency programs to offer an integrated curriculum (ABIM Research Pathway) that features both clinical and research training. Requirements include 2 years of internal medicine clinical training coupled with 3 years of research training. The research pathway is usually integrated with the supplemental clinical requirements of subspecialty training in a medical discipline. Between 1992 and 2008, 1009 individuals completed pathway training at 140 residency programs and took the ABIM certifying examination with a 90% first-time pass rate and an overall rate of 98%.13Lipner R.S. Lelieveld C. Holmboe E.S. Performance of physicians trained through the research pathway in internal medicine.Acad Med. 2012; 87: 1594-1599Crossref PubMed Scopus (14) Google Scholar A subset of these individuals (n = 385) participated in a recent Web-based survey to determine the extent to which pathway graduates actively pursued research-oriented careers.6Todd III, R.F. Salata R.A. Klotman M.E. et al.Career outcomes of the graduates of the American Board of Internal Medicine Research Pathway, 1995-2007.Acad Med. 2013; 88: 1747-1753Crossref PubMed Scopus (19) Google Scholar Seventy-three percent of the survey participants had completed graduate-level scientific training before entering the pathway, including 65% who had been awarded PhDs or an equivalent doctoral degree. Ninety-one percent of the survey respondents reported some current research effort with a group average of 59% of professional effort spent in research. Seventy-two percent reported being an academic faculty member, 8% are employed by a biotechnology firm, 2% are employed in a government position, and 10% are in private practice. A high proportion of survey respondents (>85%) reported having extramural research funding, among whom 63% reported having current NIH funding, 45% had funding from private foundations, 5% from the Veterans Administration, 22% from industry, and 32% from their home institution. Among a list of resident and training program variables, the ones that were positively associated with a particularly high level of scientific engagement after training (employment in a biomedical research position, >50% time spent in research, significant research funding, and scholarly productivity) were prior graduate-level research training (masters or doctoral-level training), any first-author publications arising from pathway training research, and the receipt of an individual career development award in support of the pathway training (including NIH K award funding). The results of this survey of a subset of pathway graduates supported the utility of the Research Pathway in facilitating the successful careers of selected individuals (many of whom were graduates of MD-PhD programs) with a desire to conduct biomedical research. Of note, the American Board of Pediatrics permits an analogous research pathway, albeit with very few participants. For many physician-scientists, receiving an NIH-mentored research award, typically for 5 years, is pivotal in career development. This discussion will focus on K08 and K23 funding mechanisms. The former most commonly supports bench and translational science; the latter supports clinical and population science. K award programs were initiated at NIH in the 1980s and have grown considerably. For NIH in its entirety, the number of awards reached an apogee in fiscal year 2007, at approximately 4300 awards, but has declined since that time with approximately 3800 awards in fiscal year (FY) 2012. Application success rates remain relatively high: across NIH, K08 application success rates exceeded 40% for each year between 2008 and 2012; for K23 applications, the rate exceeded 32% for that period. The success rates do vary by institute, however. For instance, in FY 2013 at the National Heart, Lung and Blood Institute (NHLBI), K08 funding success rate for applicants was 25%, and for K23 awards, 30%.14U.S. Department of Health a master's degree provides a lesser advantage. Moreover, the advantage afforded by these research degrees is increasing over time. In 2013, 43% of applications from aspiring physician-scientists with the MD-PhD degree were funded.14U.S. Department of Health 151: 804-811Crossref PubMed Google Scholar indicate that a minority of K award recipients have been able to make this transition. They studied a cohort who completed their K08 or K23 award by 2003. As shown in Figure 3, among a group of 2783 K08 and K23 recipients (980 women; 1803 men), the 5-year rate of R01 conversion was 19% for women and 25% for male K awardees; the 10-year rate was <40% and <50%, respectively.8Jagsi R. Motomura A.R. Griffith K.A. Rangarajan S. Ubel P.A. Sex differences in attainment of independent funding by career development awardees.Ann Intern Med. 2009; 151: 804-811Crossref PubMed Google Scholar