The precarious position of physician-scientists in academic medicine today

Jake over at Pure Pedantry pointed the way to an article in Science that I hadn’t seen yet because of my absence. Just like yesterday’s topic, this one too is right up my alley. Specifically, it’s about something near and dear to my heart, namely the trials and tribulations of being a physician-scientist. The article paints a rather grim picture, with the observation that, although most MD/PhD’s would like to remain researchers, many are dropping out in order to become straight clinicians, clinical instructors at medical schools, or industry researchers. Jake’s commentary is certainly worth reading, and I agree with much of it; however, given that I’m where Jake would (hopefully) like to be in 15 years or so, namely an MD/PhD with an independently funded lab and who still takes care of patients, I thought my perspective on the article and its topics would complement his.

My perspective is different from Jake’s in that he has not finished his training or even entered residency yet. I, on the other hand, have not only finished MD and PhD training, but have gone through residency and fellowship and am early in the third year of my first five year NIH R01 grant, the “gold standard” grant to which nearly all biomedical researchers aspire. Moreover, it should be noted that I did not come to my position in the more “conventional” manner of a combined MD/PhD program that is the rage these days. Believe it or not, when I applied to the MD/PhD program at the University of Michigan, my application was rejected. Oh, they were more than willing ot let me do the program if I paid my own way (the application was, more than anything else, for spots that were paid for by training grants), but I couldn’t afford to do that. Consequently, I simply went to medical school. Then, after my second year of general surgery residency, an opportunity presented itself to take a break and go to graduate school, and that’s just what I did, returning to complete my general surgery residency after I got my PhD and then going on to do a research fellowship in surgical oncology. It was a long, hard road. I was almost 37 before I got my first “real” job. But I was about as prepared as I could expect to be to start my own lab.

So far, I’m doing quite well. Indeed, surgeons with NIH R01 grants are fairly rare birds. However, I must note that I got my first R01 just before the NIH funding climate turned so sour. Indeed, I basically slipped in under the window, as the grant application that has funded my lab since 2005 would not have been funded had I submitted it this year. This knowledge leaves me with a profound sense of uncertainty as I rapidly approach my next big milestone: Renewing the R01 for another five years. Although my lab has been productive, like most investigators in my position, I have grave doubts about whether I’ve been productive enough or published enough. However, in a way, that’s just whining. I really feel for physician-scientists who have just gotten their first faculty position and are expected to obtain NIH funding in this current climate. Their situation is far more dire than mine.

In fact, this Science article captures the essence of the problems facing young physician-scientists:

If scientific discoveries are going to lead to treatments for patients, physicians trained to understand and do research must play a central role. After many years of decline, the number of physician-scientists available to do that work has begun to recover thanks to several new programs for recruiting and retaining talented students, according to an article published in the July issue of Academic Medicine.

But can young physician-scientists succeed in building and sustaining the research careers that they hope for during their lengthy training? The difficulties they face are so severe that many abandon the effort, says an article by four experienced physician-investigators published in the February issue of Gastroenterology. The departure of so much young talent constitutes nothing less than “the burning of American intellectual capital,” lead author Mark Donowitz of Johns Hopkins University in Baltimore, Maryland, told Science Careers in an interview.

The nearly 500 students enrolled in M.D./Ph.D. programs at 15 universities who answered a survey about their experiences and plans for the Academic Medicine article have a strong interest in becoming researchers. The majority anticipates careers primarily devoted to basic research, with many of the rest intending to focus on clinical or epidemiological research. More than 90% of the respondents want to work at academic centers.

This makes perfect sense, of course. After all, why on earth would anyone go through the torture that it takes to get an MD/PhD if he or she didn’t want to do research and be in academia? The reason that I went to the trouble to get a PhD, for instance, is because I did not think that my training in science was adequate to be a true translational researcher, who could, to cite a cliche, translate basic science findings from the “bench to the bedside.” I was correct. The training in the scientific method that came from my PhD studies was just what I needed.

One thing that the article gets right is that it is probably not the pay differential between academia and private practice. True, I was grossly underpaid when I first started ou. However, thanks to mandatory yearly pay increases for me (the joy of working for the state!) and declining reimbursements putting the squeeze on private practice surgeons, over the eight years of my career thus far my pay has increased to the point where the pay differential between what I make now and what I could make in private practice has decreased from well over 100% to probably around 30% or so. Nor is it the inherent difficulty of combining a career in research with a career in clinical medicine. And, make no mistake about it, it is very, very hard indeed to combine the two and be effective at both. I knew what I was getting into, as much as it is possible ever to know based on the experiences of residency, graduate school, and fellowship.

No, it is the structure of academic medicine that is the problem. As I’ve discussed in depth before, we are in essence free lance operators, not unlike the situation that some used care salesmen find themselves in. the university gives us a “startup package” and then expects us to become self-supporting through obtaining NIH and other grant funding within 3-5 years. We are expected to fund a high percentage of our academic salary (the NIH will not pay for the clinical part of our salary) and fund our research entirely through grants. This works reasonably well when it is not too difficult to obtain external funding. However, in today’s climate, where in my field (cancer) the NIH is funding only around 10-12% of grant applications, its flaws manifest themselves. Even excellent grant proposals do not achieve funding, and even excellent researchers cannot support their laboratories. As the article puts it:

The problem… stems from the fact that every lab chief “essentially is running a small business.” Like all businesses, “you have to pay your bills.” Lab chiefs, however, can only get the money they need by winning grants, which today’s tight funding and intense competition make unpredictable and unreliable. “You get them for a few years, then you lose them for a year, then you get them again. Consequently, people are continually essentially going bankrupt,” Donowitz says.

But unlike ordinary businesses that can use capital reserves to keep the doors open through hard times, government-funded researchers cannot save up for lean years. The rules decree that “at the end of the year, you can’t carry over more than 25% of what they give you. The grants are quite small, so you cannot weather a downturn,” Donowitz continues.

I haven’t “gone bankrupt” yet, but it could well happen in 2010, when my grants expire, if I cannot compete successfully to renew them. My failure would not necessarily mean that I’m a bad scientist, either. Better investigators than I have failed to renew their first R01. A lot will depend on whether the funding climate has improved and how productive I can be in the next two years or so.

Of course, as is pointed out, the key difference between physician-researchers and pure PhD researchers is this:

Unlike Ph.D. researchers, medical doctors can always make a living by hanging out their shingles. “But that’s not what this group of people wants to do,” Donowitz says. The substantial earnings gap separating research and practice is not an important factor in young physician-scientists’ decisions to leave the lab, he believes. “There are a bunch of us who are not interested in making this extra money but are turned on by the thought process of doing science. … The money is really, I’m convinced, not the major issue at all.”

Instead, “lack of security” drives physician-scientists from research, he says. “You’re always at risk of going bankrupt”–not personally, he emphasizes, but as a productive investigator. Anxiety and uncertainty produce “a very difficult life.” As proof that stress and discouragement, not lack of love for science, lead physicians to quit, Donowitz notes that “the people who drop out of science generally don’t leave the academic center. They become the clinician-teachers.”

That is one of the biggest advantages of being a physician-scientist. If a basic scientist fails to obtain funding before being tenured, he’ll be out of a job, after which his options will not be appealing. He can either go into industry, try to find another tenure-track academic position (not easy after a track record of failing to be funded once), disappear into the twilight world of the poorly paid and unrespected adjunct faculty, or take a job in academia as a laboratory manager, thus becoming utterly dependent on the grant support of the principal investigator for whom he works. A clinician has much better options if he fails to be funded, thus making it far easier simply to “drop out” of research if the going gets tough. Indeed, I’ve been told by more than one person never to give up clinical practice, because I can always make a living operating if this whole research thing doesn’t work out and a number of clinician-scientists weather downturns in grant funding by doing just that. Were I ever to fail to renew my grants and thus lose my laboratory, that is probably what I would do, although I would view it as a professional failure of the highest order, whether that characterization would be fair or not. Even so, I’d still want to remain in academia, perhaps doing clinical research and teaching.

So what’s the answer?

As always, it’s a question of money and commitment? Jake is correct in asking whether we’re willing to put our money where our mouth is by providing sufficient funding to allow the MD/PhD researchers in whom we’ve already invested to have a fighting chance to compete for independent funding and develop actual independent research programs. I’m less sanguine about his (and the article’s) suggestion that more flexibility in carrying over unspent funds to help researchers survive downturns in funding, given that such a solution would be a stopgap at best and only delay the day of reckoning by at most a year. The current boom-and-bust system that allowed as many as 30% of NIH grant applications to be funded in the early 2000s could obviously not be sustained, happening as it did in the context of a five year plan to double the NIH budget. The problem is that the return to reality has been far quicker and more painful than expected, anything but the “soft landing” envisioned by the NIH leadership near the end of the doubling period in 2003. If we are to sustain a high quality research programs that produce the most rapid translation of basic science findings to clinical treatments, we have to provide enough funding to allow MD/PhD researchers to sustain their laboratory efforts and be sure that we are not producing more MD/PhDs than we are willing to support.

Even so, would I do it again? The answer is: Probably. I really do believe in the value of the combined MD/PhD. Few MDs have the scientific rigor that allows truly great research to be done. Those who do almost invariably acquired it through research experience comparable to at least one rigorous postdoctoral fellowship, if not more. In addition, essentially zero PhDs whom I know have the practical understanding of human disease to be able to identify what are the true deficiencies in our knowledge of the pathogenesis of individual diseases and our ability to diagnose and treat it. They can’t really know because they’ve never taken care of a patient. Moreover, physicians have more of a sense of urgency; we see the results of the deficiencies of our treatments every day in patients whom we cannot cure or even treat well. Given all this, I am indeed heartened to see that there are more students becoming MD/PhDs. However, it is depressing to think about how many of them will become and remain productive translational researchers once their training is complete.