Respectful Insolence

This story, first brought to my attention by Drugmonkey, is something that I’ve been meaning to blog about since I first saw it. The reason, of course, should be obvious, given that my career is an example of the end product that the medical school described is going to be designed to produce: that of a physician-scientist:

The Scripps Research Institute and Scripps Health are working to set up what they hope will be the nation’s first medical school entirely geared to training physicians for dual careers in research and patient care.

[...]

The Scripps institute must raise $150 million in startup money for the medical school, which would be housed in its campus on the Torrey Pines mesa. The program would enroll up to 50 students each year in a five-year curriculum that offers routine medical school courses, such as anatomy and biology, with subsequent rotations at Scripps Health’s hospitals and doctors’ offices.

But these students would also receive training in lab work, clinical trials and research topics such as molecular genetics. The goal is to have them bring laboratory discoveries to the patients’ bedside.

“There’s no other curriculum and design such as this one,” said Dr. Eric Topol, who holds positions with the Scripps institute and Scripps Health.

Although many of the 130 medical schools in the United States offer similar physician-scientist training, they include only a few students at a time, Topol said. Those programs can take as long as nine years, he said.


Before I comment on this, let me briefly describe how I came to be where I am. I did not come to have my M.D. and Ph.D. through a medical scientist training program (MSTP), which is the standard model for training medical scientists in many medical schools. Such programs generally try to shave a year or so off of what it would normally take to fulfill the requirements of the M.D. and the Ph.D. separately by combining them and consolidating some of the clinical rotations for the M.D. That is the sort of program described by Dr. Topol, the sort that can take as along as nine years.

I wasn’t able to be accepted to the MSTP at my medical school, at least not the version that provided a full scholarship. Consequently, I made a strategic decision to complete my M.D. first. Ultimately, I applied for and matched in a good general surgery program, having for the moment given up on my dream to obtain a Ph.D. but not on my dream to be a medical researcher. In my second year, a fantastic opportunity presented itself. I had gone into residency expecting that I would take two years to do research between my second and third clinical years of residency. It turned out that my chairman was interested in an experiment. He wanted to see if it was possible to offer the opportunity for his residents to obtain a Ph.D. during the course of his general surgery residency program. There had been one resident who, he thought, would be perfect, but instead of entering the Ph.D. program, she had accepted a fellowship at the NIH for her research time.

I leapt at the chance.

It was even better than just a chance at a Ph.D. to me. It was a chance to become a graduate student and to do it without being impoverished, as the Department of Surgery would continue to pay me as a resident, not as a graduate student. Moreover, I managed to complete the program in three years, four months. True, I got lucky in my research project for my thesis, but I also chose wisely when I chose my research advisor. He supported me, and he goaded me on. He also was not the sort who held on to graduate students. His goal was to get them through the program, and I was the beneficiary of his clarity of purpose.

After I defended my Ph.D., I returned to my surgery residency and completed it. It was a serious culture shock, one that almost led me to change careers on at least two occasions. (Perhaps I will blog about that one day; now is not the time.) When I finished, I was a fully trained general surgeon who also had a Ph.D. I then went on to pursue a surgical oncology fellowship, where I obtained still more research experience. Indeed, part of it was not unlike doing a standard postdoctoral fellowship.

Clearly, my experience and path to becoming a surgeon-scientist was rather atypical.

So what about this concept of setting up a medical school designed to train physician-researchers? On the surface, it looks like a good idea. Although there are many medical schools with medical scientist training programs, they generally train only a handful of researchers each. Of course, the wag in me can’t resist wondering if Scripps is the place to set up a program like this, given how deeply steeped in woo the institution has become, with the Scripps Center for Integrative Medicine, but on the other hand maybe I should be glad that Scripps is allowing a countering of this woo with scientific medicine and a program to train medical researchers.

The question then remains: Is such a program a good idea? To me, it boils down to two questions:

  1. What is the value of a physician-scientist?
  2. Can physician-scientists be supported?

Although there are some around here who will disagree, but I think there is a unique role for the physician-scientist. Basic scientists may understand the detailed cellular and molecular mechanisms of disease beyond what physicians do. However (and this may offend some here, but it is nonetheless true), no matter how much they think they do, basic scientists cannot know what the true clinical issues are that need to be addressed by basic research. The counter to this is that physicians rarely have the detailed knowledge of the molecular medicines of disease to be truly effective as basic science researchers. There are exceptions (Judah Folkman, for example), but overall they are uncommon.

Some might say that the answer to this gap is to let the basic scientists do what they do best (basic research) and the clinical scientists do what the do best (to test the end results of what the basic scientists come up with). However, there truly is a culture gap between the two groups. Indeed, sometimes to me it seems as though the two speak different languages and have different agendas. For example, basic scientists are incredibly interested in understanding the minutiae of molecular mechanisms. Clinicians want to know things that can help patients now. They are often impatient and not interested in working out every last detail of a signaling pathway.

Enter the physician-scientist.

Although there are some who will claim that the physician-scientist (a.k.a. the translational researcher) has little added value above that of basic scientists, I see the value of researchers like myself in not only being able to identify the clinical issues that cry out for new solutions based on science but are best able to interface with the basic scientists and recognize results that are most likely to be useful clinically. Of course, there is a price. I sometimes joke that physician-scientists like myself catch flak from both sides. Basic scientists think we aren’t scientifically rigorous enough, and clinicians don’t think that we are adequately dedicated to patient care. Truly, it’s being torn between two worlds and being viewed with suspicion by both.

The second question is perhaps the more pertinent one. Even if you accept the value of physician-scientists, everything about modern academic medicine makes it incredibly difficult to be one. Indeed, I worry every day whether I can continue to pull it off. The reason is that academia is no longer a refuge largely shielded from the financial reality of practicing medicine. Academic physicians these days are expected to see enough patients and do enough clinical work to bill enough to cover their salaries and expenses. If they do a lot of research, it becomes virtually impossible to do that, and grant money alone is rarely enough to make up the difference. Consequently, physician-scientists cost medical schools money to maintain. that money must come from clinical operations and/or tuition. The only way this can work is if there is a contract, either implicit or explicit, that the clinical “workhorses” will support clinician-researchers. At the very time Scripps is planning on training an additional 50 clinician-researchers per year, academic medicine is becoming an increasingly inhospitable environment for them. I’m very fortunate in having found an institution that is willing to support me in spite of that, and I realize that I will have to deliver grant money, research results, and new therapies if I am to justify my existence.

That’s really the rub. Although I personally strongly believe in the value of physician-scientists doing translational research, I just don’t see how there will be jobs for all these newly minted translational researchers. Inevitably, many of them will end up giving up research and becoming straight clinical physicians. Although scientifically-trained clinical physicians are a worthy endpoint, they are not the intended endpoint for this program. Unless there is a major increase in NIH funding to allow these newly minted researchers to obtain grants to support their research programs, many of them will fall by the wayside.

There’s one final consideration. The Scripps program proposes to produce fully-trained physician-scientists in five years. I just don’t see how that’s long enough. It’s simply not possible in such a short period of time to provide enough laboratory experience and training to reliably and reproducibly produce researchers who can compete for NIH grant funding. Sure, there will be the occasional superstar who doesn’t need more than that, but that isn’t most physicians interested in research. It doesn’t matter that the program will require a master’s degree as a prerequisite. It’s only one year longer than medical school training, and, even if some consolidation shortens the medical school portion of the training, one extra year just isn’t enough.

The bottom line is that, although I very much like the idea of a special training program to produce physician-scientists, I’m not sure the Scripps plan is the way to go. It’s too short, and I’m worried that it will produce a surplus of researchers that current NIH funding levels will not be able to support, given that graduating 50 a year is probably equivalent the usual output of typical MSTP programs from 10 medical schools. For a program like Scripps’ to succeed, more than five years would be required and there would have to be adequate resources to produce grant support sufficient to allow graduates of such programs to develop research programs and support themselves.

Comments

  1. #1 Huan
    April 7, 2008

    While i concur that when it comes to medical science, physician-scientist are needed in addition to basic scientists. However, given the difficulties of obtaining grants for physician scientists, with or without a PhD, is it even reasonable to think there is a future for physician-scientists?

  2. #2 rglovejoy
    April 7, 2008

    You’re assuming that these physician/scientists are all going to work in academia/NIH and apply for research grants. Won’t some of them be working with drug or biotech companies?

  3. #3 BB
    April 7, 2008

    Glad you are writing about this; I’ve posted it on a forum to see what others think.
    The Scripps program is going to train through a combined MD/Master’s in translational research. The graduate training thus doesn’t give one a PhD nor does give one intense graduate training in a research academic discipline (translational research being an approach to research and not a field of inquiry).
    I also wonder what will happen to Scripps’ long-standing partnership for MD/PhD training with UCSD. The article I read didn’t mention UCSD.

  4. #4 mark
    April 7, 2008

    Isn’t this similar to the Cleveland Clinic medical school program? Dr. Topol is likely to know of the program in Cleveland.
    I dislike statements to the press about medical things that claim uniqueness or primacy. All good ideas have antecedents.

  5. #5 PhysioProf
    April 7, 2008

    Nice post, dude. While I don’t like the idea of translational research taking resources away from basic science, we clearly do need physician/scientists doing translational research as an integral and vibrant part of the overall biomedical research enterprise.

    And I have seen with my own eyes exactly the kind of shit you describe that makes this a brutal career path. The shittier the paylines get, the more academic medical centers burden their physician/scientists with clinical duties, and the less competitive they become at trying to slip in under those shitty paylines. I really do feel for you guys. But keep your fucking hands off my money!

  6. #6 PhysioProf
    April 7, 2008

    Nice post, dude. While I don’t like the idea of translational research taking resources away from basic science, we clearly do need physician/scientists doing translational research as an integral and vibrant part of the overall biomedical research enterprise.

    And I have seen with my own eyes exactly the kind of shit you describe that makes this a brutal career path. The shittier the paylines get, the more academic medical centers burden their physician/scientists with clinical duties, and the less competitive they become at trying to slip in under those shitty paylines. I really do feel for you guys. But keep your fucking hands off my money!

  7. #7 Snark
    April 7, 2008

    Great. I love playing lab rat, especially when I am sick.

  8. #8 Joe
    April 7, 2008

    It may set your mind to rest to know that I have given this matter a lot of thought, and I agree completely- one year is not enough to truly earn a doctorate. (Maybe RB Woodward did that (I don’t recall); but he was a mutant.)

    I have a friend who earned an MD/PhD (UPenn, 1981) in five years; but his dissertation was really based on his extensive and valuable undergrad research. We shared a lab for a few years, he is a damn fine chemist.

    For what it is worth, I think a person working off a (non-lab-research) masters degree in a subject (or, perhaps some intensive, clinical component of an MD) needs around two years. I expect a doctorate to include both- a deep knowledge of the literature and an extensive (hands-on) experience in research techniques. In addition to that, the person must have the time to write a good overview of the research. Time one does not have in one year.

    On the other hand, students deserving a PhD who are consigned to more than three years in the lab are being abused (as Orac somewhat noted).

  9. #9 DanioPhD
    April 7, 2008

    I agree that the Clinician-Scientist is an important bridge between bench science and applied medicine, and I share your concern that the Scripps program is of insufficient girth to give the attendants the experience they need to effectively do either. Indeed, even standard MD/PhD programs, in my experience, give very short shrift to the research requirements to make room for the volume of compulsory Med-specific endeavors. How much more streamlined can a PhD program become before it is diluted beyond recognition?

    As anticipated, I do take issue with:

    Basic scientists may understand the detailed cellular and molecular mechanisms of disease beyond what physicians do. However (and this may offend some here, but it is nonetheless true), no matter how much they think they do, basic scientists cannot know what the true clinical issues are that need to be addressed by basic research.

    You go on to explain that your unique perspective as a clinician gives you insights into research directions that a ‘basic scientist’ might miss. That sounds reasonable, but somewhat shortsighted, considering that the current bottlenecked, intensely competitive state of NIH funding almost always requires a clear, intellectually profitable link between proposed basic research and potential biomedical applications. Researchers can’t afford to be ignorant of the clinical ramifications of their work, and most of the better ones aren’t. Furthermore, as much of the pharmacology developed for treating humans also works very well in a wide range of animal models, we researchers would be remiss if we did not keep a working currency of information about clinical trials, or work to establish collaborations with pharmaceutical companies to further our mutual interests in discovery.

    My research modeling hereditary deaf-blindness in zebrafish is directly relevant to human disease. I attend meetings several times a year to exchange information with a host of clinicians as well as other researchers in the field I keep current on the literature detailing clinical progress in diagnosis and treatment of my disease of interest. How can I interpret the statement “basic scientists cannot know what the true clinical issues are that need to be addressed by basic research.” in a way that doesn’t devalue my considerable efforts to do exactly that?

  10. #10 Orac
    April 7, 2008

    How can I interpret the statement “basic scientists cannot know what the true clinical issues are that need to be addressed by basic research.” in a way that doesn’t devalue my considerable efforts to do exactly that?

    It’s not a matter of “devaluing”; it’s a matter of difference in training, perspective, and talent. You’ve never personally taken care of a patient with the disease of interest, and, as much as you might not believe it or think I’m pulling the arrogant physician scthick here, there are elements of knowing what works, what doesn’t, and what the practical difficulties of caring for patients involves and what is really needed to improve patient care that you just can’t get in a laboratory and that no amount of going to conferences will make up for. It’s a perspective that allows clinicians to identify therapies that would be so impractical that even if they worked they wouldn’t be helpful, for instance. There are certainly PhDs who make prodigious efforts to understand and even come close, but there remains a certain element of hands-on experience that just can’t be replicated any other way.

    For some diseases and specialties, this is probably not as important as for others. For example, my experience may be colored by being a surgeon where, quite frankly, no basic scientist I’ve ever met has understood surgical problems in quite the same way a surgeon does. The clinical ramifications of basic science are important, and basic scientists must have at least some understanding of them, but in my experience that understanding is mainly used to justify the usefulness of work (as well it should), not to describe how it will actually be turned into a therapy. Think of it as the difference between book learning and actual experience. I’m not saying that it always makes a big difference, but in many cases it does.

    Think of it this way: Few physicians have the time or ability to understand the deepest mechanisms behind disease. I view the role of the clinician-scientist mainly as bridging the gap between the theoretical and basic scientific and the practical (i.e., the clinician). We don’t always do it that well, but I think collaborations leading to real to work better when there are at least a few of us around. I also think that we tend to catch crap from both sides.

The site is currently under maintenance and will be back shortly. New comments have been disabled during this time, please check back soon.