A medical school only to train physician-scientists?

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.