Most people have no idea what a physician-scientist is or the job description for such a person. Many think that by definition medicine is a science and therefore an MD must be a scientist. Physicians get training in the rudiments of science during the first two years of medical school and may get a bit more during their post-graduate residencies and fellowships. But rigorous scientific training in a branch of bioscience is not part of their curriculum.
A brief historical aside. For the first 70 years of the last century, it was possible to be proficient at all four components of academic medicine – clinical practice, teaching, administration, and leading-edge science that produced important new knowledge. But no longer. Biomedical science has reached a level of sophistication and intricacy such that it consumes virtually all of its practitioner’s time.
The career path for a physician-scientist is something like this: Medical school, a few years of clinical training, followed by four or more years of intensive laboratory training in one of the leading fields of biomedical research. Such fields include immunology, molecular medicine, genetics, DNA sequencing and/or editing, etc.
Why not go directly into the sciences just described and skip clinical education? The answer is that a unique familiarity with the details of human disease is the result of clinical training applied to a keen and inquisitive mind. A scientist without such training may do wonderful things, but the pursuit of biomedical advancements is benefited beyond measure by the presence of clinician-scientists.
A recent article in Medscape The Emerging Physician-Scientist Crisis in America details the worsening shortage of physician scientists. The article briefly describes the problem and offers a few explanations for the decrease in clinical scientists. I think the problem is even larger than the author of the paper posits. Currently, the percentage of American doctors who work as physician-scientists is only 1.5% a more than a threefold drop compared with 30 years ago when the figure was 4.7%.
The first explanation offered in the paper is the most conventional and simultaneously poorly reasoned. Inadequate federal research funding. The main source of federal funding is the National Institutes of Health. When I first started doing serious clinical and laboratory research it was explicitly conveyed that if I were to have any success I must gain NIH funding. For the entirety of my research career, less than 10% of approved grants (RO1) were funded. Almost as much time was spent writing grant applications as was spent doing the work for which funding was requested. Next was the problem of ‘indirect costs’. The medical schools at which most of the NIH funded research was performed claimed that they needed reimbursement for the use of their facilities. This claim had some reasonableness behind it, but the medical schools claimed exorbitant rates for such usage. It took decades to put some sort of a cap on these costs, but they remain too high. The growth of a huge federal research bureaucracy was inevitable and federal research funding has helped metastasize the medical school administrative staff to the gargantuan sizes it now encompasses.
Politics inevitably entered the research soup with endless regulations and mandates that have nothing to do with unbiased science. We may have reached the point where we’d be better off without federal funding. It’s a difficult call and I don’t know what would replace it. The deans and their ilk will defend the status quo to the grave and beyond. They view research funding as a cash cow and seem relatively indifferent to the science it creates. In government no matter how pure and noble the initial stimulus to start a program – power, political pressure, and unrelated issues contaminate the product. The NIH has gone from the jewel of worldwide biomedical research to a bloated institution tinged with the taint of corruption. See its performance during the late COVID epidemic.
As just mentioned most biomedical research is carried out in medical schools. These institutions vary enormously in their ability to attract first rate bioscientists. Most of the important medical research is performed at about 10%, maybe less, of the nation’s medical schools. The rest are trade schools turning out practitioners whose skill at their profession varies in direct proportion to their innate abilities. The medical schools have proved susceptible to the current lunacy regarding race, merit, gender, and all things unrelated to the training of a doctor who will help you during a health crisis and who is trained to evaluate the efficacy of new diagnostic and therapeutic procedures, even if unable to develop them himself. The last place in a rational society where a move of even a millimeter from meritocracy should be allowed is medicine.
A patient should be looking for the same kind of doctor as was Gutle Rothschild (1753-1849) the matriarch of the famous financial family. Living into her 96th year she constantly complained to her doctor about the inadequate medical he provided her. In frustration, he finally exclaimed, “Madame Rothschild I cannot make you any younger.” Her retort is germane today. “Doctor, I’m not paying you to make me younger. I’m paying you to make me older.” I don’t care if my doctor looks like me or what his background is. I want what Madame Rothschild wished.
I doubt the efficacy of any programmatic effort to increase the number of physician-scientists other than to recruit future physicians who are deeply interested in medical science. Their path will be difficult, but there will always be those who wish to trod it. The explosion of medical bureaucrats will not make the journey easy. Such a career must be its own reward. There will always be a few hardy souls who will gravitate to it.
