At the 2017 National Conference for Physician Scholars in the Social Sciences and Humanities in Boston, MA, APSA Founder Freddy Nguyen, MD, PhD moderated a discussion on physician-scientist training in the social sciences and humanities (SSH) with Jeremy Greene, MD, PhD; Helena Hansen, MD, PhD; Seth Holmes, MD, PhD; and Scott Stonington, MD, PhD.
Chronicle of Higher Education: The Need for More M.D.-Ph.D. Hybrids, and What Colleges Are Doing About It
Chronicle of Higher Education – Paul Basken – January 16, 2017
Physician-scientists are uniquely adept at translating basic discoveries into cures. But graduate programs aren’t producing many such scholars.
Back in 1979, The New England Journal of Medicine warned of a crisis: The ranks of physician-scientists — typically, holders of both an M.D. and a Ph.D. — were fast shrinking, threatening science’s ability to translate basic discoveries into actual cures.
Some 37 years later, the warnings are still coming. They might have even intensified.
Physician-scientists, with in-depth training in both medicine and research, are uniquely poised to address pressing challenges at the forefront of biomedicine. In recent years, a number of organizations have outlined obstacles to maintaining the pipeline of physician-scientists, classifying them as an endangered species. As in-training and early-career physician-scientists across the spectrum of the pipeline, we share here our perspective on the current challenges and available opportunities that might aid our generation in becoming independent physician-scientists. These challenges revolve around the difficulties in recruitment and retention of trainees, the length of training and lack of support at key training transition points, and the rapidly and independently changing worlds of medical and scientific training. In an era of health care reform and an environment of increasingly sparse NIH funding, these challenges are likely to become more pronounced and complex. As stakeholders, we need to coalesce behind core strategic points and regularly assess the impact and progress of our efforts with appropriate metrics. Here, we expand on the challenges that we foresee and offer potential opportunities to ensure a more sustainable physician-scientist workforce.
American Physician Scientists Association – April 15, 2014
The Directors’ Award was given to Freddy Nguyen, founder of the American Physician Scientists Association, in recognition of his innumerable contributions to APSA since the organization’s initiation. To honor Freddy’s legacy, the Board of Directors will present the Founder’s Award (successor to the Directors’ Award) to recognize extraordinary and dedicated service to APSA. Freddy will play a role in selecting the recipient of that honor. Read below for Freddy’s reflections on a decade of APSA.
We question the implications of the study by Jeffe and Andriole,1 who assembled a novel database from disparate sources to investigate the role of Medical Scientist Training Program (MSTP) funding for MD/PhD student training. MSTPs (i.e., MSTP programs) were stratified by duration of MSTP funding to their respective institutions. As reported in Table 2, recent MSTPs were more similar in student prematriculation characteristics to non-MSTPs than they were to long-standing MSTPs. Because the authors did not compare all MSTPs with all non-MSTPs, their concluding recommendation that future studies take into account the MSTP funding status of MD/PhD trainees should be evaluated with the duration of MSTP funding to the institution in mind.
The authors found that female and minority students were more likely to graduate from long-standing MSTPs than from non-MSTPs. However, the analysis did not normalize the ethnic and gender diversity of the MD/PhD cohort to the overall medical student cohort at each respective school. Thus, it is unclear whether the increased diversity is due to MSTP funding or certain institution-specific factors. Intra-institutional normalization could also have been performed on other variables (e.g., MCAT score and the undergraduate institution’s Carnegie Classification).
Another potential confounder of the analysis is the research milieu in which the long-standing MSTPs function, that is, the home medical school. For example, as a crude analysis, out of the 43 medical schools with MSTPs in 2010–2011, 36 (84%) were concurrently among the top 43 medical school recipients of NIH funding in 2010.2 We maintain that the institutional environment plays a more integral role in the development of physician–scientists than does the funding mechanism. Institutions giving higher priority to research are more likely to have invested in the proper infrastructure and resources to support MD/PhD students and to fully fund them. With the authors’ finding of increased MD/PhD graduate debt linked to increased likelihood of pursuing a nonuniversity clinical practice, further investigation is warranted regarding the role of institutional trainee support, level of financial support, and sources of funding beyond MSTP support alone.
Based on Table 4, there was no significant difference between long-standing MSTP, recent MSTP, and non-MSTP graduates regarding pursuing a career outside that of full-time faculty/research scientist. This suggests that obtaining both the MD and PhD degrees, regardless of MSTP funding, is in itself sufficient for this outcome. However, a comparison of the students’ research career intentions at the time of matriculation—from the AAMC Matriculating Student Questionnaire (MSQ)—with their intentions at the time of graduation would have been a better measurement of the influence of MSTP funding on the persistence of career intentions. The fact remains that no studies have shown the predictive value of career intentions on actual outcomes.3,4
Incorporating information from the MSQ and implementing postgraduation longitudinal studies would provide a better understanding of the impact of factors such as training environment and funding support on the retention of physician–scientists in the career pipeline.
POWERED BY THE COMPUTATIONAL MUSCLE OF BIOINFORMATICS AND THE BROAD PERSPECTIVE
of systems biology, advances in biomedical science now have the capacity to transform medicine. Yet to fully realize the health benefits of new scientific insight, we must ensure a vibrant flow of information between the basic sciences and clinical medicine. This takes both systems and people.
The U.S. government has made an unprecedented investment in the infrastructure required to support a new generation of translational researchers. Through the Clinical and Translational Science Award program (CTSA), the National Institutes of Health has created a national consor- tium that already includes 39 centers in 23 states with an annual funding commitment of $500 million by 2012. Still in its infancy, this initiative seeks to shorten the time required to translate research results into therapies by many means, including training researchers and providing them with an academic home, developing tools for clinical research, streamlining regulatory processes, and fostering interdisciplinary and interinstitutional research.
The potential is clear.
But people are the prerequisite for success. We need an array of inno- vative investigators whose expertise spans all the disciplines of basic discovery and medical science. As a counterpoint to federal efforts, our private, nonprofit organizations have addressed the human capital need in robust ways, training and funding physicians and other clinical scientists, and piloting models for interdisciplinary graduate training involving biologists, physical and computational scientists and engineers, as well as a wide range of clinical and public health professionals.
In his July 2007 editorial,1 Dr. Whitcomb questions the value of U.S. MD–PhD training, citing the low percentage of students desiring research as their primary professional activity2 and their low rate of NIH grant applications.1 He laments the current system of training as having too much time away from the lab and advocates a system more conducive to research.
He makes a number of assumptions, two of which we challenge here. One, the lower than expected percentage of students desiring research is a function of time away from the lab. This is essentially an academic argument, since we cannot randomize students to different training protocols. Yet, we must still consider how best to improve students’ education. While simply increasing the integration of research into early training appears reasonable, it is not the answer. We believe it is too much to ask students (or residents) to effectively integrate both research and doctoring at the earlier stages of learning. Instead, delving deeply into one discipline at a time as a novice, rather than striving for true coherence via integration, is more likely to develop solid foundations. We want our young physicians and scientists to treat their patients and execute their experiments with expertise and not just acceptable competence. The current system should certainly be modified to fit modern needs, but simply more integration and lab time are not the solution.
Two, the need for MD–PhDs to perform more lab research as a part of their profession is a more contentious matter. We must remember that most medical lab research is not performed by MD–PhDs, and the majority of physician scientists are not MD–PhDs. Then what do MD–PhDs do? They are uniquely positioned, by virtue of learning two traditional disciplines, to see complex problems from different perspectives—to be innovators, teachers, integrators, and leaders. It is the duty of dual-degree programs to provide the education to encourage such qualities. To push all MD–PhDs toward the lab or particular subspecialties is shortsighted. All fields of medicine and surgery—and, indeed, pubic health policy and many business disciplines—need those who can integrate the skills of rigorous investigation with an understanding of patient issues.
For the National Institute of General Medical Sciences to truly get its money’s worth, MD–PhD programs should provide exceptional multidisciplinary education, not career training. They need to encourage creativity, exploration, vision, and, especially, leadership. Only then will our society realize its full investment potential.
IN THIS TOGETHER. Freddy Nguyen had such a hard time learning about M.D./Ph.D. programs that he vowed to help other applicants avoid a similar fate. Last month, the organization that grew out of his frustration, the American Physician Scientists Association (APSA), hosted its fourth annual meeting in Chicago. The group is doing well enough for the 26-year-old Nguyen, an M.D./Ph.D. candidate at the University of Illinois, Urbana-Champaign, to step down as president and hand the reins to the next generation. APSA (www.physicianscientists.org) has more than 1000 student members from about 120 medical schools. It organizes national and regional conferences each year where this rare breed—who face a 10-to-14-year slog—can meet fellow students, present their research, and learn from senior investigators who have traveled the same path “It’s really about connecting people across organizations,” says Nguyen. “Freddy has a remarkable passion for this,” says Joseph Bast, director of the M.D./Ph.D. program at the University of Kansas Medical Center, who calls the group “a very worthwhile organization.” The new president is James Pauff, who attends Ohio State University in Columbus.
The American Society for Clinical Investigation (ASCI) was started a century ago to foster and to address the needs of the younger physician-scientists. A hundred years later, ASCI remains one of the premier organizations for physician-scientists and one of most well-respected organizations in the medical community. I have had the opportunity and pleasure to interact with the ASCI not only as an organization through my tenure as president of the American Physician Scientists Association, but also with its members over the last four years. In my view, the same characteristics that permeate ASCI the organization also define ASCI the membership–mentorship, exemplary role models, advocacy, and leadership.
Student feedback on the proposed changes to the USMLE
Since the formation of the Committee to Evaluate the USMLE Program (CEUP), several avenues have been made available for students to provide feedback. One of those avenues have been through a student representative to CEUP who has jointly appointed by the leaders of the American Medical Student Association (AMSA), the American Medical Association – Medical Student Section (AMA-MSS), and the Association of American Medical Colleges – Organization of Student Representatives (AAMC-OSR). Student feedback, at the time, had been largely limited to the input from the leaderships of the aforementioned organizations who were primarily surveyed by the NBME. Subsequently, students were also given the opportunity to participate in focus groups and on an electronic message board (http://usmle.org/comprev). In addition to these opportunities, the American Physician Scientists Association (APSA) felt that there was a paucity of quantitative, objective data aimed at gathering broad student feedback; therefore, APSA undertook the initiative to develop a national survey intended to gauge medical student sentiment in an effort to further help shape and support the dialogue surrounding the Comprehensive Review of the USMLE.
Association of Professors of Medicine Physician-Scientist Initiative: Recommendations for Revitalizing the Nation’s Physician-Scientist Workforce
Physician-scientists, because of their perspective of asking scientific questions influenced by their experience of caring for patients, are uniquely positioned to perform research that directly benefits patients. Yet, the physician-scientist workforce is shrinking and aging, portending decreases in the effectiveness of the medical enterprise to discover new treatments and cures. Recognizing the detrimental effects of a physician-scientist shortage, the Association of Professors of Medicine (APM)—the organization of departments of internal medicine represented by chairs and appointed leaders at medical schools and affiliated teaching hospitals in the United States and Canada—has begun a long-term initiative to identify, develop, and implement substantive and practical solutions that will ensure the survival, growth, and diversity of the physician-scientist workforce.
The APM Physician-Scientist Initiative—led by Principal Investigator Andrew I. Schafer, MD—is planned in linked phases. Phase I focused on evaluating the physician-scientist problem and creating a set of recommendations for growing, revitalizing, and diversifying the physician-scientist workforce. This goal was achieved through a series of structured surveys and focus groups (results summarized in Appendix A), which in turn helped inform the agenda for the APM Physician-Scientist Initiative Consensus Conference, “Revitalization of the Nation’s Physician-Scientist Workforce,” in November 2007. The consensus conference (planning committee, Appendix B) assembled leaders of the academic, medical, and research communities; representatives from the various governing bodies that influence, fund, and regulate biomedical research and academia; respected experts on issues facing the physician-scientist workforce; and young physician-scientists (conference participants are listed in Appendix C).
Following plenary lectures presenting the perspectives of academia, industry, and the federal government, the conference was largely interactive, with targeted breakout groups focused on specific aspects of the physician scientist career path (see Appendix D). Breakout group participants proposed their single, best, articulated recommendation for enhancing the highlighted areas, while the full group debated and discussed additional opportunities to improve the pipeline, whether via entry or improved retention. The complete list of 30 recommendations emanating from the conference breakout sessions and general group discussions is provided—in no priority order—in Appendix E. Participants provided a preliminary assessment of the recommendations followed by a more detailed, analytical assessment post-conference, prioritizing, commenting, and editing the recommendations to create a more sharply focused action plan.
While Phase I of the initiative was intended to understand the driving contemporary forces that shape the problem today and to formulate specific recommendations, Phase II will expand and activate a coalition group of key leadership organizations to move the agenda forward by developing next steps, a coordinated national strategy, and oversight of implementation of the action plan.