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Do we need a new model for Training Physican Scientists?

There are fewer and fewer nephrology trainees opting for a career in laboratory based kidney research. In our own training program the vast majority of renal fellows who want an academic career pursue training in clinical science. There are many reasons for this including (but not limited to) an extended training period in a field in which they may have little prior experience, the perceived uncertainty of maintaining adequate funding over the long haul and the difficulty inherent in "wearing many hats". Another observation is that lab based science is like a cottage industry with each investigator ultimately working independently. There is less of a role for group interactions that might provide a more supportive environment for physicians who are under a lot of pressure to obtain salary support. If the community believes that practicing M. D.s can make valuable contributions to basic research, what do we need to do to recruit, train and retain these individuals? Should all M. D.s who choose a lab based career obtain a Ph.D.? Should M. D.s who want to do basic research participate in larger cooperative groups? How are M. D.s doing in comparison to M. D./Ph.Ds and, Ph. D.s in terms of R01 grant funding?

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Submitted by 4 years ago

Comments (12)

  1. The same is true in cardiovascular training programs. If the initial exposure to science is late (i.e. subspecialty stage), the "road" is perceived to be too long, uncertain and financially risky to follow. The trainees don't see how rewarding a science career can be or understand that scientific skills enhance their ability to conduct translational research. For fellowship programs that want to train future academic faculty, the option to start research first may be helpful for those individuals that are interested in translational or more basic biomedical problems.

    4 years ago
  2. Moderator

    I can try and find some data on dual degree holders vs. MDs vs. Ph.Ds. wrt R01 funding--NIH has certainly looked at this, as as the IOM. I think early exposure to research is essential to recruit clinical folks in to basic science--the question is how early and when to incorporate this exposure into the clinical training. From the opposite side--does the current structure of training the clinicians need to increase its flexiblity to allow for "alternative" models?

    4 years ago
  3. Terry Watnick Idea Submitter

    Would be great to take a look at this data. Since I was a fellow more than 15 years ago, our program has trained approximately 2 physicians who stayed in basic science. The other M. D. trainees who tried the lab either went to private practice or transitioned to the clinical/clinical research track. I do think that we seriously need to consider alternative models. Any ideas out there?

    4 years ago
  4. The earlier exposure to the excitement of a career in investigation the better. What is lacking is a "navigator" as a role model for the young professional to see as someone who has successfully followed a career pathway leading to productivity and satisfaction. Also, new formats for translational research training are needed that emphasize the "team" approach across disciplines to research.

    4 years ago
  5. I agree early exposure to research training is essential. But, at the same time I feel the value of clinical experience in asking the right research questions is ignored in the current setup. If a mid-career clinician wants to come back into an academic and research setting, there are no mechanisms to either support or encourage such moves. It is an unhill task for someone to return to an academic environment.

    4 years ago
  6. There is definitely a need for a physician-scientist in the new field of Interventional Nephrology. The clinical part of performing procedures is enticing for the fellows in training but the available opportunities are limited in an academic setting. The scope of translational research related to dialysis vascular access is tremendous but the academic interventional nephrologists in their mid-career are unable to devote time to train an academic interventionalist due to lack of supportive resources. A new model that can support both clinical and research training would promote academic faculty in this new field of nephrology.

    3 years ago
  7. When I interview fellowship applicants for our program I find that they all want to pursue research but for about 95% of them this means retrospective case studies and "outcomes" analysis. The rare fellow is prepared to do "wet" bench work (almost all of these are M.D./PhD's). This is not because M.D's are not interested; they don't know if they are interested or not because they lack experience. For a PI the question becomes do you take on an M.D. in your lab who for practical purposes is at the level of a first year graduate student?

    The gap for M.D.'s can be bridged with education. There are successful, short, intensive courses in clinical research offered and I think the same can be done for molecular approaches to disease. We are encouraging interested M.D. fellows to take a short intensive course at the outset of their fellowship (like a woods hole or cold spring harbor course) to train them in molecular approaches and techniques. Perhaps what is needed more than a course is reducing the perception of risk of doing something new. As long as clinical case study type work is offered, this is the easy choice for fellows.

    Perhaps a middle ground is genomics. The benefit here is that methods are evolving to be easier and higher throughput and the techniques are relevant to all diseases. A focused training in genetics / genomics coupled with institutional support for acquiring DNA samples might make for an easier transition of M.D.'s into research. This might go hand in hand with better training in recognizing genetic syndromes in patients and improve disease phenotyping.

    3 years ago
  8. I am in my first year of a K08, after spending 3 years of conducting post-fellowship research. Aside from experience/exposure, a major factor dissuading young physician-scientists from a career in original investigation is money. The K08 pays $90,000 in salary per year, without adjustments for inflation and without regard to locality. This is 30-40% LESS than what a new attending physician typically earns as clinical faculty. The financial gap is compounded by a difference in job security. A K-award no longer gaurantees a start-up package and tenure-track position. Thus, shying away from a research track is a rational economic decision regardless of ability or desire. Potential solutions include 1) raising K-award salaries, 2) increasing indirect costs associated with K-awards to make candidates more attractive to institutions and 3) more stringent criteria for institutional commitment in terms of career development (e.g. promotion schedule, tenure-track eligibility, etc).

    3 years ago
  9. Moderator

    Manish's suggestion about increasing indirect costs associated with K awards is interesting. It would not have occurred to me until recently, when I heard a senior investigator at another institution make the observation that institutions lose money on K recipients because of the unfunded overhead. I wonder to what degrees this tempers some institutions' enthusiasm for investing in K recipients?

    3 years ago
  10. Mary: I don't think the overhead issue dissuades us at all from applying for K awards.

    As regards physician research training in general I have to amend my comment above about how education in research methods for fellows could encourage more of them to engage in research. I made a point of asking all the prospective fellows this year whether they would opt for a more basic research track (vs. clinical) if training were offered. All said no. It became clear to me that the fellows interested in basic research had all had prior basic research experience and were committed to bench research (despite the pay issue) by the time they got to the fellowship stage of their careers.

    Bottom line: the best investment to encourage more fellows to commit to basic research would be to support laboratory experience during their medical school years. By the time fellows get to be fellows they are terminally differentiated. The fellowship is a time in their life when they want to be maximally productive (based on what skills they already have) and they are not interested in taking a risk on a new direction in life/career.

    We need to support funding opportunities for medical students to engage in laboratory research and encourage more medical schools to offer research programs. Many medical schools already do encourage/require students to do research so the structure is in place. Maybe an NRSA type award focused on medical students for a 6 month to 1 yr research experience would be a good idea. Does such a mechanism already exist? Maybe more advertising/recruitment is what's needed.

    3 years ago
  11. I agree that the overwhelming majority of fellows are not interested in pursuing a research career. This is true even when they are interviewing for a fellowship position. Even for those who initially contemplated a research career, many pursue clinically-oriented jobs. That said, I’m not sure that more exposure is the most efficient way of attracting more qualified physician-scientists.

    There are already a large number of trainees with research experience, but they choose not to pursue a career in research because it is not as attractive as clinical practice. Inflation-adjusted medical student debt is increasing. Research funding is increasingly more competitive. Job security for a physician-scientist is decreasing. These are major factors in choosing a career track that cannot be ignored. Why is it that dermatology and ophthalmology are consistently amongst the most competitive residency programs? Is it because there is an obvious love for these fields amongst medical students or is it because of the compensation and lifestyle they offer?

    Further, funding is essentially zero-sum. Where would the money come from for medical student funding? For example, a single K-award may be the rough equivalent of 4 pre-doctoral positions. Is there data that suggests that >25% of NRSA awardees pursue a career in research?

    Increasing indirect costs is a potential mechanism for encouraging institutions to invest in early-phase physician-scientists. Are there data on how many K-awardees receive start-up packages or equivalent investments from institutions? It seems that the return on the NIH’s investment would be greater if it led to a greater investment from medical centers.

    As far as cost-neutrality, how many K-awardees go on to receive an R01 or equivalent? Would it be higher yielding to have fewer K awards with higher indirect costs and salaries? Are there data on the trade-off in yield between # of awards and amount per award?

    3 years ago
  12. I think that some of the problem is in the "attraction" of a career and earning potential in subspecialty medicine. Academics will always be at a disadvantage to clinical practice. One way, I believe, to attract the "right" people for Physician-Scientist is to adopt research requirements by the American Board of Internal Medicine similar to the American Board of Pediatrics (I am a pediatric nephrologist). ABP states that "all fellows will be expected to engage in projects in which they develop hypotheses or in projects of substantive scholarly exploration and analysis that require critical thinking. Areas in which scholarly activity may be pursued include, but are not limited to: basic, clinical, or translational biomedicine; health services; quality improvement; bioethics; education; and public policy." ABP requires a minimum of 3-years of fellowship compared to 2-years by ABIM for nephrology. I also think that academic institutions have been "feeding at the trough" of the NIH for too long with their F&A rates. Scripps is reported to be around 85%, Salk Institue > 90%. F&A is supposed to cover building maintenance & utilities, library support, centralized administrative costs for the grant management and other administrative costs. Perhaps cutting/re-negotiating the R-awards F&A rates with HHS will allow for more than the 8% for K- & T-awards and 0% for F-awards.

    3 years ago

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