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Requests for reprints should be addressed to James D. Marsh, MD, University of Arkansas for Medical Sciences, 4301 W. Markham St. #832, Little Rock AR 72205.
Physician-scientists, MDs or MD-PhDs, are very important contributors to the advancement of biomedical science.
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The current process for developing and sustaining physician-scientists is not working well.
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Three programs substantially enhance physician-scientist development: MD-PhD programs, Internal Medicine Research Residencies, and National Institutes of Health (NIH)-supported K-award programs.
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For even the best-trained physician-scientist, chances of receiving an independent NIH grant are declining.
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Additional measures of success for an investigator should be considered.
Physician-scientists—MDs or MD-PhDs who are trained and function as scientists in the broad sense—are viewed as key contributors to the advancement of biomedical science, translation of discovery, and improvement in health and health care.
Much has been written about the critical role of physician-scientists, how difficult they are to develop and to sustain, and their decline in number and impact over the past 20 years. Leaders of academic medicine agree that current processes for developing and supporting physician-scientists are not working well and need improvement. A comprehensive report on this topic has recently been issued by the National Institutes of Health (NIH).
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. The Physician-Scientist Workforce Working Group Report 2014. Available at: http://report.nih.gov/workforce/psw/psw-group.aspx. Updated September 22, 2014. Accessed October 1, 2014.
Without doubt, training a successful physician-scientist is a long, costly, and convoluted process with considerable attrition, and it is likely that the process can be improved.
however, we have little agreement on broad definitions of success for physician-scientist development and relatively poor measures of success for physician-scientists.
Determining what success is, as well as how to measure it, is crucial to improve programs for physician-scientist development and support. At present, there are partial definitions of success, often rather parochial, and limited outcomes measures.
Medical schools, teaching hospitals, and biomedical science program leaders need more information to develop and sustain physician-scientists.
There are at least 3 major well-developed pathways for physician-scientist development, as well as a traditional amorphous apprenticeship system. Often, the pathways are intertwined in a way that appears to produce synergies, each unquestionably contributing to physician-scientist career development. Pathways include MD-PhD programs; the American Board of Internal Medicine (ABIM) research residency pathway; and a series of mentored career development award programs supported by the National Institutes of Health (NIH; K awards), the Veterans Administration, private foundations (Doris Duke Charitable Foundation, American Heart Association, Sarnoff Foundation, and others),
and certain professional societies. This analysis will focus on the 3 larger pathways: MD-PhD, ABIM research residency, and the NIH K award programs.
MD-PhD Programs
The Medical Scientist Training Program (MSTP) funded by NIH supports learners at 44 medical schools. Additionally, in 2011, of 131 medical schools, 111 offered MD-PhD programs.
analyzed data from a survey of a cohort of MD-PhD candidates who matriculated in 1995-2000. The survey of 2582 matriculants indicated a success rate for receiving a PhD degree as MSTP program 80%, non-MSTP programs 60%, and overall 72%.
developed a multivariate regression model to find predictors of success in receiving a PhD degree. Important predictors of not completing a PhD include studying at a non-MSTP-supported institution, age > 23 years at entry into the program, and having a Medical College Admission Test score lower than 34. Factors without predictive value include sex, ethnicity, and student debt.
MD-PhD programs are growing. From 2002 to 2013, the enrollment in MD-PhD programs nationally has increased from approximately 3600 to 5100, a 41% increase.
Association of American Medical Colleges. Table 36: Total active M.D.-Ph.D. enrollment by U.S. medical school and sex, 2009-2013. Available at: https://www.aamc.org/download/321554/data. Updated February 2, 2014. Accessed May 14, 2014.
In 2013, approximately 520 potential physician-scientists received the combined MD-PhD degree. NIH leadership is developing methods to track success of graduates of MD-PhD programs.
With the goal of fostering the careers of physician-scientists, ABIM permits internal medicine residency programs to offer an integrated curriculum (ABIM Research Pathway) that features both clinical and research training. Requirements include 2 years of internal medicine clinical training coupled with 3 years of research training. The research pathway is usually integrated with the supplemental clinical requirements of subspecialty training in a medical discipline.
Between 1992 and 2008, 1009 individuals completed pathway training at 140 residency programs and took the ABIM certifying examination with a 90% first-time pass rate and an overall rate of 98%.
A subset of these individuals (n = 385) participated in a recent Web-based survey to determine the extent to which pathway graduates actively pursued research-oriented careers.
Seventy-three percent of the survey participants had completed graduate-level scientific training before entering the pathway, including 65% who had been awarded PhDs or an equivalent doctoral degree.
Ninety-one percent of the survey respondents reported some current research effort with a group average of 59% of professional effort spent in research. Seventy-two percent reported being an academic faculty member, 8% are employed by a biotechnology firm, 2% are employed in a government position, and 10% are in private practice. A high proportion of survey respondents (>85%) reported having extramural research funding, among whom 63% reported having current NIH funding, 45% had funding from private foundations, 5% from the Veterans Administration, 22% from industry, and 32% from their home institution. Among a list of resident and training program variables, the ones that were positively associated with a particularly high level of scientific engagement after training (employment in a biomedical research position, >50% time spent in research, significant research funding, and scholarly productivity) were prior graduate-level research training (masters or doctoral-level training), any first-author publications arising from pathway training research, and the receipt of an individual career development award in support of the pathway training (including NIH K award funding). The results of this survey of a subset of pathway graduates supported the utility of the Research Pathway in facilitating the successful careers of selected individuals (many of whom were graduates of MD-PhD programs) with a desire to conduct biomedical research. Of note, the American Board of Pediatrics permits an analogous research pathway, albeit with very few participants.
NIH-Sponsored Mentored Research Awards (K Award Track)
For many physician-scientists, receiving an NIH-mentored research award, typically for 5 years, is pivotal in career development. This discussion will focus on K08 and K23 funding mechanisms. The former most commonly supports bench and translational science; the latter supports clinical and population science. K award programs were initiated at NIH in the 1980s and have grown considerably. For NIH in its entirety, the number of awards reached an apogee in fiscal year 2007, at approximately 4300 awards, but has declined since that time with approximately 3800 awards in fiscal year (FY) 2012. Application success rates remain relatively high: across NIH, K08 application success rates exceeded 40% for each year between 2008 and 2012; for K23 applications, the rate exceeded 32% for that period. The success rates do vary by institute, however. For instance, in FY 2013 at the National Heart, Lung and Blood Institute (NHLBI), K08 funding success rate for applicants was 25%, and for K23 awards, 30%.
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. Funding Success Rates. Grants: applications, awards, success rates, and total funding by Institute/Center, mechanism, activity code, and funding source (Table #205-A, Research Project Grants FY 2014). Available at: http://report.nih.gov/DisplayRePORT.aspx?rid=601. Updated January 14, 2014. Accessed February 9, 2015.
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. Funding Success Rates. Training and research career development programs. Career development awards: applications, awards, success rates, and funding, by Institute/Center and activity code (Table #204, NIH Career Development (K) Grants FY 2005-2014). http://report.nih.gov/DisplayRePORT.aspx?rid=551. Updated January 1, 2014. Accessed February 9, 2015
Figure 1 shows the NHLBI trend in funding success rate for FY 2003-2012. The 4-year downward trend since 2009 is not encouraging to applicants or to those charged with developing and nurturing early-stage physician-scientists.
Figure 1National Heart, Lung and Blood Institute (NHLBI) trend in funding success rate 2003-2012.
For NHLBI, the decline in number of applicants from 2005-2012 is striking: almost half of the peak in 2005. The number of grants awarded has declined even more substantially.
We sought to determine whether more extensive preparation as a scientist and investigator affected funding success rates for K08 and K23 applicants across all NIH institutes and centers. Figure 2 shows the temporal course for applicants with an MD only, an MD plus a master's degree, or an MD-PhD. It is evident that a PhD in addition to an MD does afford a substantial advantage; a master's degree provides a lesser advantage. Moreover, the advantage afforded by these research degrees is increasing over time. In 2013, 43% of applications from aspiring physician-scientists with the MD-PhD degree were funded.
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. Funding Success Rates. Grants: applications, awards, success rates, and total funding by Institute/Center, mechanism, activity code, and funding source (Table #205-A, Research Project Grants FY 2014). Available at: http://report.nih.gov/DisplayRePORT.aspx?rid=601. Updated January 14, 2014. Accessed February 9, 2015.
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. Funding Success Rates. Training and research career development programs. Career development awards: applications, awards, success rates, and funding, by Institute/Center and activity code (Table #204, NIH Career Development (K) Grants FY 2005-2014). http://report.nih.gov/DisplayRePORT.aspx?rid=551. Updated January 1, 2014. Accessed February 9, 2015
Transition from Career Development (K) Award to Individual Investigator (R) Award Funding
The mentored K award program is designed to prepare awardees to become independent clinician-scientists who are eligible and qualified to compete effectively for independent research awards from the NIH (R21, R01, and equivalent federal awards). If the transition from K to R funding is a measure of success of this initiative, the results of a national survey conducted by Jagsi et al
indicate that a minority of K award recipients have been able to make this transition. They studied a cohort who completed their K08 or K23 award by 2003. As shown in Figure 3, among a group of 2783 K08 and K23 recipients (980 women; 1803 men), the 5-year rate of R01 conversion was 19% for women and 25% for male K awardees; the 10-year rate was <40% and <50%, respectively.
Figure 3Funding success rate for K awardees completing training by 2003. Actuarial rates of R01 attainment by the K awardees studied, by sex.
From: Jagsi R, Motomura AR, Griffith KA, Rangarajan S, Ubel PA. Sex differences in attainment of independent funding by career development awardees. Ann Intern Med. 2009;151:804-811.
To determine whether there was a change in K to R conversion rates for a more contemporary cohort, we examined a random sample of all 416 K08 and K23 awardees that initiated funding in 2006 and would complete their 5-year award in 2011. Awardees were stratified by award type; with current NIH funding (in 2014) queried via NIH Reporter.
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. NIH Reporter. Available at: http://projectreporter.nih.gov/reporter.cfm. Updated June 7, 2014. Accessed June 10, 2014.
A random sample of 35% of K08 awardees and 41% of K23 awardees were studied. As of 3 years after award completion (May 2014), 37.5% of K08 awardees received independent NIH funding and 21.3% of K23 awardees received independent NIH funding. Thus, in the more recent cohort, K to R conversion has been somewhat more successful for K08 awardees. The “success” rate of K23 awardees is very low.
Redefining Success
In examining the overall success of the research career development in the US, there are major shortcomings: the definition of “success” is not uniform, sometimes closely held and not in the public domain, often dependent on surveys of program graduates (with problems of respondent bias), and too narrow a measure of success. These shortcomings make rational planning of physician-scientist development very difficult.
The relatively simple, currently used definitions of success of training of a physician-scientist are too narrow for 21st-century biomedical science. On one hand, a great number of well-trained, successful physician-scientists never apply for or never receive a research project grant (RPG or R01 award) from NIH. In the era of team science, not being an R01 principal investigator does not equate with failure. Clinical and population science research is often funded by mechanisms other than NIH R01s. Many major research-intensive medical schools and teaching hospitals are broadening their base of funding mechanisms as R01 funding rates remain in single digits.
Merely counting training pathway graduates who have R01 support is simply missing many “successful” graduates.
Conversely, it can be argued that for some faculty, receiving a first R01 grant is too generous a definition of success of a training program. Is R01 funding for 4 years of a 40-year career an example of success of a training program? It is evident that a single definition of success for a physician-scientist training pathway will not suffice.
What We Know at This Point and the Gaps in our Knowledge of Career Development
Developing a successful career as a physician-scientist is long and costly. Currently, several pathways contribute to successful career development (Figure 4). At this point, there are reasonable data on completion rates for MD-PhD programs and academic career rates for those who pursue a physician-scientist residency, as well as extensive data on aspiring physician-scientists who seek K award funding. The intersection of these 3 pathways appears to be particularly propitious for career development (>60% of individuals in the ABIM research residency have received a PhD before starting residency). Furthermore, the success rates for MD-PhD applicants for K awards is 43% and is considerably higher than the K award funding rate for applicants with MD training only (34%). This carefully selected 3-fold training track (MD-PhD, physician-scientist residency, followed by K award) puts physician-scientists in a particularly strong position for achieving success as determined by research project grant funding.
Figure 4Pathways contributing to successful career development.
Is there any room left for the “late bloomer”? Is “late” a time frame that may need redefinition? We know that even starting on the MD-PhD track at an age >23 years predicts less success than for individuals who start younger. The data are accumulating that a learner who develops a substantial interest in learning clinical or basic investigative skills at the conclusion of a clinical fellowship will be at an immense disadvantage. In the current intensely competitive research environment, initiating serious research training at this point may be analogous to starting serious violin study at age 28 years, with aspirations of being a self-supporting concert violin soloist. It is rarely successful.
Areas of Uncertainty
What is Success in the Development of a Physician-Scientist?
As outlined, the definition is elusive. For years, receiving an R01 grant or equivalent has been a surrogate end point, but it misses many true end-point events. Ultimately, we are developing physician-scientists not to get grants, but rather to make biomedical discoveries and publish high-impact research papers. A case can be made that numerous high impact publications is the real and measurable outcome. One approach is calculating the H-index
for physician-scientists, or perhaps other measures of numerous high-impact publications. The H index is a measure of high-impact publications (N publications that have been cited N times).
How do we Measure Success?
Once there is an agreed-upon definition of success, one must have a scale that can be broadly applied. The H-factor is one approach. Is an H-factor of 10, 5 years after achieving independence as an investigator, the right height for the bar? An H factor of 20 after 10 years of independence? This measure is imperfect but can be determined using data in the public domain. To shape training policy, some reproducible and quantifiable measure of success is important.
What is the Cost of Success?
What is the total training cost for each successful physician-scientist, taking into account the huge attrition rate of learners who start on the path? These analyses may permit us to determine, for instance, if it is a better plan to start with a few learners with immense promise at an early age and mentor them well; or to continue the current course of encouraging more learners at the starting line, and over the course of the marathon, permit the late bloomers and early bloomers to sort themselves out. Alberts et al
recommend a gradual contraction of training programs for PhD scientists.
Conclusion
In 2014, there is notably little science underlying the processes and pathways of training physician-scientists. There are many substantial but not well-coordinated efforts in bolstering training. A comprehensive examination of training strategies could be timely. Over the past 30 years, the immense public and private investment in training physician-scientists has yielded some notable achievement, but overall disappointing success rates. By current measures, there is ample room for improvement.
Acknowledgment
We appreciate the expert assistance of Ms. G.A. Berryhill in the preparation of this manuscript.
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. The Physician-Scientist Workforce Working Group Report 2014. Available at: http://report.nih.gov/workforce/psw/psw-group.aspx. Updated September 22, 2014. Accessed October 1, 2014.
Association of American Medical Colleges. Table 36: Total active M.D.-Ph.D. enrollment by U.S. medical school and sex, 2009-2013. Available at: https://www.aamc.org/download/321554/data. Updated February 2, 2014. Accessed May 14, 2014.
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. Funding Success Rates. Grants: applications, awards, success rates, and total funding by Institute/Center, mechanism, activity code, and funding source (Table #205-A, Research Project Grants FY 2014). Available at: http://report.nih.gov/DisplayRePORT.aspx?rid=601. Updated January 14, 2014. Accessed February 9, 2015.
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. Funding Success Rates. Training and research career development programs. Career development awards: applications, awards, success rates, and funding, by Institute/Center and activity code (Table #204, NIH Career Development (K) Grants FY 2005-2014). http://report.nih.gov/DisplayRePORT.aspx?rid=551. Updated January 1, 2014. Accessed February 9, 2015
U.S. Department of Health & Human Services, National Institutes of Health. NIH Research Portfolio Online Reporting Tools. NIH Reporter. Available at: http://projectreporter.nih.gov/reporter.cfm. Updated June 7, 2014. Accessed June 10, 2014.
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