A number of challenges confront the physician who elects to pursue a research career. Increases in the cost of obtaining medical education can burden students with high amounts of debt, especially those who were not enrolled in a combined MD/PhD program. The training required to obtain competency in clinical and scientific research continues to increase, resulting in a marked prolongation of the training process. The transition between finishing a clinical or post-doctoral fellowship and initiating an independent research position is a very vulnerable period in the career path of all physician investigators. Financial pressures have mounted with the decrease in NIH funding, and physician-scientists are increasingly being asked to support a higher percentage of their salaries by seeing patients.
PSW-WG data clearly indicate that young physician-scientists are at the greatest risk of leaving the career path. There has been a steady decline in the size of the applicant pool for early stage NIH grants in the past five years, as shown above.
Women appear to be particularly challenged because they are often having their children at the same time that they are starting their laboratory. Finally, more cumbersome requirements have been added to the process of maintaining board certification for clinical practice, which may accelerate the exit of physician-scientists from the bedside.
Key factors that put pressure on early career physician-scientists include:
Qualitative research undertaken by and on behalf of the PSW-WG indicated that the uncertainty of funding is by far the biggest concern of young physician-scientist faculty; its importance cannot be overestimated. K awards, other than the K99/R00, typically provide inadequate support at the time needed to launch a career as an independent investigator. Therefore, new investigators may spend time writing grant applications and seeing patients, rather than generating preliminary data for an R01 application. Furthermore, MD applicants for R01 grants may be at a disadvantage during the grant review process because study section reviewers do not understand the career paths of physician-scientists, and may interpret fewer publications (compared to PhD scientists) as a lack of productivity, rather than time spent in training and clinical responsibilities.
Laboratory-based physician-scientists have all the challenges of other investigators, but additional factors contribute to the decrease in numbers and proportions of MD investigators who successfully transition through this period of their career. The PSW’s qualitative research suggests that start-up packages for laboratory-based physician-scientists are often not as large as those for PhDs, potentially due to a much higher percentage of MD investigators staying at their training institution.
The number of years required to become a physician-scientist is daunting and may be a barrier to recruiting an adequate supply of physician-scientists. The sequence and structure of training is also problematic. For those pursuing dual degree programs that are structured as two years of medical school, then four years of graduate school, followed by two more years of medical school and then residency and fellowship, their research skills often become outdated before they can return to the laboratory. Those with medical degrees who wish to pursue in-depth research training may find their options limited, unless they are at research-intensive institutions.
Integral to these aspects of training is the age factor. The extended education and training in the dual degree MD/PhD track, delay for family leave, and other factors contribute to the increasing age of early-stage investigators and attrition from the physician-scientist track towards other careers.38 The age factor is illustrated by the trend of the average age of first time RPG awards increasing since 1999 for MDs, MD/PhDs, and PhDs.39 With the 2014 release of the NIH Pathway to Independence Award (Parent K99/R00, PA-14-042), NIH encourages applicants to apply before they complete 4 years of post-doctoral experience, thereby moving researchers’ timetable to become an independent investigator earlier in their career.40 Of note, very few MDs have been applying to the K99/R00 mechanism: In 2012, only 51 MDs and MD/PhDs applied for a K99/R00, compared to 700 PhDs.
Debt burdens limit career options for laboratory-based physician-scientists. Eighty-six percent of students graduating from medical school in 2013 carried a student debt burden; the median debt was $175,000. Resident/fellowship stipends at this same period were in the low-to-middle $50,000 range.41
Becoming a physician-scientist prolongs the training period at compensation levels lower than clinical careers; this can be particularly difficult for individuals with substantial debt and/or young families.
NIH supported research on causal factors and interventions that affect the careers of women in biomedical and behavioral science and engineering. Results from the research described one of the factors as struggling to attain a work-life balance in order to establish a healthy work climate. The work-life issues faced by both male and female professionals included family life, child care, finances (debts and wage compensation), geographic location, and other interests. Among the study population of NIH K08 and K23 trainees, women were less likely to apply for tenure-track positions especially among women with children or planning to have children. The flexibility policies that address work-life balance were reported to vary widely throughout the range of scientists and physicians workplaces. Institutional flexibility policies were reported to be under-recognized and under-used. Challenges to overcoming academic culture which countered these policies contributed to frustrations in workplace satisfaction among both men and women.42
The impact of an effective mentor-mentee relationship is a well-recognized factor in career success of the mentee. Both men and women linked their career satisfaction with their mentoring experience. Results from the NIH supported research on causal factors and interventions that affect the careers of women in biomedical and behavioral science and engineering described the importance of receiving effective mentoring. Among the study population of NIH K08 and K23 trainees, women described different mentorship of their career development than men. The results showed that in order to achieve effective mentoring, a mentoring network, rather than a single mentor, is important as well as including multiple mentors representing diverse expertise, experience, resources, and background.43
A major difference between physician-scientists and PhD scientists is that the physician-scientists often have multiple individuals who have control over their careers. They have a scientific mentor, a clinical mentor and sometimes also have to answer to the leadership of the health care system. All of these supervisors request different things from the physician-scientists: to focus on their research, to take care of patients, to participate in the education of scientists in the laboratory and classroom, to participate in the education of medical students and fellows in the classroom and clinic, to maintain a clinic and to attend on ward services. Oftentimes, the physician-scientists lack a mentor who can help balance and protect them, especially during the most vulnerable part of their career, at its beginning.
Academic medical centers, where most physician-scientists are employed, are under increasing financial pressures. Their need to increase clinical revenue to maintain current levels of operation can translate into pressures on physician-scientists to see more patients at the expense of protected research time.
At the same time, the current environment does not encourage laboratory-based physician-scientists with clinical training to maintain their clinical skills. In some cases, laboratory-based physician-scientists are pressured to give up all patient care activity because their clinical revenue-generating capacity is exceeded by their practice expenses. For example, malpractice expenses are usually not prorated for amount of clinical activity and can exceed clinical revenue, so laboratory-based physician-scientists can be viewed as “money losers.” Therefore, many abandon (or are pressured to abandon) clinics to maintain their research program.
Finally, many lab-based physician-scientists are housed in clinical departments where some feel increasingly out of place and unsupported. The fraction of MD/PhD program graduates with a primary appointment in a basic science department, never high to begin with, declined to 9 percent for the cohort of individuals who graduated after 1998.44 Due to the recent financial pressures facing the clinical departments, emphasis has increasingly been focused on maximizing the efficiency and financial health of the clinical services, rather than on the generation of new knowledge. Physician-scientists often do not get sufficient administrative support as the regulatory demands of conducting both clinical and lab-based science continue to increase.
Specialty and subspecialty board certification and recertification are becoming increasingly time-consuming and demanding, which is impacting the decisions made by junior physicians about their career paths. Such certification is necessary for a professional with clinical activities to maintain hospital privileges and to bill as a specialist. Although a number of boards have designated research tracks, some of the boards impose requirements that may discourage trainees from a research career. Maintenance of certification processes developed by some boards appears to be discouraging physician-scientists from maintaining their clinical privileges.
A large percentage of physician-scientists voluntarily restrict the scope of their practice to narrow “super subspecialties” and are often the most clinically knowledgeable physicians in these areas because of their experience in assessing cohorts of patients with rare disorders. Thus, they can have a profound effect on the quality of care delivered by large numbers of more general subspecialty physicians who seek their advice and refer patients for consultation.
Finally, policies that discourage physician-scientists from maintaining certification also diminish the value of the physician-scientists to the biomedical enterprise, since a physician-scientist becomes a depreciating asset when she or he stops being actively engaged in medical practice: clinical acumen begins to decay with lack of use.
There is a need for certifying boards to collaborate with the physician-scientist community, federal agencies and payers to find more targeted and efficient ways to assess the very focused practice of such physician-scientists. The PSW-WG applauds the plans of the American Board of Medical Specialties (ABMS) and its member boards to consider the special issues of physician-scientists through a special committee review planned later in the year.
38 Gordon, R., (2012) The vanishing physician scientist: a critical review and analysis. Account Res. 19(2, 89-113)
39 Koniaris, L.G., Cheung, M.C., Garrison, G, Awad, W.M. Jr, Zimmers. T.A., (2010, Apr). Perspective: PhD scientists completing medical school in two years: looking at the Miami PhD-to-MD program alumni twenty years later. Academic Medicine. 85(4), 687-91
40 NIH Office of Extramural Research (OER), Research training & research career development. (2014). Retrieved, from https://grants.nih.gov/training/index.htm
41 Association of American Medical Colleges. (October 2013). Medical student education: Debt, costs, and loan repayment fact card. https://www.aamc.org/download/152968/data/debtfactcard.pdf
42 NIH causal factors and interventions workshop summary. (2012). Retrieved, from https://orwh.od.nih.gov/career/pdf/Causal-Factor-Summary.pdf
44 Brass et al, ibid.