Physician-scientists include those with a medical degree (MD or DO), as well as those with both MD and PhD degrees. Becoming an MD physician-scientist requires an investment of many years of training that begins in medical school, graduate school, or both, and typically proceeds through multiple years of specialty and subspecialty clinical and research training (residency/fellowship).
NIH supports the training of physician-scientists at several points during their training (see Figure 2.2). Institutional T32 grants support predoctoral and post-doctoral research training of health professionals; institutional T35 grants support intensive short-term research training for predoctoral students.
The largest group of NIH-funded US physician-scientists continue to be those who hold an MD as their only professional degree (see Figure 2.1). Of the 8,278 physician-scientists who held an NIH RPG award in 2012 (using a rolling 5-year window estimate, see Figure 3.3), 4,192 (50.6 percent) were MDs (without a PhD), with this group comprising 57.9 percent of first-time physician-scientist applicants for RPGs in 2012 (Figure 3.6) (and 57.8 percent of awardees from this pool). These trends have been stable for more than a decade, despite an ever-increasing number of graduates from MD/PhD programs, and despite the increasing debt burden of MDs outside of these programs.
MD/PhD physician-scientists are a heterogeneous group of individuals that includes those who pursued their degrees in series (including many who may have gone through medical education or research training outside the United States), as well as those who earned both degrees simultaneously through participation in a combined MD/PhD program, including those offered by an institution receiving Medical Student Training Program (MSTP) funds from the National Institute of General Medical Sciences (NIGMS). Disaggregating MD/PhDs into these various career paths was not possible for this workforce study, in part because matching individuals tracked within data sources on combined MD/PhD program graduates collected by non-NIH organizations to NIH data was limited by data availability and data quality. Nevertheless, information on NIH support for combined MD/PhD programs reveals some interesting aspects of this part of the MD/PhD physician-scientist workforce.
The NIGMS-sponsored Medical Student Training Program (MSTP) supports MD/PhD training through 43 participating programs currently, with a total of 932 trainees supported each year.14 In addition to the 43 MSTP-funded programs, there are approximately 34 active MD/PhD programs in the U.S. that do not receive NIGMS support. In 2013, 609 students entered an MD-PhD program, 444 (73 percent) admitted to programs with MSTP support.15 Students in MD/PhD programs can apply for individual F30, and in selected cases, F31, predoctoral fellowship awards, which typically provide support during the graduate phase of the program, but can also support completion of medical school after thesis research is completed. The Biomedical Workforce Working Group recommended that NIH expand the F30 and F31 to all NIH Institutes and Centers, and that occurred in March of 2014.16
MD/PhD trainees in the MSTP typically receive their PhDs in one of the biological or physical sciences, A very small number of MSTP MD/PhDs have received their PhD in a social science (e.g., economics), outcomes research, clinical informatics, or other field outside the biological or physical sciences.
MD/PhD programs commonly provide full or substantial tuition and stipend support for students. As a result, MD/PhD program graduates usually have far less student debt than other medical school graduates. The costs related to MD/PhD programs are high and MSTP T32 awards typically provide only 20-25 percent of total MD/PhD program expenses. As a result, medical schools use a combination of other NIH training and research grant dollars, philanthropic and, most prominently, institutional resources to fund students. An analysis in 2008 of outcomes data from 24 MD-PhD programs enrolling 43 percent of the then-current trainees showed that 67 percent were employed at academic medical centers and universities, 4 percent were working at research institutes such as the NIH, and 8 percent were employed in industry.17 Attrition from MSTP-funded MD/PhD programs is relatively low. The rate of obtaining the PhD (and presumably the MD as well) for individuals who were appointed to a NIGMS MSTP T32 training grant for the first time in 1980-1989 was approximately 88 percent.18 Consistent with the result from reference 17, 68 percent of graduates in that cohort became medical school faculty. Data on NIH RPG applications and awards are included later in Chapter 3.
NIH also provides support for MD/PhD training through the MD/PhD Graduate Partnership Training Program (http://mdphd.gpp.nih.gov/). The GPP represents a unique physician-scientist training model in which graduate training at the NIH is combined with medical school completed elsewhere. Students complete their thesis research at the NIH or through one of NIH's graduate partnership programs. They then complete their MD education at an MSTP-associated medical school. Partial funding for medical school is provided through an additional training slot co-funded by the NIH institute in which the student performs his or her research. There have been 38 graduates of the program since 2007 and there are 46 current students. The majority of these students have done their PhDs in the NIH-Oxford-Cambridge Scholars program (http://oxcam.gpp.nih.gov/), in which students are co-mentored by investigators at NIH and either Oxford or Cambridge University in the U.K. Long term outcomes data from the GPP are not yet available; all of the program graduates are currently completing postgraduate residencies and fellowships.
To shorten the post-graduate training period for physician-scientists, Short-Track Programs are offered by various medical specialty boards. Physician-Scientist Training Programs (PSTP) are offered at several institutions. In these programs, the number of years in clinical specialty and subspecialty training are reduced to accommodate more training in clinical or laboratory-based research. Data from the American Board of Internal Medicine suggests that such short-track research residency programs are effective at developing physician-scientists. Surveys of 385 (of 813) participants who completed the American Board of Internal Medicine’s ‘short track’ research pathway residency (1995-2007) revealed that:
During the late phases of fellowship training and initial employment as a faculty member or researcher, NIH supports early career investigators primarily through two mechanisms:
15 2013 MD-PhD matriculants from AAMC internal report
17 Brass, L.F., Akabas, M.H., Burnley, L.D.. Engman, D.M., Wiley, C.A., & Andersen, O.S. (2010). Are MD–PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD–PhD programs. Academic Medicine 85(4):695-701.
18 Preusch, P. Personal communication.
19 Todd R.F., Salata R.A., Klotman M..E, et al. (2013). Career outcomes of the graduates of the American Board of Internal Medicine Research Pathway, 1995-2007. Academic Medicine, 88(11):1747-1753.