Much has been written recently regarding the disappearance of the physician–scientist.1 To many, this seems strange, as the past decades have seen nothing short of a revolution in our understanding of biology, particularly as related to medicine. What better world could there be for raising physician–scientists? As currently funded, the federally supported Medical Scientist Training Program (MSTP) finances 42 physician–scientist training programs across the nation, but only to a limited degree. Various informal estimates by directors of these programs have suggested that less than 20% of the cost of training MD-PhD students is covered by the National Institute of General Medical Sciences MSTP. The rest of the funds come from a wide variety of sources, including institutional endowments, other federal grants (for both research and training), and, ever more commonly, dwindling clinical resources. It is in response to the scarcity of these resources (and with apologies to Jonathan Swift) that I offer the modest proposal of eliminating federal funding of MSTPs. So, as the number of physicians entering the biomedical sciences declines, why would one suggest decreasing funding for a federal program explicitly targeting the development of just such individuals?
Let me be clear at the beginning: I am not advocating elimination of the MSTPs at individual institutions. To the contrary, I believe this proposal will supply numerous incentives to strengthen truly creative training programs and encourage the development of independent physician–scientists. Instead, what I am recommending is eliminating the institutionally funded MSTPs in favor of individual training grants to particularly promising young physician–scientists who have forged coherent training plans under superb mentorship.
Like all established federal programs, the MSTP has a history whose momentum perpetuates both good and bad practices. Programs are competitively renewed every five years, but historical precedent establishes a base number of “slots” which the federal program is slow to change. Like other National Institutes of Health (NIH) institutional research training grants (called T-32s), MSTPs set a standard for general training requirements and then allow the funded institution to fill from its applicant pool. There are only minimal funds available in T-32s to support the infrastructure of institutional MSTPs. Even if one were to muster all potential revenue sources from the T-32, the vast majority of the infrastructure funding for physician–scientist training programs must come from somewhere else, and this doesn't even account for the funding of tuition and stipends for the trainees!
Another way of funding the training of physician–scientists is the individual National Research Service Award (NRSA). To receive such funding, an individual trainee must identify a mentor, create a training and research plan, and be a competitive applicant for such support. Only bright and accomplished applicants in a truly supportive environment are competitive for such awards. This individual competition contrasts with the philosophy of the T-32, which grants meager funding to institutions on the basis of historical precedent and a theoretically larger applicant pool, irrespective of the reality on the ground. Perhaps a compromise would refocus the federal MSTP funds on paying for the first two years of medical school for a large pool of competitive applicants and then allowing these more differentiated students to compete for individual scholarships from institutes to cover the remainder of their training.
Even more troublesome, the existence of the federal MSTP implies that the importance of training physician–scientists is recognized and appropriately funded, which is clearly not the case. In fact, some NIH institutes do not fund individual MD-PhD NRSAs, and one that historically did has recently elected to no longer support such fellowships as part of a cost-savings initiative. How are the individual MSTP institutions going to make up the difference?
The recent health care debate has highlighted the public's overall suspicion of large, bureaucratic, federal programs. The current modest proposal in one small way addresses that concern by refocusing federal funding directly on training the individual physician–scientist. It will also allow each individual NIH institute to appropriately support the training of such individuals, who are critical to improving our nation's health. At the same time, as stewards of the public trust and investors in advancing our health care, this proposal will hold the individual NIH institutes accountable for creating the intellectual capacity to carry out their individual health missions.
1 Schafer AI. The vanishing physician–scientist? Transl Res. 2009;155:1–2.