Dr. Wiley's proposal to eliminate federal support for Medical Scientist Training Programs (MSTPs) in favor of funding individual physician–scientist trainees relates to a long-standing problem in the funding for training of physician–scientists in the United States, namely that the National Institutes of Health (NIH) support for predoctoral research training has been relatively flat for many years. To compound the problem, the MSTP that is supported by the National Institute of General Medical Sciences (NIGMS) is one of many predoctoral institutional training programs supported by the Institute, meaning that there is no fixed number of funded physician–scientist trainee positions. Indeed, when new programs are funded, established MSTPs may experience a decrease in the number of funded trainee positions, which also occurs when stipend levels are adjusted; this is not even a zero-sum game. Yet, we believe that Dr. Wiley's “modest proposal” is tantamount to throwing the baby out with the bathwater.
The MSTP has had an enormous influence on the training of physician–scientists in the United States. For over 45 years it has provided a model for building and improving the training process. Indeed, without such a structure, physician–scientist training probably would not have achieved widespread presence in our nation's medical schools, whether or not the programs receive NIGMS funding. Importantly, the MSTP structure provides a critical focus for the development of individual program identities, in effect building communities of like-minded physician-scientist trainees (and mentors) that provide mutual support and a sense of being a cadre of elite trainees, which likely contributes to their low attrition rate of just 10%.1 This development occurs, in part, because MSTP grants are subjected to competitive renewal every five years, effectively forcing programs to evaluate all aspects of their activities, a process which invariably leads to changes in program structure—often prodded on by comments arising from the review. It would be difficult, if not impossible, to maintain this ongoing review and improvement of program structure if not for the need to regularly apply for continued support.
Though at times painful, the review process has enabled programs to institute major changes that would have been difficult to negotiate otherwise. For example, the training process has moved away from the traditional “MD-PhD = MD + PhD” model, with minimal attempt to optimize the training, toward the present model, where the MD and the PhD training components are integrated and give credit in one component for the training that is provided in the other component. This transition has been critical for providing the depth of training required by modern biomedical disciplines and relating these disciplines to clinical problems without dramatically affecting the overall length of training. Different programs may implement the training differently but, because there is an overall similarity, it is possible to compare the different structures and identify the best practices, which is an ongoing activity at the meetings of the MD-PhD Section of the Association of American Medical Colleges Graduate Research, Education, and Training Group.
Another important advantage conferred by the MSTP, as currently implemented under the aegis of NIGMS, is that most MD-PhD trainees begin their studies as undifferentiated students, who during their early medical studies identify areas of focus for their biomedical research. As was pointed out long ago,1 key advances in clinical medicine depend on discoveries in areas that may appear to have little direct interface with clinical problems. The present structure, in which trainees differentiate only after two or three years of training, promotes an environment in which outstanding trainees are exposed to a wide range of important research problems before settling on a research project.
We contend that the many important roles served by the MSTP would be difficult to maintain if federal funding were eliminated. The MSTP is arguably the most successful NIH predoctoral training program, as evidenced by a number of outcomes studies.2,3 Considering repeated calls for increasing the numbers of physician–scientists in our workforce, we believe that funding for the MSTP should be increased. We also agree with Dr. Wiley that it is important to increase support for the training of physician–scientists through other mechanisms, including individual predoctoral National Research Service Awards (NRSAs), funded by the categorical NIH institutes. A critical component of the MSTP and most MD-PhD-specific NRSAs is their support of trainee stipends and tuition in both phases of training (i.e., graduate and medical school). Many resources exist for funding the graduate portion of research training, but the funds available for support during the medical school years are limited, which constitutes a major challenge for training future generations of physician–scientists. Thus, continued and enhanced support through both institutional training grants and individual MD-PhD fellowships is vital if the nation is to keep physician–scientists from becoming a vanishing species.4
1 Comroe JH Jr, Dripps RD. Scientific basis for the support of biomedical science. Science. 1976;192:105–111.
2 Brass LF, Akabas MH, Burnley LD, Engman DM, Wiley CA, Andersen OS. Are MD-PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD-PhD programs. Acad Med. 2010;85:692–701.
3 National Institute of General Medical Sciences. The Careers and Professional Activities of Graduates of the NIGMS Medical Scientist Training Program. Bethesda, Md: National Institutes of Health; 1998. NIH Publication No. 98-4363.
4 Schafer AI, ed. The Vanishing Physician–Scientist? Ithaca, NY: Cornell University Press; 2009.