Bonham, Ann C. PhD
Dr. Bonham is chief scientific officer, Association of American Medical Colleges, Washington, DC.
Editor’s Note: This is a commentary on Jeffe DB, Andriole DA, Wathington HD, Tai RH. Educational outcomes for students enrolled in MD–PhD programs at medical school matriculation, 1995–2000: A national cohort study. Acad Med. 2014;89:84–93.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Correspondence should be addressed to Dr. Bonham, Association of American Medical Colleges, 2450 N St., NW, Washington, DC 20037; telephone: (202) 828-0509; e-mail: firstname.lastname@example.org.
MD–PhD programs provide rigorous, integrated training for physician–scientists, enabling them to frame scientific questions in unique ways and to apply clinical insight to fundamental science. Few would question the influential contributions of MD–PhD physician–scientists in advancing medical science. In this issue of Academic Medicine, Jeffe et al affirm high levels of excellence in educational outcomes from MD–PhD training programs at U.S. MD-granting medical schools, especially programs that receive funding from the NIH Medical Scientist Training Program (MSTP). The author of this commentary observes that, in the face of current economic pressures, comprehensive, longitudinal national outcomes data from MSTP- and non-MSTP-funded MD–PhD programs will help verify the value provided by MD–PhD physician–scientists. She proposes that MD–PhD programs should better prepare the next generation of physician–scientists for future research environments, which will provide new technologies, venues, and modalities. These research environments will be more closely integrated within health care delivery systems, extend into diverse communities and regions, and employ complex technologies. MD–PhD physician–scientists also will train and gain expertise in broadening areas of research, such as health policy, health economics, clinical epidemiology, and medical informatics. Program leaders are ideally situated to foster innovative learning environments and methodologies. By sharing their innovations, they can help ensure production of a diverse MD–PhD physician–scientist workforce, prepared to engage in myriad research opportunities to meet patient and population needs in a new environment.
MD–PhD programs provide a demanding course of study that integrates the MD program’s rigor in science and medicine and the PhD program’s rigor in science and research. MD–PhD training positions physician–scientists to apply a clinical medicine perspective to the broad spectrum of biomedical research—from research that explores fundamental biological and disease processes, to research that translates findings for clinical communities, to research that focuses more directly on patient outcomes. This integrated training helps MD–PhD researchers frame scientific questions in unique ways and enables them to bring their clinical insight to bear on basic science questions that may appear to others to have little clinical relevance.
Few would question the influential contributions that the relatively small population of MD–PhD physician–scientists has made to advancing medicine through research. One only has to look at the number of Nobel Prizes awarded in Physiology or Medicine between 1997 and 2013: More than half were granted to physician–scientists or teams with at least one physician–scientist, and several were granted to teams with at least one MD–PhD physician–scientist. These historical statistics provide a basis for expectations that scientists dually trained in medicine and research will continue to contribute to significant medical advances.
In the United States, federal investments and national initiatives underscore the significance that the National Institutes of Health (NIH) and the academic medicine community place on MD–PhD dual-degree programs and the training of a physician–scientist workforce. Jeffe and colleagues1 report in this issue of Academic Medicine that NIH support for MD–PhD programs through the National Institute of General Medical Sciences’ Medical Scientist Training Program (MSTP) doubled from 1994–1995 to 2010–2011, reaching almost $33 million. However, it should be noted that the actual purchasing power of these MSTP funds is much less given that overall NIH funding has lagged inflation by over 20% in the last decade.2 The NIH is not the sole source of support for MD–PhD programs; medical schools and academic institutions also provide significant internal dollars to fund programs that do not receive MSTP support, or to help leverage or expand on the MSTP investment in physician–scientist training. Academic institutions increased their support for institutionally funded MD–PhD programs by sixfold over the same 16-year period described above, investing close to $94 million collectively in 2010–2011.1
In 2004, the Association of American Medical Colleges (AAMC), recognizing the importance and contributions of MD–PhD physician–scientists, welcomed MD–PhD program directors and administrators (who had already developed their own organization) and worked with them to establish a distinct section within the AAMC’s professional development group for Graduate Research Education and Training. In 2012 the NIH Director’s Advisory Committee recommended the establishment of a new Working Group on the Physician–Scientist Workforce,3 which follows on other recent NIH working groups, such as the Working Group on the Biomedical Research Workforce (focused primarily on PhD scientists) and the Working Group on Diversity in the Biomedical Research Workforce.4,5 A key recommendation by these latter working groups is to establish national trainee databases to evaluate training programs effectively and track the outcomes of graduate students who enter these programs.
The NIH Working Group on the Biomedical Research Workforce4 has noted that a general consensus now exists in the research community on the need to determine outcomes and metrics for success across all research training programs, including integrated MD–PhD programs. In the current political and economic climate, in which policy makers are taking a harder look at returns on investments in biomedical research and research training, data that demonstrate successful outcomes are becoming essential. MD–PhD programs are not likely to escape this scrutiny. The combined effects of a decade of NIH budget stagnation and the current sequester pose real threats to federal funding. Moreover, economic pressures are cascading down to medical schools and teaching hospitals, where the clinical margins that are often used to support research and research training are growing increasingly fragile. Medical schools’ collective investment in non-MSTP-funded MD–PhD programs is significant, and the $94 million figure noted above does not take into account the collateral support that medical schools provide to programs funded through the MSTP or other NIH training mechanisms. Given the levels of government and institutional investment, the results of recent efforts to assess various aspects of MD–PhD program outcomes have been encouraging.
Jeffe and colleagues’1 study in this issue helps clarify the educational outcomes for a cohort of 2,582 MD–PhD students who entered medical school between 1995 and 2000 and enrolled in MSTP- and non-MSTP-funded MD–PhD programs at the time of matriculation. They report MD–PhD completion rates and multiple factors affecting completion. Their results indicate that strong Medical College Admission Test scores, MSTP support, and greater planned career involvement in research at matriculation correlated positively with higher MD–PhD completion rates. They also found that the attrition rate in MSTP-funded programs (20.5%) was slightly lower than the overall attrition rate (27.0%). Although gender was not independently associated with attrition, the authors caution that race/ethnicity was independently associated with a greater likelihood of attrition due to withdrawal/dismissal from medical school, suggesting the need to redouble efforts to retain students from underrepresented groups in medicine in MD–PhD programs. A recent study by Brass and colleagues6 also added to our knowledge base by providing a one-year snapshot of the career choices made by graduates of 24 MSTP programs. That study indicated that over 80% of those graduates were in academic medicine, research institutes, or industry. Together, these studies shed light on the education and professional outcomes of MD–PhD students and graduates and provide insight into key factors that training program leaders can address to maximize completion rates.
Looking forward, the academic medicine community must ask how we can work together to gain a broad understanding of the contributions of MD–PhD physician–scientists and to ensure that we produce an MD–PhD workforce that is prepared to meet the health needs of the nation through research.
To accomplish this, first, we should recognize that economic pressures and questions regarding investments in research and research training may call for comprehensive, longitudinal national outcomes data from both MSTP- and non-MSTP-funded MD–PhD programs. Such data will help demonstrate the value of the research and leadership provided by the MD–PhD physician–scientists trained in our medical schools and help these programs secure continuous federal and institutional support.
Second, we should prepare future physician–scientists to engage in research in an environment that will look much different from that of their mentors. Exponential advances—such as those in the molecular understanding of cancer, the evolution of systems biology, and the rapid expansion of science based on big data—have set the stage for the exploration of compelling research questions that call for team-based approaches. MD–PhD physician–scientists must be trained to participate in and lead transdisciplinary research teams to elucidate biological processes and fundamental disease mechanisms.
In addition, clinical and outcomes research are now being integrated and applied within health care systems, where researchers are making use of technologies such as electronic health records, telemedicine, and comprehensive databases. This environment creates a wide range of opportunities for MD–PhD scientists trained in research in fields such as health policy, health economics, clinical epidemiology, and medical informatics, as well as basic biological, behavioral, or other sciences. Academic health centers are increasingly partnering with communities and local health departments to provide care where people live and work, which presents new opportunities for community-based participatory research driven by physician–scientists. Clinical trials are increasingly being conducted across national and international networks, further transforming the field of medical research.
Scientists with dual training in medicine and broad research areas will be critical in these expanding venues. Moreover, these opportunities may attract a new cohort of students who may not have considered pursuing MD–PhD training in the past. MD–PhD program leaders and mentors are ideally situated to foster the development of innovative learning environments and methodologies and to share those innovations with other programs to help them recruit and nurture talented and interested students.
Perhaps one of the most significant downstream implications of the work by Jeffe et al1 and Brass et al6 is that these studies and others like them will help the academic medicine community focus not just on demonstrating the value and outcomes of MD–PhD training but also on ensuring that we train a diverse MD–PhD workforce that is prepared to engage in emerging and myriad research opportunities to meet patient and population needs in a new environment.
In the end, medical research is about making advances that will improve the health and well-being of all. Ultimately, people are the ones who benefit from continued investment in and support for MD–PhD training across the full spectrum of medical research.
Acknowledgments: The author would like to thank Stephen Heinig, MA, at the Association of American Medical Colleges for his assistance in preparing this commentary.
1. Jeffe DB, Andriole DA, Wathington HD, Tai RH. Educational outcomes for students enrolled in MD–PhD programs at medical school matriculation, 1995–2000: A national cohort study. Acad Med. 2014;89:84–93
3. National Institutes of Health, Advisory Committee to the Director. . Physician–scientist workforce. http://acd.od.nih.gov/psw.htm
. Accessed September 30, 2013
5. National Institutes of Health, Advisory Committee to the Director. . Report of the Working Group on Diversity in the Biomedical Research Workforce. Published June 13, 2013. http://acd.od.nih.gov/dbr.htm
. Accessed September 24, 2013
6. 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