In Reply to Roberts et al and Rysavy et al:
I read with interest the article by Roberts et al1 and the letter by Rysavy et al. Roberts et al tie delays in the translation of basic discoveries to a decline in the number of physician–scientists. Rysavy et al highlight the need for physician–scientists whose research training is in population health. I’d like to broaden the discussion to include other PhD fields outside the “traditional” biomedical research areas that attract MD–PhD students, and add additional data to the conversation.
First, not stated in Roberts and colleagues’ article is that current physician–scientists already engage in a broad spectrum of research. In a study of graduates from 24 MD–PhD programs who were in academia,2 my colleagues and I found approximately equal numbers doing basic, translational, and clinical research. However, MD–PhD programs do not traditionally include the training in statistics and trial design needed to do rigorous clinical research or even, in most cases, exposure to the skills required to bring new therapies and devices to the point where they can be tried on people. Acquiring those skills often requires on-the-job training and retooling. Not impossible, but certainly time consuming. If my anecdotal experience is any indication, most physicians who have engaged in clinical research are not graduates of MD–PhD programs, but increasing numbers complete master’s or certificate training in disciplines such as clinical epidemiology, public health, and translational research.
Even were it available, it is doubtful that traditional PhD-level training would be warranted for every physician who engages in research. However, for some it makes complete sense. Rysavy et al make a strong case for its need in disciplines outside of the usual biomedical research fields. I agree with them, but the number of people who have done that and can serve as role models is small. The MD–PhD outcomes study cited above2 included data on approximately 6,000 MD–PhD students and alumni. Only 105 (<2%) were in epidemiology, public health, health policy, health services, anthropology, sociology, or population health. Nonetheless, the career choices that these MD–PhD program alumni made after graduation are striking. As a group, they were even more likely to have careers in academia or at research institutes than were alumni as a whole (87% versus 73%) and were less likely to enter private practice (3% versus 16%). Recent graduates were also more likely to choose internal medicine or pediatrics (67% versus 39%) and less likely to chose surgery (0% versus 11%). These choices, along with their PhD training, will undoubtedly influence the problems they tackle in the future, which could well include problems of translating research findings into practice.
Finally, an opinion. Career and research choices tend in aggregate to follow the money. As suggested by Roberts et al, debt relief and a policy emphasis on translational research are good things if the goal is to encourage physician–scientists to do translational research, as are the considerable accolades that come to those who are successful. However, a steady decline in the purchasing power of the NIH budget and a fear of failure to obtain sufficient research funding to sustain a multiyear research program are not.
Lawrence F. Brass, MD, PhD
Professor, Department of Medicine, and associate dean and director, Combined Degree and Physician Scholars Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; [email protected]
1. Roberts SF, Fischhoff MA, Sakowski SA, Feldman EL. Perspective: Transforming science into medicine: How clinician–scientists can build bridges across research’s “valley of death.” Acad Med. 2012;87:266–270
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