The physical, social, and economic conditions in which people live powerfully influence health and well-being, and these effects may be lifelong and passed from generation to generation. By reshaping the environments where people live, learn, work, and play, we may be able to prevent health inequalities related to socioeconomic status, race/ethnicity, and neighborhood.1 Such an endeavor clearly overlaps with medicine’s urgent yet unmet social mission to address health issues beyond clinical practice. At present, however, aspiring physician–scientists will find few integrated training pathways2–4 by which they might learn to study and amend the social determinants and other nonmedical factors that influence the health of their patients, communities, and society.
The current dearth of physician–scientists with expertise outside conventional biomedical or clinical sciences raises the question of whether MD–PhD training programs should allow or even encourage scholars to pursue doctoral studies in “nontraditional” disciplines that are nonetheless intrinsically germane to major influences on the health of individuals and populations. Should MD–PhD programs encourage their scholars to cross boundaries into less traditional disciplines such as epidemiology, statistics, anthropology, sociology, ethics, public policy, management, economics, education, social work, informatics, communications, and marketing? In this article, we argue that MD–PhD scholars pursuing nontraditional disciplines should be welcomed and supported as valuable members of the biomedical research workforce.
The Goal of Clinical Translation Is Health Equity
MD–PhD training programs are meant to produce physician–scientists who, from their unique and critical positions, can successfully advance research that spans basic, clinical, and translational sciences. This clinical translational mission is still too often described in hackneyed terms such as “bench-to-bedside,” even though for the past hundred years we have witnessed basic science discoveries translate far beyond routine medical practice. The biochemist E.V. McCollum, for example, pioneered molecular nutrition techniques that led to the discovery of vitamin D and the effective treatment of rickets. But then Dr. McCollum stepped beyond the “bedside” to widely disseminate knowledge about nutrition and tirelessly advocate for putting milk and leafy vegetables on dinner tables. Eventually, his discovery was translated into a national public health prevention program—the fortification of milk and bread with vitamin D—which resulted in rickets being eradicated in this country.5
Unlike the unidirectional “translation” of basic science into clinical treatments, clinical translation moves both ways. Epidemiologists, for example, identify factors that confer risk or protection and discover biomarkers for disease. With these guideposts, basic scientists can then explore the molecular mechanisms that underlie disease and validate biomarkers for diagnosis. This, in turn, informs clinical decision making.
Even an expanded and bidirectional “bench to bedside to population” framework is too narrow for the clinical translational mission as now envisioned by leading health experts and institutions.6 For example, the Clinical and Translational Science Awards program of the National Center for Advancing Translational Sciences supports academic medical centers, encouraging them to transform scientific discoveries into health improvements by engaging in the full range of health translation, from basic discovery to clinical and community research, and by collaborating with community partners to identify and address public health needs.7 Today, the central value and ultimate goal of the academic medicine community is commonly viewed as the realization of health equity.8,9 Health equity is defined simply as “attainment of the highest level of health for all people.”10 Equity in health implies that everyone can reach his or her full health potential and that social or economic circumstances should not preclude anyone from realizing optimal health.
Advances in medical science and practice, along with improvements in health care access and delivery, are steps toward health equity, but alone they will not come close to eliminating health inequalities because few medical interventions affect forces in society that cause health problems. The greatest obstacles to health equity are disparities in behavioral or environmental risk factors and the social and economic conditions that shape those behaviors and environments.11 People’s health and chances of dying prematurely are influenced far less by the clinical care they receive than by the social conditions—family integrity, housing, neighborhoods, education, employment, and income—in which they live.12 These “upstream” social determinants are too important to health equity for medical leaders to continue ignoring them.
Some traditionalist physicians may argue that addressing social determinants of health is “beyond the scope of practice.” Yet, the American Medical Association’s Declaration of Professional Responsibility insists that physicians solemnly commit themselves to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”13 Even traditionalists would agree that it is well within their professional boundaries to intervene in their patients’ day-to-day lives by asking them to, for example, consistently take medication, stick with a therapy, stop smoking, reduce stress, change their diet, exercise, and get a full night’s sleep.
If such “lifestyle medicine” is accepted as an approach to treat and manage disease, it is not a far leap to accept medicine that addresses potent, yet malleable social determinants of behavior and other environmental influences on health. Removing population-level barriers so that individual patients can achieve healthy lifestyles is not merely within the realm of medicine, it is increasingly imperative. True health equity requires transdisciplinary sciences and practices, including a clinical translational mission that assertively makes wholesale improvements to the health and welfare of entire populations. Only then can we protect and restore the optimal health of the individuals they comprise. Thus, MD–PhD training should prepare a cadre of physician–scientists well equipped to carry out this essential mission.
The Need to Diversify MD–PhD Training
Traditional biomedical and clinical sciences cannot effectively address the behavioral, environmental, social, economic, political, cultural, familial, and other nonmedical causes of health inequities. To prepare future practitioners and researchers who can affect patient and population health beyond medical determinants, academic medical centers must leverage diverse disciplines, skill sets, and competencies, both within and outside traditional biomedical and clinical sciences. Indeed, prominent members of the academic medicine community have embraced this broader charge for translational research. Notably, Meyers and Pomeroy14 urged a task force of the Advisory Committee to the Director of the U.S. National Institutes of Health (NIH), formed in 2011 to examine the future of the biomedical research workforce, to include new approaches, people, and skills such as “bioinformatics, statistics, the ‘omics,’ nanotechnology, regenerative biology, economics, social and behavioral sciences, and communication.” From its onset, the task force recognized that a primary issue in the development of the future biomedical research workforce model was “[PhD] training for multiple career paths including bench and non-bench science.”15
If the anticipated biomedical research workforce, including physician–scientists, requires diverse training outside traditional bench sciences, we must assess current progress toward this diversification. The flagship of MD–PhD program funding—the Medical Scientist Training Program (MSTP) of the National Institute of General Medical Sciences (NIGMS)—offers no specific definition or limitation of graduate scientific training:
MSTP participants may choose from a wide range of research training programs in the biological, chemical, or physical sciences. Other disciplines in which MSTP participants can pursue graduate study include the computer sciences, social and behavioral sciences, economics, epidemiology, public health, bioengineering, biostatistics, and bioethics.16
Despite the breadth of graduate training possibilities allowed by NIGMS, a recent survey of 24 MD–PhD programs (representing 43% of current trainees in the United States and nearly half of all programs receiving MSTP grants) revealed that only 5% of trainees were studying a discipline outside biomedical sciences (86%) or engineering (9%).4 Although the Association of American Medical Colleges (AAMC) estimates that nearly one-third of MD–PhD programs offer graduate training options in disciplines other than biological or physical sciences,3 the American Physician Scientists Association identifies only 13 out of 127 MD–PhD programs (about 10%) that have current trainees pursuing PhDs in a social science or humanities discipline.2 On closer inspection, almost all programs that allow nontraditional PhDs limit options to a few specific disciplines, such as public health and medical anthropology.3
Even at institutions where progress has been made toward offering opportunities to pursue nontraditional disciplines, those MD–PhD students who do so may not be valued or supported as well as those training in traditional disciplines. At one leading institution, MD–PhD students training in a biomedical science receive MSTP-supported tuition waivers, medical insurance, and stipends. At that same institution, MD–PhD students training in a social science receive considerably less financial support (through non-MSTP sources). Another leading institution encourages medical students to take leaves to pursue PhD training in select disciplines (such as epidemiology or health care policy) but considers this educational pathway separate from its MSTP-supported MD–PhD program. Consequently, these students receive no directed financial support. These and other inequities in MD–PhD scholar funding based on discipline demonstrate the diminished value given to nontraditional disciplines in physician–scientist training. If the call to diversify future biomedical research workforce is to be taken seriously, nontraditional MD–PhD scholars should be as valued and supported as traditional biomedical scholars.
Given the NIH recommendations to diversify15 and the MSTP grants that support a wide range of academic disciplines,16 why do only a small minority of MD–PhD programs foster diversified options for graduate training? Program directors may be unaware that slots and funds can support nontraditional graduate training, or they may not understand how such training is relevant to research careers in academic medicine. Perhaps they simply do not value these disciplines as scientifically rigorous or capable of contributing to medicine and health. Territoriality may also hinder diversification at institutions where MD–PhD programs derive from, and currently serve, basic science departments. Even infrastructure may impede diversification at universities where medical schools are not well integrated or are geographically distant from the classrooms where nontraditional graduate training would occur.
Alternatively, the scarcity of nontraditional MD–PhD scholarship may originate with the students. They may be unaware of opportunities and support for nontraditional graduate training, uncertain of its relevance to their medical careers, or skeptical of its value. According to AAMC data,17 36% of students who enroll in medical school majored in disciplines outside biological or physical sciences (humanities, math or statistics, social sciences or specialized health sciences). This percentage suggests great potential to attract more nontraditional MD–PhD scholars. Unfortunately, no published data are available to gauge applicants’ demand for nontraditional scholarship. Personal conversations with long-standing directors of MD–PhD programs that offer diversified training options reveal that the nontraditional applicant pool is small. The reasons for this are twofold. Primarily, medical school applicants with potential interest in nontraditional MD–PhD scholarship are often unaware of diverse training options. Secondly, interested applicants are often viewed as underqualified compared with traditional applicants, who generally have more exposure to research opportunities through their undergraduate disciplines. This insight suggests that, to increase diversity of MD–PhD scholarship, we need to focus on the pipeline—for example, by educating premed advisors to inform students about nontraditional dual-degree options and offer guidance on how to structure their undergraduate activities to improve their competitiveness for acceptance and funding in these programs. These and other potential barriers to increasing diversity of MD–PhD training need to be identified and dislodged to meet the anticipated needs of the future biomedical research workforce.
Having a rich diversity of scholarship is an important goal of many academic institutions and programs. Diversity of scholarship includes not just individuals creating new knowledge (discovery) but also individuals connecting knowledge to other knowledge (integration), communicating knowledge (teaching), and making knowledge accessible and useable (application).18 Including in MD–PhD programs students with interests and skill sets outside biomedical or clinical sciences enhances diversity of scholarship and enables transdisciplinary collaborations. A recent illustration of such a collaboration involved physician–scientists, economists, psychologists, anthropologists, and public policy researchers working together to evaluate a wide-scale housing experiment implemented in major U.S. cities during the 1990s. The study showed that single mothers who took advantage of rent-subsidy vouchers (to relocate to more affluent neighborhoods) were less likely to become obese or develop diabetes than mothers who remained in poor neighborhoods.19 By integrating the unique skills of diverse disciplines, such transdisciplinary projects potentially make bigger strides in understanding and ameliorating health disparities than any one discipline could alone.
The inclusion of nontraditional MD–PhD students in medical classes sows the seeds for transdisciplinary partnerships that may grow throughout the careers of these future physicians. Physician-scientists are often socially conscious, influential professionals whose careers extend far beyond their clinic or lab. They engage with the world outside medical practice and research to address health issues of patients, communities, and society. One need only follow the careers of current federal health agency directors such as Francis Collins, global health leaders like Jim Yong Kim and Paul Farmer, and countless other government officials and organization leaders who were trained as physician–scientists. Addressing the complex health issues in our communities and society as a whole requires a biomedical research workforce with knowledge, practice, and research skills that transcend traditional biomedical and clinical sciences or even proximal disciplines such as epidemiology. To make real progress toward health equity, educational pathways must train physician–scientists to treat both micro and macro determinants of health.
If the academic medicine community truly embraces its social and moral obligation to advance health equity, then MD–PhD programs should encourage their scholars to cross boundaries into less traditional disciplines such as epidemiology, statistics, anthropology, sociology, ethics, public policy, management, economics, education, social work, informatics, communications, and marketing. To fulfill current and coming health care needs, MD–PhD scholars should not merely be allowed to leave the wet lab, but, when they do, they should also be welcomed and supported as valuable members of our future biomedical research workforce.
Acknowledgments: The authors thank several MD–PhD program administrators who provided data and insight for this article, including Dr. Peter Preusch (director of the National Institute of General Medical Sciences–Medical Scientist Training Program), Dr. Robinna Lorenz (director of the Medical Scientist Training Program at the University of Alabama at Birmingham School of Medicine), Dr. Lawrence Brass (director of the Medical Scientist Training Program at the University of Pennsylvania Perelman School of Medicine), Dr. Myles Akabas (director of the Medical Scientist Training Program at Albert Einstein College of Medicine of Yeshiva University), and Dr. Gyongyi Szabo (director of the Medical Scientist Training Program at the University of Massachusetts Medical School).
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