The physician–scientist workforce has declined over the past 3 decades. In 2011, the total number of physicians reporting medical research as their main practice area comprised only 1.6% (13,557/847,313) of physicians across medical specialties, 1 down from 4.6% (23,268/505,826) in 1985. 2 Of the population of 9,000 physician–scientists with a Research Project Grant (RPG, the R01) from the National Institutes of Health (NIH) from 2008 to 2018, 4,192 held an MD and 4,086 held MD–PhD degrees. 3 Among RPG applicants from 2002 to 2012, the number of PhDs had nearly doubled, while the number of MDs and MD–PhDs was stable.
The declining physician–scientist workforce raises significant concerns for the future of biomedical research. Physician–scientists play an important role in translating basic science research into clinical populations to guide diagnosis and treatment. This decline can delay scientific discovery and its translation into disease diagnosis and treatment. 4–7 As the number of physician–scientists entering the workforce is declining, there is also observed aging of the NIH-funded population, as evidenced by the increasing age at which investigators receive their first NIH R01 grant. 8,9 Simultaneously, early-career physician–scientists are being underused, evidenced by the decrease in funding for early-career and new investigators. 8,9 Unless this trend is reversed, this trickling pipeline of new physician–scientists may lead to diminished contributions to biomedical research from this uniquely qualified physician–scientist workforce in coming generations.
Compounding the problem of the declining physician–scientist workforce is the significant gender disparity in NIH-funded research across academic medicine. Although women now represent 50% of medical students, women currently represent approximately 25% of all physician–scientists. 3 Female physician–scientists with either an MD–PhD or an MD comprise only 22% and 29% of NIH RPG awardees with an MD–PhD or MD, respectively. The NIH has identified increasing the diversity of its workforce as a primary goal to increase creativity and innovation, broaden the scope of inquiry, narrow racial and gender health disparities, and promote and ensure fairness in scientific investigation. 10–12 There is also evidence that gender diversity on research teams leads to more effective problem solving and improved use of individual expertise on teams. 13,14 Despite this emphasis, racial and gender disparities in NIH funding have persisted.
Women apply for NIH grants less often and are therefore less likely to receive one. Women comprise a minority of the applicants and recipients of 2 awards offered by the National Institute of General Medical Sciences, the Mentored Clinical Scientist Development Award (K08) and the Mentored Patient-Oriented Research Career Development Award (K23), and are less likely than men to receive an R01 award. 15,16 Women who applied for R01 grants between 2000 and 2006 were less likely to receive an award because they applied significantly less often than men. 17 Women receive fewer grants with smaller awards than male applicants: For example, in 2018, only 33% of all NIH research grants were awarded to women, and their average grant award was nearly $70,000 less than grants with a male principal investigator. 18
When women do apply for NIH grants, their funding success is comparable with that of men. In 2018, the NIH reported that men and women had equivalent funding success for new R01-equivalent grants (20%) and renewals (45% for men vs 41% for women). 18 Longitudinal analyses of career grant funding revealed that men are more likely to apply and to be funded than women. 19 Rather than leaving the NIH funding pool at much greater rates than men, women are dramatically underrepresented from the start among first-time grant awardees, comprising only 30.7% of researchers. 20 However, women are more likely than men to leave the NIH funding pool after 1 unsuccessful proposal. 17
The gender disparity among physician–scientists is exacerbated by race. The Association of American Medical Colleges defines underrepresented in medicine as “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” 21 Individuals from UIM backgrounds are less likely to apply for and less likely to receive NIH funding. In 2012, 70.0% of NIH RPG applicants were White, with Hispanics representing only 4.5% of applicants and African Americans only 2.4%. 3 Award rates were significantly lower for underrepresented racial and ethnic minorities in 2012 than for White applicants. The funding rate for White scientists has been approximately 1.7-fold higher than the rate for African American scientists for nearly 2 decades. 22,23 African American scientists are significantly less likely to receive an R01 award than White scientists, even after controlling for educational background, country of origin, training, previous research awards, and employer characteristics. 23 Among MD applicants for an R01, multiple studies have observed that Black applicants are significantly less likely to be funded, both as new and experienced investigators. 24,25 Despite actions by the NIH, including establishing a Working Group on Women in Biomedical Careers,” 26,27 this funding gap persisted from 2010 to 2013; during this period, only 11.8% of Black applicants received NIH funding, compared with 19.0% of White applicants. 28
The intersectionality of gender and race results in the greatest disparities among existing physician–scientists for women of color. Among all applicants for an R01 from 2000 to 2006, only 5.1% were women of color. 17 Across all race and gender groups among MD applicants (White, Asian, Black, and Hispanic men and women), Black women were least likely to receive an R01, both as new and experienced investigators (i.e., those who have previously received an R01).
There are many proposed reasons for the observed gender disparity among physician–scientists. Pursuing a research career as a physician–scientist requires significant training after the completion of residency, often at great cost of time and money. Therefore, factors contributing to gender disparity may include the financial cost of pursuing additional research training 29 and rising medical school debt. 30,31 Parenthood and domestic responsibilities may also be a contributing factor, as research training often coincides with early parenthood. Partnered women spend significantly more time on parenting and household duties than men do. 32 This disparity has been exacerbated by the COVID-19 pandemic, leading to more lost productivity among women in academic medicine than among men. 33–36 In this article, we make several recommendations to address all these challenges that women and other UIM groups face when pursuing a career as a physician–scientist.
Recommendations
To increase representation of women and other UIM individuals in the physician–scientist workforce, we must both improve the pipeline by providing support during training and actively assist early- and midcareer women physician–scientists—and especially women who are UIM—to advance. These same challenges may confront women as they progress in their careers along less traditional paths to becoming an independent physician–scientist. We therefore propose initiatives to address the challenges women face at each career stage, whatever path they follow.
Medical school programs
Medical school programs designed to attract women and other UIM groups into research careers are necessary to increase the number of physician–scientists in biomedical research who are women or other UIM individuals. In addition to institutional grants for research support for students, national mentorship programs through the NIH for medical student women and other UIM individuals committed to physician–scientist careers could increase the number of women and members of other UIM groups who pursue this career path. Creating national cohorts of women and UIM medical students who pursue research at their home institution and have access to nationally renowned mentors at the NIH and other medical schools can provide not only research training and skills but also networking opportunities, including mentorship and sponsorship. Such programs for early-career investigators interested in research in health policy and services funded through the Robert Wood Johnson (RWJ) Foundation have been highly successful in creating a national network of physician–scientists invested in this type of research (RWJ Foundation Clinical Scholars Program). 37 A similar program funded by the NIH to increase the number of women and UIM physician–scientists could have similar success and impact. This type of training, mentorship, and national exposure could assist women and UIM physician–scientists throughout their careers.
Residency programs
Residency is a clinically intensive training stage of career development. Programs through new grant mechanisms for residents and fellows (through research education program [R25] grants) that provide additional support to women and UIM individuals during residency could provide protected time for research training. Existing R25 and institutional research training grants (T32 programs) could be financially incentivized for training women and UIM individuals. NIH summer institutes could provide training, scientific mentorship, and career mentoring for women and UIM individuals interested in research with stipend funding and longitudinal activities through the calendar year. The NIH might consider a mechanism whereby research faculty could apply for funding specifically to sponsor women and UIM residents in research projects within a lab.
Institutional and individual grants
After residency, the next obstacle for the early-career investigator is the transition to receiving an NIH mentored career development award. During this time between residency and receiving an NIH career development or equivalent award, investigators need significant financial support for their time and research costs. Because resources at the level of academic medical centers are often inadequate to bridge early-career investigators through this phase, physician–scientists may divert from the research pipeline to clinical careers at this time. Once investigators receive a career development award, their next challenge is to receive an R series grant, which signifies their transition to independence as an investigator. However, this transition (i.e., from a K grant, a career development award, to an R grant) is also a precarious one for many physician–scientists—especially for women. Given this challenge, there may be a lapse in funding between the end of a K award and the receipt of an R award.
To address these potential gaps in research time and funding, we propose institutional and individual grant initiatives specifically targeted to women and UIM groups. The NIH could institute grants to institutions for research training programs for women and UIM physicians with significant mentorship and match the institutional funding of such programs. These programs should be targeted to early-career investigators to provide them with dedicated time, funding, and mentorship to collect data and prepare a K award application.
Another mechanism to support the research careers of women and UIM physician–scientists is the institutional training grant, which could be used for research time and costs. Institutional grants may be an important mechanism to improve equity in funding success. In a survey of KL2 (an NIH institutional grant mechanism) awardees, men and women received independent funding at similar rates. 38 This result is in sharp contrast with results from prior studies, in which findings indicated that women and UIM individuals across the NIH who received K awards had a lower likelihood of applying for and obtaining R01 awards compared with their male and non-UIM colleagues. 15,19,39,40 The institutional KL2 selection process can consider firsthand knowledge of the applicant, the mentor, and the fit within the institutional environment, an approach that might provide greater support for female applicants. 38 Institutional grants may also appeal more to women, as women who are K awardees have been significantly less likely to change institutions than men (28.7% of women awardees vs 36.8% of men awardees). 39
There are several highly successful grant programs at academic institutions that provide financial support for junior women researchers. These programs exist at Harvard Medical School, Massachusetts General Hospital (MGH), the University of Pittsburgh School of Medicine, the University of Massachusetts Medical School, and Stanford University and generally provide $30,000 to $50,000 per year for 1 to 2 years, which recipients can use for technical support, funding a student or postdoc, supplies, or buying out their clinical time. 41–43 Some of these programs specifically require applicants to have significant extraprofessional caretaking responsibilities, such as childcare or elder care. These programs have been successful in the retention and promotion of women’s research careers. At MGH, from 1993 to 2004, 90% of award recipients were retained and promoted. 41
Not only are institutional grants an important investment in research talent and diversity, but they are financially beneficial as well: Institutional investment in these programs has yielded a 20-fold return in external funding. 41,42 A $2.1 million investment in 35 individual awards yielded over $51 million of outside funding to the scholars as principal investigators, 41 while the University of Pittsburgh School of Medicine invested over $1 million in 18 awards, which led to over $23 million in external funding. 42 At the time of writing, the funding and support of these programs for early- and midcareer investigators were still in place.
There are also nonfederally funded programs, such as the Fund to Retain Clinical Scientists launched by the Doris Duke Charitable Foundation at 10 U.S. institutions, which provides funding for research, including salary and project expenses. 44 Women in this program described the importance of the time it provided, both protected time for research and flexibility in using this time to accommodate varying research and caregiving responsibilities.
Other financial assistance
The NIH has invested in early- and midcareer investigators through the NIH Loan Repayment Program (LRP), which offers forgiveness of student loans for researchers working at academic or government institutions. Given the financial cost of pursuing research training and the lower salaries associated with conducting academic research (compared with clinical work), the NIH LRP is an important mechanism for attracting and retaining physician–scientists. In July 2020, the NIH LRP announced a new program to support health professionals from financially disadvantaged backgrounds who conduct clinical research. 45 Preliminary data suggest that NIH LRP awardees are significantly more likely to persist in research careers up to 15 years longer than those who are not funded. 46 It will be important to measure the effectiveness of this program to assess whether it is demonstrated to enhance physician–scientist retention, including for women and UIM individuals.
Mentorship and training programs
While obtaining funding is a challenge, there are also gaps in research skill sets and productivity. Individual mentorship and institutional training programs can address this need. NIH K24 mentoring grants for senior researchers could provide additional incentives to mentors who work with women and UIM individuals. Institutions can create rigorous programs to help K award recipients develop the requisite skills to successfully receive an R series award. For example, Harvard Medical School and Columbia University have created programs (Grant Review and Support Program [GRASP], Reach for the First R01, respectively) for early-career investigators to identify funding sources and develop effective grant writing skills to improve the likelihood of these investigators obtaining R level independent funding. 47,48 Ensuring that the specific needs of women and UIM individuals are met in these programs, including overcoming barriers that may be specific to them, may also enhance successful outcomes.
Childcare stipends
While some challenges are unique to specific career stages, other challenges that women face, including childcare and domestic responsibilities, persist throughout their careers. To better support women and other caregivers, the NIH might offer extensions to K and R series awards for investigators with significant caregiving responsibilities, which may include parental leave, childcare, or elder care. Grant funding mechanisms for those in financial need might also include a stipend for childcare. These initiatives are likely to benefit women and UIM physician–scientists in overcoming specific barriers to sustained career success.
Joint responsibility for diversity
In addition to these targeted programs, we also propose that the NIH require all R series grants to include the effort that investigators will implement, either individually or as part of an institution, to increase gender representation and diversity of UIM groups among the physician–scientist workforce. This proposal is modeled on the “Broadening Participation” section in grants funded by the National Science Foundation that are designed to help institutions increase representation of women and minorities through focused activities and through the inclusion of efforts as an accepted and expected part of their research and education award portfolios. 49 Such a requirement emphasizes that it is the joint responsibility of investigators, institutions, and funding agencies to make concerted efforts to increase diversity among the scientific workforce.
Conclusion
In summary, women and minorities have been underrepresented in the NIH physician–scientist workforce for decades. Despite numerous initiatives by the NIH and other institutions, there continues to be a significant gap in representation that needs to be addressed. We propose that implementation of these targeted approaches that address the challenges unique to women and UIM individuals can improve diversity among physician–scientists for future generations and increase the impact of biomedical research.
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