Future Directions of Training Physician–Scientists: Reimagining and Remeasuring the Workforce

Abstract

In academic medicine, the attrition of the physician–scientist workforce has been significantly discussed for the past three decades, with substantial attention and funding targeted to stop this attrition and attempt to reinvigorate the workforce. Despite these concerns and efforts, the attrition has not been stopped or even significantly slowed, and thus a further understanding of the physician–scientist workforce is needed with a closer look at how this workforce is measured and quantified. Through reviewing three methods by which physician–scientists are identified and understood, limitations in these definitions arise, leading to the basic question: Who qualifies to be a physician–scientist? Answering this question may lead to developing more comprehensive and less restrictive approaches when qualifying and measuring the physician–scientist workforce and appreciating the varying contributions physicians make to research. Through suggesting an expanded appreciation of these research contributions, recognition of collaboration, and funding models that support both of these aspects, the authors hope to add to the conversation by challenging traditional approaches and encouraging movement toward forward-looking definitions that encourage and promote all physicians to engage with research. This reimagining of physician–scientists will result not just in a remeasuring of the workforce but, subsequently, in strengthening the clinical and translational research continuum as well.

Physician–scientists, often defined as physicians who have substantial protected time for research, play a crucial role in academic medicine because of their unique ability to conduct translational and clinical research. As early as 1981, these clinical investigators were termed an “endangered species,”¹ and subsequent studies between 1980 and 1996 found that the number of physicians engaged in research and teaching remained relatively stagnant while the number of physicians engaged in patient care jumped, highlighting an overall attrition in the physician–scientist workforce.^2,3 Since then, substantial efforts have been made to better understand the causes and determine what can be done to halt this attrition because of its impact on advancements in disease cure and treatment. The effects of attrition can be seen, for example, in the field of neurology, where there is an expanding burden of chronic neurological diseases that are failing known treatments. Thus, physician–scientists with a particular focus on the neurosciences are called upon to develop new and better treatments that can translate advances in basic neurosciences.^4–9 Recent evidence has indicated that while the number of physicians has steadily increased, the number of those who report research as their major activity has decreased, as data for the general physician and neurology workforces demonstrate (Figure 1).^3,10–13

Figure 1: Trends of number of all physicians and neurologists conducting research. Data from the 2008, 2012, 2014, and 2016 Physician Specialty Data Reports of the Association of American Medical Colleges.^10–13

The Decline of Physician–Scientists

Although the number of neurologists conducting research is greater than other subspecialties, the downward trend underscores that even specialties that have seen relative success with clinicians engaging in research are suffering attrition. In 2014, the National Institutes of Health (NIH) Physician–Scientist Workforce Working Group issued a report discussing the reasons for this problem and the challenges to overcome it, including lack of funding for research during the early stages of a physician’s career which guarantees protected time and mentorship, the increasing financial burden of medical education and training, lack of mentorship, absence of training programs focused on just research, and the increasing demands of clinical work.^14,15 Unfortunately, the efforts over the past three decades to improve the situation have not reversed this attrition,² as demonstrated by the decreasing proportion of physicians across specialties engaging in research as their primary activity between 2005 and 2017 (Figure 2).^1,3,14–19

Figure 2: Change of proportion of the major activity of physician by specialty between 2007 and 2015, of the top 20 specialties. Data from the 2008, 2012, 2014, and 2016 Physician Specialty Data Reports of the Association of American Medical Colleges.^10–13

Most often, there are three ways in which numbers of physician–scientists are measured: through their funding, their job title and description, and self-report mechanisms (surveys). These mechanisms, while having their strengths, present flaws that limit our ability to truly understand the status of the workforce.

Limitations of the NIH R01 Definition

Achieving research independence through validated funding sources is one of the key defining features of becoming a scientist because it helps guarantee protected time for research work and, when obtained with a federally funded R01 grant, is frequently regarded as the “gold standard” measure of a physician–scientist. This measure is seemingly appropriate because of the structure of the grant-review process, which involves independent and nonbiased peer review. However, many argue that using R01 possession as the primary indicator of a physician–scientist may be inappropriate and outdated,^14,20–24 especially since achieving an R01 grant has become increasingly challenging and is taking longer.^6,25 Further, the pathway to R01 funding is uncertain, with data indicating that even NIH-funded training grants are limited in their ability to propel a physician toward R01 success.²⁶

There are two major issues when using R01 funding as a gold standard and relying on it to evaluate the size of the physician–scientist workforce. First, those physicians who are committed to research for much of their time but do not hold an R01 grant themselves are not counted in this group. Recent research has identified that a number of individuals who do not have an R01 nonetheless regularly and meaningfully contribute to research.²⁷ Second, this metric, and the broader understanding of physicians participating in research, actively ignores many physicians who contribute to research by means of purely clinical activities, such as evaluating and referring patients to research protocols or participating as a clinical site for later-phase trials. Presently, this population of physicians is unknown, but expanding systems at the NIH would help capture a number of these individuals via unique identifiers or other ways of tracking the research contributions of all of those involved in funded programs. Further, these systems would gather data allowing for an understanding of an individual’s research progression and trajectory through measuring various contributions in addition to just grants and publications.

The Changing Landscape of Academia and Clinical Research

Decades ago, physicians in academic medicine were assumed to follow research-oriented careers. Therefore, when becoming a young faculty member at an academic institution, a physician was automatically placed on a pathway to becoming a tenured academician and a physician–scientist, with guaranteed protected time for research. Considering these facts, the declining rate of tenured physician–scientists over the last few decades is also used as a measure of attrition in the workforce.¹⁴ Similar to the R01, the structure of promotion of academic physicians subjects them and their scientific contributions to review by their peers—creating what appears to be a strong measure of the workforce.

However, because of a changing health care financial system, more academic hospital institutions are moving to a revenue-generating model where “hard money” (money directly earned from service-based activities such as patient care) is the priority rather than “soft money” (money provided by outside sources for scholarly activities such as research).^28,29 This means that physicians employed at academic institutions may solely commit themselves to patient care and not participate in any research activity. On the other hand, more private practices and community hospitals are affiliating with academic centers to perform activities such as teaching and research. Some of these private practices have academically inclined physicians and follow a “privademia” (private practice + academia) model, with clinical research being conducted outside of academic centers.³⁰ This changing landscape in health care has made the relationship between the job title and research contributions less certain.

Surveys of Alumni

Significant effort is spent by organizations and training programs to track and survey their graduates.^14,31,32 In such questionnaires, graduated trainees are asked to either qualify themselves as researchers or quantify their time spent in various activities including patient care, research, education, or administration, such as the data presented in Figures 1 and 2. A graduate is then qualified as a physician–scientist solely based on their self-reported description of time committed to research. This self-reporting, or effort reporting, is a well-established traditional method of classification of a physician’s primary career path.¹⁰ These surveys are, perhaps, the strongest method in understanding the time physicians spend in various activities because they capture a fairly honest breakdown of time.

However, the data collected by this method may not accurately represent the number of hours spent doing research because these data are solely focused on the physician’s major activity. By so doing, it does not measure other potential variances such as more physicians conducting research through traditionally clinical activities, which may produce important epidemiological and outcome-based observations and lead to significant scientific contributions. An example of this difficulty is a physician who sees a patient in clinic who is also enrolled in a research protocol and attempting to differentiate the time spent as “clinical” versus “research” work, as it may not follow a traditional activity generally included in research protected time. By requiring a qualifying definition of how much time a physician–scientist needs to spend on research versus clinical activity to be counted as a scientist, a significant number of physicians and their research contributions are likely to be overlooked.

Redefining Physician–Scientists

It is clear that a new approach to defining physician–scientists is needed to better understand this workforce—one that should capture the current broad range of clinical and scientific activities. Narrow inclusion criteria may exclude many physicians who do not fit a classic definition and may be discouraging to many who continue to contribute to scientific endeavors through various clinical and educational activities. In addition, because of an increasingly limited definition of a physician–scientist, the transition of mid- or late-career physicians, who have led successful careers as clinicians and would like to spend more time in scientific research work, is more challenging than ever. Additionally, some physicians who continue to be clinically oriented may not perceive an equal opportunity for research participation because it may seem to come at the cost of worthwhile clinical activity. The NIH has recognized the importance of clinical experience in guiding research, with some grants allowing for increased time for clinical work.³³ It has been found that physician–scientists who are not successful in their first attempt at an R01 grant were less likely than their PhD colleagues to reapply.⁴ This does not necessarily mean that these physicians will no longer engage with research but, rather, that they may not do so as their primary activity.

When discussing physician–scientists, being able to include all physicians who contribute to science, rather than rely on restrictive definitions, is beneficial not just to address the attrition in the workforce but also to better understand how research is being accomplished today, such as in collaborative teams. Moving away from strict categorization and opening the field by encouraging physicians to participate in research through their specific expertise will not just enhance the research enterprise but also increase the impact of such research.

Appreciating Collaborative Research and Team Science

Taking neuroscience and neurology as examples, data from the NIH indicate a substantial growth in students receiving a PhD in the field, which then increases the need for physician–scientists to translate new findings to the bedside.⁹ Additionally, the insights that physicians gain during their clinical time are vital to providing new and relevant ideas for their labs to pursue. It is also important to note that the translation of these basic neuroscience discoveries to clinical trials and clinical care is very complicated, further reinforcing the need for well-trained physician–scientists. However, as the number of PhDs in the neurosciences is increasing, so is the need for clinically focused neurologists. One study found that by 2025, the need for neurologists will increase from 11% to 19% to meet the clinical demand, meaning that the incentives for a career consisting primarily of patient care will continue to increase.³⁴ Whereas neurology is just one specialty where the issues of physician–scientist attrition are of particular concern, the data are representative of the issues facing the broader workforce.

The spectrum from disease discovery to cure, as diagrammed in Figure 3, is becoming more complex than ever, and it is clear that no one physician or scientist can master all facets. The role of primarily clinical physicians is very important at many of these stages, and enabling physicians to contribute to scientific endeavors without requiring an absolute or a substantial time commitment may be a more reasonable approach. Acquiring techniques and skills to effectively collaborate with their colleagues in other research disciplines may be a more important skill set for such physicians than performing the tasks themselves. The ability to conduct collaborative clinical care has received much attention in patient care, and it may be important to bring that training and approach to science.³⁵

Figure 3: Example of the many stages of the research continuum, highlighting the need for clinically trained researchers for the successful progression through these stages. Adapted from the National Center for Complementary and Integrative Health.³⁶

Implementation Impact and Funding Challenges

Reimagining the physician–scientist workforce through first changing our restrictive definitions and subsequently appreciating the role of collaboration requires solutions that are neither quick nor simple. Institutions that fund and support the future of research should invest time and resources in understanding how science, specifically research that involves and relies on clinicians, will continue to change. Pursuing these areas can shift these conversations from reactive to proactive approaches in defining how science and funding can most efficiently and appropriately conduct meaningful research.

Yet, simply expanding the definition or labeling more individuals as “physician–scientists” will not make these changes have an effect; rather, funding models need to recognize and support the complexity of contributions to science. Although it would be possible to simply add another category of physician–scientists who do not fall into classic definitions but contribute to science, this solution would not truly address the issue because trainees would still be pressured to follow the classical path to a physician–scientist career even as those paths are divergent from the practice of science and are becoming increasingly out of reach for many with great talent. There is always value in retrospectively understanding what contributed to an individual’s success, but the greater value will be in understanding how to succeed and produce research to improve people’s health in the changing landscape of clinical research.

Concluding Observations

The physician–scientist is a complex entity, and limiting our understanding by strict classical definitions and attempts at quantification might yield an erroneous estimation of the current state of the physician–scientist community. Instead, trying to assess contributions made by physicians in scientific research and measuring those contributions may be more appropriate. With an expanding basic science workforce, there is a growing need for physicians who will be able to collaborate and translate meaningful clinical information to the basic scientist and back to the bedside. The next steps to address the issue of a shrinking physician–scientist workforce are to better understand who contributes to science and support their abilities, rather than try to increase the absolute number of physician–scientists under outdated definitions.

Acknowledgments: The authors wish to acknowledge and thank Devee Schoenberg for her thorough editing of this manuscript.