In the field of biomedical research, the physician-scientist offers a unique perspective as one who can arguably best comprehend the clinical issues at hand and direct new avenues of research in the laboratory. The physician-scientist is also ideally situated to translate discoveries made at the bench to therapies used at the bedside. Such was the vision of James Shannon, who was the first associate director of the National Heart, Lung, and Blood Institute and later director of the National Institutes of Health during the 1950s and 1960s. He postulated that diseases would only be cured through a fundamental understanding of physiology, and in the early days of the National Institutes of Health, he assembled a cadre of M.D. and Ph.D. researchers, including three future Nobel laureates and 13 future members of the U.S. National Academy of Sciences.1 Promoting this model of physicians at the interface between the clinical realm and basic science, Shannon oversaw dramatic growth of biomedical research, not only at Bethesda but also at universities and medical schools across the country.
History is actually rife with archetypes of successful physicians making significant contributions to the world of science. After internship and medical training, Arthur Kornberg later isolated DNA polymerase I, for which he won the Nobel Prize in 1959. Similarly, Daniel Nathans, a clinically trained physician, was awarded the Nobel Prize in 1978 for his discovery of restriction enzymes. In 1989, J. Michael Bishop and Harold Varums, both immunologists at the University of California, San Francisco, were awarded the Nobel Prize for their work on retroviral oncogenes. From the surgical perspective, there have in fact been 10 Nobel laureates, beginning with Emil Kocher in 1909 to the most recent, Joseph Murray, a trained plastic surgeon, who was awarded the Nobel Prize in 1990 for his contributions to the development of organ transplantation.
Contemporary physician-scientists, and in particular surgeon-scientists, however, face an increasingly difficult challenge to simultaneously navigate both a clinical and a scientific world. The old standard of triple-threat surgeon-scientists who could seamlessly move between the clinic/operating room, laboratory, and classroom has increasingly fallen by the wayside in today's environment of universal and managed health care. Mounting clinical demands naturally segue into dwindling devotion to basic science among young physicians. In addition, the pace of research is often so brisk that, to stay abreast of new technical developments, one must have more than just a part-time interest. Less than 10 years ago, RNA interference for gene-specific knockdown was viewed as an innovative approach, sitting just on the cusp of widespread adoption. In just the past 5 years, however, an ever-deepening understanding of gene regulation has facilitated the discovery of novel long noncoding RNAs and minicircle DNA vectors.2–4 The same can be said of stem cell research, in which enthusiasm has rapidly shifted in recent years to the induced pluripotent stem cell.5,6 One can only begin to imagine what the next decade may hold in store.
Beyond the dichotomous time demands commanded by both clinical and research endeavors, though, a more disturbing trend has evolved that challenges the future of surgeon-scientists. As elaborated by Andrew Schafer in his book The Vanishing Physician-Scientist?, National Institutes of Health grant applications have more than doubled in the past 15 years.7 This, however, can be attributed solely to investigators holding Ph.D. degrees, as the number of physicians with M.D. degrees applying for National Institutes of Health funding has remained relatively flat for three decades. Given the vacillating nature of funding cycles, a large number of young physician-scientists are therefore more likely to leave the applicant pool relative to their Ph.D. counterparts. The unpredictability of grant support is often traded for more dependable avenues (i.e., patient care) of compensation.
A perusal of recent funding patterns for the Howard Hughes Medical Institute further emphasizes the dwindling numbers of successful physician-scientists. Of the 332 current Howard Hughes Medical Institute Investigators, only 85 hold an M.D. degree. Excluding those with both M.D. and Ph.D. degrees, only 13 percent of all Howard Hughes Medical Institute Investigators hold an M.D. degree alone. The numbers are even more alarming when evaluating Howard Hughes Medical Institute Early Career Scientists. There are only five physicians among the 50 scientists identified by that program to receive funding through the Institute, all of whom hold M.D. and Ph.D. degrees. Furthermore, none of the Howard Hughes Medical Institute Investigators or Early Career Scientists are surgeons.
At least some of the challenges facing contemporary surgeon-scientists can be attributed to current training paradigms, which in many respects can place surgical trainees at a relative disadvantage in the world of science. In the field of plastic surgery, for example, postdoctoral training can take one of two main paths. From the independent model, residents complete formal training in one of a variety of surgical specialties before entering a plastic surgery program. Often, this prerequisite training also entails 2 dedicated years of postdoctoral research. From the integrated model, medical school graduates complete at least 3 prerequisite years of general surgery before training in plastic surgery at the same institution. In many of these integrated models, such as at Stanford University, residents are now given 1 full additional year between general and plastic surgery that can be spent as a postdoctoral research fellow, in effect making the training a “3 + 1 + 3” program. The inherent drawback of both the independent and the integrated model, however, is the compartmentalization of science in both time and place. In either training paradigm, at least 3 (and often more) years separate time spent in the laboratory and completion of training. For the reasons discussed above, the pace of contemporary research during this hiatus can potentially leave surgeons fundamentally trailing in science during the critical early years of their career in academic medicine.
In contrast to this model, many programs in dermatology have offered a different approach to the training of a physician-scientist. In addition to 1 year of internship, many residencies now offer a 4-year track combining clinical dermatology with basic laboratory research training in a “2 + 2” model. Whereas the first 2 years are spent strictly in clinical training, the last 2 are considered a postdoctoral fellowship where clinical work—typically reduced to 10 percent—is combined with time spent conducting research. The benefits of such an approach are manyfold, the most obvious being a lack of interruption in laboratory exposure. This allows for a more seamless transition between postdoctoral fellowship and independent principal investigator. In addition, board certification in dermatology can be acquired during the fourth year before completion of the program, allowing the trainee to bill and generate revenue as an attending physician. This model has proven somewhat more successful, with one of the five physicians currently funded through the Howard Hughes Medical Institute Early Career Scientist program being a practicing dermatologist at Stanford.
With respect to Howard Hughes Medical Institute funding, however, internal medicine has been particularly successful in training competitive physician-scientists. Many of their trainees can now fast-track into an area of subspecialty following just 2 years of residency. During the fellowship, 1.5 years are first spent in clinical training, followed by 2.5 years of dedicated research. In effect, this constitutes a “2 + 1.5 + 2.5” model. During research time, clinical responsibilities are dramatically reduced, allowing for primary focus on scientific pursuits. In the Division of Oncology in the Department of Medicine at Stanford, fellows are provided research mentors and are even encouraged to pursue laboratory experience outside of the Division.
Considering these alternative approaches to training, how then can surgeons, and in particular plastic surgeons, likewise bridge the research training gap that has vexed so many young surgeon-scientists? The fundamental difficulty stems from the nature of the field, as one cannot simply translocate the dedicated “research” years to the end of residency training. Although this would undoubtedly facilitate a smooth transition scientifically, the clinical interruption would be certainly disastrous to a new faculty surgeon. Nor can one just simply integrate laboratory research time and clinical responsibilities into an extended program, as this would prolong the training of many residents who are not interested in pursuing a career in academic medicine. More importantly, such a scheme would raise issues with Medicare funding of trainees through both direct and indirect medical education payments.
Given these constraints, the solution to how we may better train and prepare surgeon-scientists may lie in a paradigm shift for postresidency fellowships. After completion of a plastic surgery residency, many opt for further training in 1-year clinical fellowships, including craniofacial, microvascular, hand, cosmetic, and burn surgery. Although these fellowships have excelled at preparing young surgeons for a clinical career, responsibilities of a fellow have typically precluded extensive laboratory experience during this time. Importantly, however, this is not the focus of clinical fellowships, nor should it be. In light of this, one may consider, though, the creation of an extended fellowship (i.e., 2 or 3 years), in any given subspecialty, which would allow for integration of both clinical education and research exposure. This would, in many respects, parallel the structure of many internal medicine subspecialty fellowships. Although this would certainly not be for everyone, for those particularly inclined to pursue a career as a surgeon-scientist, this would provide integrated training and a more preferable route to transition into an eventual role as an independent principal investigator.
Many programs already have the volume to support multiple fellows, and although it may require more logistical planning, one can readily imagine joint fellowships offering both a purely clinical route and a research-oriented track. To provide protected time in the laboratory, the clinical responsibilities of the research fellow would have to be scaled back, perhaps to 1 and at most 2 days per week in the operating room and/or clinic. Programmatic buy-in would of course be absolutely necessary to support and nurture any scientific endeavors, but in such a paradigm, neither clinical nor scientific compromise would be necessary.
Ingenuity, perspective, and passion have all been particular traits ascribed to surgeon-scientists, but in an arena where it has become increasingly difficult to compete and succeed, a fresh approach to how we provide training must be considered. With the unpredictability of National Institutes of Health funding and the rapid pace with which science evolves, the conventional independent route or “3 + 1 + 3” model may not optimally prepare trainees to successfully enter the scientific world on firm footing. A “3 + 3 + 3” approach in which laboratory experience is integrated into clinical fellowship may better suit the plastic surgeon dedicated to a career in science. Although this may not be the best solution, it provides, at the very least, a starting point for subsequent discussion. Nonetheless, changes must be made to our current training paradigm to facilitate the highest caliber work from future surgeon-scientists.
Derrick C. Wan, M.D.
Department of Surgery
Stanford University School of Medicine
257 Campus Drive West
Stanford, Calif. 94305