The Evolving Relationship Between the Physician and the Scientist in the 20th CenturyAddressing the Needs of Basic and Clinical Research: Analysis of Graduates of the University of Pennsylvania MD-PhD ProgramBridging the Worlds of Medicine and Science: An Interview With Bert I. Shapiro, MDAnnouncement1999 John Conley Ethics Essay Contest for Medical Students FREE

The architecture of the academic medical center can be viewed as a reflection of the contemporary relationship between physicians and scientists in the United States: the bustling hospital sits next to a high-rise of laboratories, and clinicians and researchers hurry between them. Yet the arrangements that bring physicians and scientists together may disguise the divergent historical and philosophical perspectives that separate them.

Hands-on laboratory instruction in medical training appeared at Harvard University in the 1880s and reached its most exemplary form at Johns Hopkins University in 1893 through the support of physician and educator William Welch.¹ Trained in Germany, Welch argued that "nothing can replace the careful study of fresh specimens" for the student doctor. Abraham Flexner, surveying medical schools in 1910, concurred that medical students gained more through personal investigation than through didactic learning: the ideal medical student "no longer merely watches, listens, memorizes; he does."² Early 20th-century physicians studied the approaches and techniques of the laboratory to apply them to problems arising in patient care. During this period, physicians, rather than professional scientists, formulated research questions in the clinic, used the lab to study them, and brought the results back to patients. Frederick Banting's research on insulin in the 1920s provides one example. After his surgical practice failed, Banting convinced a group of scientists and a medical student to join him in investigating a possible treatment for diabetes. The insulin extracted from canine pancreas in the summer was tested on hospital patients in the fall.³

Lab work also provided early 20th-century physicians with a prestigious professional identity. The physician who posed with a microscope or at a bench connected himself to the new techniques of microbiology and pharmacology and their anticipated benefits. Through devotion to scientific experimentation, physicians also differentiated themselves from the profit-driven businessman of the era.⁴

After World War II, as the nation's economic and social priorities changed, however, science became an independently funded and self-sustaining enterprise. In the 1950s the Office of Scientific Research and Development, the National Science Foundation, and the National Institutes of Health (NIH) expanded dramatically, providing new sources of funds for scientific research. At the same time, scientists gained new institutional positions as academic medical centers began to replace community hospitals as the site of medical training. Federal matching funds that were awarded to medical schools to build research facilities also came to support their educational infrastructure.⁵ By the 1960s, funded science research supported one third of all medical school expenditures.⁶

Although scientists and physicians began to work together in academic medical centers, the laboratory and the clinic emerged as arenas with distinct perspectives. Newly empowered scientists chose less clinically oriented research, and shared decision-making power with physicians on many projects. Cellular and biochemical characteristics of disease, not Welch's "fresh specimens," became prominent objects of investigation. After the 1950s, studies on treatment and symptomatology also declined, as did the use of clinical evidence like physical exams and patient histories.⁷ When the National Cancer Institute first opened in the 1930s, research into chemotherapeutics had faltered because physicians were concerned for patient safety. In the new academic medical centers, researchers moved beyond chemotherapies to molecular characterizations of viruses and oncogenes.

Ultimately, these developments served to widen the gap between the scientists who conducted experiments and the physicians who applied the results. Science had become an exacting and intricate method of investigation tied to the laboratory and its tools, a method that most physicians no longer learned first-hand. The science taught to medical students involved less laboratory experimentation and relied more on the study of other people's results. Physicians-in-training still studied techniques of DNA sequencing and configurations of protein channels, but had little experience in developing these tools themselves. The Medical Scientist Training Program (MSTP), created by the NIH in 1964 to provide support for medical students seeking an MD and a PhD in the basic sciences, institutionalized one route to becoming a medical researcher: laboratory training.⁸ While the program stressed the connection between medicine and science, its very inception attested to the distance that had developed between them. The MSTP reinforced the notion that clinical acumen was insufficient preparation for a career in research. Leaving the hospital rather than contending with its actualities became the preeminent method by which doctors could contribute to medical knowledge. Today, while MD-PhDs ensure that the path from the clinic to the lab is well-worn, other physician-researchers are moving beyond basic science methods. Physicians who have internalized Welch's inquisitive ethos pool clinical evidence in randomized controlled trials or conduct outcomes research to investigate medical interventions. In the next decades, the physician-researcher, emulating the MSTP, will tread more numerous and diverse paths from the clinic to the site of research.

In the mid-1960s, leadership within the National Institutes of Health (NIH), private foundations, and academic institutions recognized that the explosion of information in the biomedical sciences created opportunities for translational research on human disease. Their efforts resulted in the creation of training programs to produce joint MD-PhD physician-scientists who would bring the insights of clinical practice into their research and vice-versa. Thirty-three years later, empirical analysis is needed to evaluate the impact of these programs in academic medicine.

The MD-PhD program at the University of Pennsylvania (Penn), which was initiated in 1969 and has 255 total graduates, provides a locus for such a study. Penn's MD-PhD program has 167 current trainees and offers joint degrees in 19 separate programs including 8 in traditional biological sciences as well as 11 other programs, such as philosophy, demography, health care policy, and law. Similar analyses of MD-PhD programs have been published in recent years. A 1995 study of the 147 graduates of the Duke University program from 1970 to 1990 showed 74% working in academic medicine or research, with 82% of these holding full-time faculty appointments and conducting major efforts in research.¹ Another study of MD-PhD graduates from Washington University showed that 89% of graduates who had completed their medical training were working in academic medicine or at the NIH.²

Data on graduates of Penn's MD-PhD program (1969 to 1998) were collected by self-report, in the form of curricula vitae requested annually by the MD-PhD program office, and by direct phone solicitation. This information included graduates' current career appointment (academic institution, government or private research institute, industry, or private/hospital clinical practice) and career trajectory (postgraduate fellow, assistant professor/staff scientist, associate professor/senior scientist, professor/section chief, and department chair/director). The questionnaire also surveyed the percent of time spent on research, clinical practice, teaching, and administration, as well as records of publications and funding. Information on national trends in residency selection (PGY-1) was obtained from the March 13, 1998, registry of the National Residency Match Program.

The response rate for the survey of Penn's 255 MD-PhD graduates was 85% (n = 216).

Because of recent changes in the allocation of residency positions, our analysis focused on MD-PhD students graduating in the period 1992 to 1998. Ninety-nine percent of the graduates during this period entered residency training (64/65). The most common choices among Penn's MD-PhD graduates mirrored those of the national pool of medical graduates: internal medicine (23.1%), pediatrics (18.5%), pathology (10.8%), and surgery (9.1%). However, compared with residents at large, Penn MD-PhD graduates disproportionately favored neurology and neurological surgery, ophthalmology, and otolaryngology over the fields of emergency medicine, family practice, and orthopedic surgery. Further data are available online.

Of the 216 responding MD-PhD graduates from 1969 to 1998, 35.2% (76/216) were still in training as of November 1998. Of the 140 MD-PhD graduates who had completed their training by the time of the survey: 83.6% (117/140) held positions as academic faculty, 5.7% (8/140) held positions at government or private research institutes, 4.3% (6/140) were in industry, and 6.4% (9/140) were in full-time private or hospital-based clinical practice(Figure 1).

Overall, 92.1% (129/140) of the MD-PhD graduates who completed their training defined their current positions as containing a significant research component. Within the past 12 months, 93% (130/140) had published a peer-reviewed manuscript; within the past 36 months, 98.4% (138/140) had. As many as 92% (129/140) currently serve as principal investigators on funded projects of any kind; 87% (122/140) are principal investigators on extramurally funded projects. Sixty-seven percent (94/140) listed their research commitment as greater than 50% of their efforts; 82% (115/140) reported less than 50% clinical effort. Nearly all of Penn's MD-PhD graduates listed administration and teaching as significant but minor components of their activity (less than 25% effort) (Figure 2).

Among graduates who entered academic medicine and had completed their training by the time of the survey (n=140), there was a steady increase in the number that entered junior and senior positions. After 6 to 10 years postgraduation, 74.2% of these graduates held the rank of assistant professor or higher; at 11 to 15 years, 100% held the rank of assistant professor or higher; and at 16 years or more, 100% held the rank of associate professor or higher, with 58.5% as full professor or equivalent. Further data are available online.

A major goal of MD-PhD programs is to produce academic leaders who use their interdisciplinary training as physician-scientists. The data gathered from the 216 respondents who graduated from 1969 to 1998 reveal that Penn's MD-PhD graduates enter academic and other research positions in high numbers. Overall, more than 90% of MD-PhD graduates who have completed their clinical training report that research is a significant professional activity. This is supported by observations that 89.3% hold positions in academic or research institutions, and that more than 90% of graduates published a peer-reviewed manuscript and served as a principal investigator on an extramurally funded project within the preceding year. We note that these results were obtained primarily through self-reporting from graduates without independent verification. Another potential limitation to this study is the uncertain status of the 15% of graduates (39/255) who did not respond to the survey.

Our results indicate, however, those the career positions held by Penn's MD-PhD graduates are markedly different from that of Penn's MD trainees and more similar to those of biomedical science PhD trainees. Although 24.3% of MD graduates hold academic faculty positions, 73.4% are in full-time private or salaried clinical practice, in contrast to only 6.4% of the MD-PhD graduates. Graduates of Penn's biomedical science PhD program also favor academic positions (55.2%), although they are distributed more heavily in basic science departments (82.4%), compared with academic-track MD-PhDs (8.8%). A much greater proportion of PhD graduates also track to positions in industry (33.5%) than is seen in either the MD-PhD (4.3%) or MD (1.6%) groups.

The combination of basic and clinical training, which serves as an integral part of MD-PhD training programs, is evident in the activities of program graduates. More than 98% of graduates selected clinical residency training, and nearly 75% of graduates who had completed their training retained clinical activity despite an active research effort. Although the level of effort in research and clinical areas varied widely among individual graduates, there was a clear trend toward research rather than patient care.

Several preferences were noted in the selection of residency programs by Penn MD-PhD graduates. Recent Penn program graduates entered 8 fields more frequently than the national average for residents: general surgery, neurology/neurological surgery, ophthalmology, otolaryngology, pathology, pediatrics, psychiatry, and radiology. Of these, chi-square analysis indicated that neurology/neurological surgery, ophthalmology, otolaryngology, and pathology were significantly favored. At this time, it is not possible to determine whether these trends are due to perceptions of these fields' compatibility with research activities, the perceived strength of Penn's clinical training in these fields, or other factors unrelated to the structure of the MD-PhD program itself. Taken together, this information indicates that Penn MD-PhD graduates enter academic medicine in significant numbers, retain a varying mix of basic research and clinical activity, and generally progress in academic positions. Analyses of other MD-PhD programs in the country will be useful in determining how these characteristics compare with national MD-PhD graduates.

Supplemental data are available at the MSJAMA web site: http://www.ama-assn.org/msjama.

Q. How has the Medical Scientist Training Program (MSTP) changed over time in its goals, strategies, research focus, and applicant pool in response to the changing health care climate?

A. The basic MSTP goals have not changed, although our program announcement has recently been updated to emphasize "nontraditional" fields of doctoral study, such as biomedical engineering and epidemiology, that have always been acceptable for combined-degree training. Other fields, such as medical economics and bioethics, are relevant to medicine but fall outside the area of biomedical research. In the increasingly complex world of health care delivery, we believe that students in these fields can provide an important contribution to society.

The applicant pool for the MSTP has always been strong, and my impression is that it is becoming stronger yet. We are seeing a significant number of trainees entering the MST programs with backgrounds in the physical sciences and engineering. This has resulted in an increase in the number of students entering graduate programs in biomedical engineering, biophysics, and neuroscience. A significant number of MSTP students with PhDs in some area of engineering are choosing residencies in radiology.

Q. Sutton and Killian1 recently reported that the proportion of MSTP graduates doing laboratory research vs clinical research resembles that of graduates with PhDs only. How does this relate to the MSTP's primary goals of training physician-scientists?

A. The recent study considers all laboratory research to be equivalent and provides a rather strict definition of "clinical" research as that which focuses on patient care. Someone looking at tumor vascularization or Salmonella toxin secretion is considered a "laboratory researcher" according to this characterization. However, I would argue that a researcher on either of the above problems, who is board certified in medicine, sees patients (as do over half the MSTP graduates), has an appointment in a clinical department, teaches medical students and perhaps even some residents, and collaborates with medical colleagues, is indeed a physician-scientist.

MSTP students can, and do, select their doctoral area from a wide array of graduate programs available at the grantee institutions, but most students select topics that are medically or disease related. We hope that MSTP graduates are more than physicians plus scientists, but rather researchers who can bring together the unique perspectives of medicine and basic research. There are many bench-to-bed and bed-to-bench transfers that require a combination of medical and research understanding that MSTPs can provide.

Current MSTP training provides students with many opportunities to ask questions about the clinical potential of basic discoveries, as well as the basic questions raised by clinical observations. Most programs have incorporated these issues into regular seminars, retreats, and workshops where speakers and discussants provide numerous and diverse examples of successful translational efforts. MSTP graduates are also entering highly selective residencies, often with arrangements to integrate research with their clinical training. I believe that these residencies, and the subsequent clinical fellowships chosen by 70% of the MSTP graduates, are outstanding opportunities for the appropriate training.

We recently compared the career outcomes of MSTP graduates with a matched group of PhD graduates who had received their degrees from the same programs or departments as the MSTP graduates and were also supported by National Institutes of Health National Research Service Award Act funds. The MSTP graduates were about 3 times more likely to have published in clinical (eg, Journal of Nephrology) and mixed (eg, JAMA, Pediatrics) journals. I judge that the program has trained and continues to train physician-scientists who play a crucial role in bridging the two worlds of science and medicine.

Dr Shapiro is the director of the MSTP at the National Institute of General Medical Sciences. This is an excerpt; full text of the interview is available at the MSJAMA Web site.

Applications for the MSJAMA editors group are due by January 15, 1999. Please refer to the November 1998 issue of MSJAMA for details.

The Medical Student JAMA is pleased to announce its fifth annual essay competition for medical students, sponsored by the John Conley Foundation for Ethics and Philosophy in Medicine. This year's topic examines an issue raised by the growing importance of cost containment in medical practice.

Traditionally, optimal patient care has been the foremost concern of medicine. More recently, physicians are facing pressures to restrain health care expenditures, presumably without sacrificing the interests of the patient. In their essays, medical students are asked to address the following scenario: Suppose a potentially useful procedure is available that is not covered by a patient's medical insurance. Under what circumstances, if any, would you consider it appropriate to miscode (and thereby make available) the needed procedure? See the November 1998 MSJAMA, p 1534, for complete details.