In the past decade, many individuals and organizations have expressed concern about the future of clinical research (1–5) and about those principally concerned with leading it: physician-scientists (6 –9). Some believe that there is a “crisis” in clinical research or that physicianscientists are an “endangered species.” All agree that the problems are serious and will get worse if they go unattended. To find this much accord among such organizations as the Institute of Medicine, the National Institutes of Health (NIH), the Federation of American Societies for Experimental Biology (FASEB), the Association of American Medical Colleges, and the American Medical Association is, in itself, remarkable. That substantial agreement exists about the proposed remedies is also notable and encouraging. The litany of problems in the clinical research enterprise, however long, bears repeating. Too small a fraction of the NIH budget is devoted to patient-oriented research; too few MDs are included on NIH study sections and institute review groups; too few career development programs are sponsored by the NIH, the Howard Hughes Medical Institute, voluntary health agencies, and foundations; too little emphasis on research in clinical departments in academia; and, most important, too little appreciation that sustaining the national investment in medical research depends on demonstrating to the public a commensurate return in terms of extending and enhancing life, reducing disability, and preventing, treating, and curing disease.
The warning signs that the physician-scientist career path is in danger are a decade-long decline in the stated intention of matriculating and graduating medical students to pursue a research career; the rising debt burden carried by newly minted MDs, which must affect career choices for some; participation of fewer MDs in NIH-sponsored postdoctoral fellowship programs; an age shift of NIHsupported physician-scientists toward those 45 years of age or older; and an overall reduction in the number of MDs who claim research as their principal professional activity—the definition of physician-scientist (9). In response to these alarums, the NIH has created several new career award programs for young and established MD investigators, and more MDs are being recruited to serve on study sections and other review groups. The U.S. Congress is considering the Clinical Research Enhancement Act, which, if enacted, would help considerably, and a FASEB-sponsored proposal to fund a broad loan-repayment program for MDs engaged in rigorous research training is moving toward Capitol Hill. Finally, interest on the part of selected foundations and private companies is quickening.
In this issue, Whitcomb and Walter (10) prompt us to think about the role of departments of internal medicine in being responsible for the national problems in clinical research and in helping resolve them. Internal medicine, after all, has been the favored habitat for physician-scientists for 40 years; it houses the largest number of such persons and serves as the most common academic destination for MDs who wish to establish and sustain a scientific career. The authors remind us, in this regard, that about 45% of all principal investigators in clinical departments who have received NIH grants are faculty in internal medicine. That said, Whitcomb and Walter conclude that “few internal medicine subspecialty programs are currently designed to provide adequate research training as defined by the Institute of Medicine and the ABIM” (10). They surveyed six subspecialties: cardiology, endocrinology, gastroenterology, infectious disease, nephrology, and rheumatology. The average time that fellows spent doing research in their final year of training was less than 50%. Furthermore, only about one quarter of the programs at academic medical center hospitals planned to accept persons interested in pursuing the “new” (short-track) research pathway to ABIM certification. The study has limitations that the authors acknowledge: only 2 years were surveyed, only a subset of subspecialties were investigated, and the temporal superimposition of this questionnaire study and the introduction of the “new” research pathway of ABIM was awkward. Nonetheless, the data support Whitcomb and Walter’s central conclusion, leading me to ask what the conclusion means.
Because residency training in internal medicine, either general or subspecialty, is designed to train clinicians, it should come as no surprise that it does just that. In the past, many programs added training in research to the principal experience of preparing expert clinicians, and that, too, was good—as long as the research training was rigorous and extensive enough to prepare internists for lengthy careers as physician-scientists. As information in the life sciences relevant to health and disease has exploded, however, obtaining the requisite research training within a medical subspecialty or even a department has become increasingly problematic. It is simply not possible to become a scientifically competitive cardiologist or gastroenterologist, for example, by spending one third or less of one’s specialty training in research, yet that is what most programs offer. Perhaps the good news from Whitcomb and Walter’s study is the implication that most subspecialty program directors have abandoned the misguided notion that research training can always be tacked on to an already full clinical subspecialty experience. Training the next generation of physician-scientists is not a right for all; it is a responsibility for those who choose to make it a top priority. Furthermore, I am not surprised that so few internal medicine residents in the United States (only about 120 to date) are opting for the research pathway of the ABIM, because it doesn’t shorten postdoctoral training appreciably and hasn’t been embraced by many heads of subspecialty training programs for several reasons, not the least of which are financial ones.
If departments of medicine are to retain their role as standard bearers for patient-oriented research and physician- scientists in academia, their current chairs and leaders— who have been remarkably quiet—must demonstrate that they are up to that heavy responsibility. First, they must help their faculties decide whether they can and will sponsor rigorous research training. Second, in departments that decide to sponsor such training, chairs must demonstrate to their faculties that research is second to none as a departmental mission and bestow their coin and kudos accordingly. Third, they should fashion institutional training programs that are both broad and deep, programs that give trainees the tools and the confidence for a successful career-long journey in clinical research. Fourth, they must develop a database for their field and keep it current. For instance, they should follow first-time NIH applicants for research project grants from internal medicine because their number has been disturbingly small and flat for 10 years—241 in 1989, 255 in 1998—even though the NIH budget for research project grants doubled during this time, and they should monitor the fraction of the NIH extramural budget awarded to departments of medicine (29.6% of funds awarded to medical school departments in fiscal year 1990 compared with 27.2% in fiscal year 1999 [Moore R. Office of Extramural Research, NIH. Personal communication]). Finally, they should lobby Congress and the NIH to offer financial incentives for physician-scientists by authorizing loan repayment to MDs engaged in full-time research training and by expanding MD/PhD programs and other means of recruiting students to research tracks.
To paraphrase an old political slogan, as internal medicine goes, so goes clinical research and the physicianscientist career path. That is a challenge worthy of this proud field at the millennium.
Leon E. Rosenberg, MD
Princeton, NJ 08544
Ann Intern Med. 2000;133:831-832. © 2000 American College of Physicians–American Society of Internal Medicine.
1. Ahrens EH Jr. The Crisis in Clinical Research: Overcoming Institutional Obstacles. New York: Oxford Univ Pr; 1992:236.
2. Kelley WN, Randolph MA. Careers in clinical research, obstacles and opportunities. Washington, DC: National Academy Pr; 1994:332.
3. Thompson JN, Moskowitz J. Preventing the extinction of the clinical research ecosystem. JAMA. 1997;278:241-5.
4. Nathan DG. Clinical research: perceptions, reality, and proposed solutions. National Institutes of Health Director’s Panel on Clinical Research. JAMA. 1998; 280:1427-31.
5. Schechter AN. The crisis in clinical research: endangering the half-century National Institutes of Health Consensus [Editorial]. JAMA. 1998;280:1440-2.
6. Goldstein JL, Brown MS. The clinical investigator: bewitched, bothered, and bewildered—but still beloved [Editorial]. J Clin Invest. 1997;99:2803-12.
7. Rosenberg LE. The physician-scientist: an essential—and fragile—link in the medical research chain. J Clin Invest. 1999;103:1621-6.
8. Foster DW. Why the disappearing physician-scientists? [Editorial] FASEB Newsletter. 1999;32:2.
9. Zemlo TR, Garrison HH, Partridge NC, Ley TJ. The physician-scientist: career issues and challenges at the year 2000. FASEB J. 2000;14:221-30.
10. Whitcomb ME, Walter DL. Research training in six selected internal medicine fellowship programs. Ann Intern Med. 2000;133:800-7.