Paul Spring, MS, MD, is Associate Professor and Director of Research in the Department of Otolaryngology–Head and Neck Surgery at the University of Arkansas for Medical Sciences in Little Rock.
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Academic medical centers within the United States bear the primary responsibility for promulgating and performing life sciences research. James Shannon, MD, PhD, is considered the father of the modern National Institutes of Health (NIH)—established in the late 1940s and early 1950s—and creator of our nation’s biomedical research enterprise. Among his most passionate charges was the development of research programs that focused on disease processes as described and treated by physicians. Thus, during the “golden years” of the NIH, the concept was born regarding the unique perspective and role of a physician–scientist.
Fifty years have passed since Dr. Shannon’s idea was originated. It is at once an interesting irony and a troublesome reality that contemporary medicine and state-of-the-art technology have arrived at a time when the cultural, societal, and fiscal challenges facing those engaged in the conduct of medical research are greater than at any previous time in our country’s history. Physician–scientists and the infantry of clinicians who devote their professional efforts toward the attainment of new medical knowledge using established scientific principles are a tenuous, yet necessary, link in medical advancement. Many scientists and educators have been instructive about the major problems facing the clinical research community and the fact that these problems are affecting the training of physicians who wish to enter this career path.
At the annual meeting of the Society of Head and Neck Surgeons in 1995, Dr. Helmut Goepfert delivered the Hayes Martin Lecture on “Training the Head and Neck Surgeon–Scientist.”1 His paean to physician–scientists in general and the surgeon–scientist in particular was one of the society’s first public calls to the significance and need for individuals to pursue this career track within our specialty. Dr. Goepfert stressed the notion that “clinical training alone is not enough to forge the future.” He also challenged modern head and neck surgeons by reminding them that “faithful acceptance of dogma” was a misguided practice and that it represented the greatest obstacle to constructive change in our specialty. Dr. Goepfert, a preeminent leader of a surgical discipline, was warning a skeptical generation about the consequences of repeating the past. He averred that the confluence of clinical excellence and scientifically applied theory was the most valid approach to improving the lives of our patients. His concept of a true surgeon–scientist was his answer to the dilemma.
The Making of a Physician–Scientist
Fortunately, many defining examples exist of successful surgeon–scientists translating their basic science research into clinically applicable concepts and practice. One such individual is Cherie-Ann Nathan, MD, Professor and Vice-Chairman of Otolaryngology/HNS at Louisiana State University Health Sciences Center–Shreveport and Director of Head and Neck Surgical Oncology at Feist-Weiller Cancer Center. Dr. Nathan has researched and published extensively on characterization of surgical margins through the molecular analysis of the eIF4E proto-oncogene. Dr. Nathan offers the following insights for developing a bona fide physician–scientist career: “Collaborations with basic scientists are the key. They love clinicians, as we understand the disease and they want our patient samples. However, if they do not see our commitment, they lose enthusiasm.”
Unfortunately, the realities of modern medicine in general, and academic medicine in particular, dictate that the earnest physician–scientist must be willing to negotiate up front with his or her institution in order to secure the proper financial and philosophical support combined with necessary release time to concentrate on his or her projects. Dr. Nathan opines, “The first five years of one’s academic career are most important in developing a research program. The institution should make a commitment toward paid protected time for a physician–scientist for the first five years. Salary should not suffer because of decreased clinical load. After five years, if funding is not obtained, then one can expect faculty to bring in their share clinically.”
This model seems to be the de facto approach that many institutions are employing with their young faculty, who they project will be successful at establishing their careers combining research with clinical interests.
Physician–Scientists in Otolaryngology–Head and Neck Surgery
In our specialty, we are fortunate to have bright individuals who have upheld the surgeon-scientist model. The greatness of our specialty is the commitment of our members who have willingly waded into the often thankless and unrecognized path of academic educators and innovators seeking excellence in their pursuits. As a specialty we have numerous subspecialties that lend themselves to meaningful research that can be combined with clinical satisfaction. Our neurotologists, head and neck surgeons, rhinologists, laryngologists, pediatric otolaryngologists, and plastic and reconstructive surgeons have made substantial contributions to their subspecialty fields. These contributions have come neither easily nor without a price.
For many physician–scientists, the “payoff” for their time and investment comes with attainment of the signature honor of investigator independence, the NIH R01 award. However, that measure of success is not easily or equitably reached by every physician–scientist. In a recent article in the Journal of the American Medical Association, Dickler et al. performed a comprehensive analysis that documented the experience of first-time investigators with a medical degree over a 40-year period.2 Their objective was to ascertain the perseverance and comparative success of physician–scientists for independent investigator NIH awards (i.e., R01 awards). They determined that the annual number of first-time investigators with an MD only who applied for NIH R01 grants remained stable over four decades. The first-time applicants with an MD degree only were less successful than those holding PhD or combined MD/PhD degrees by a statistically significant measure. Perhaps more disconcerting was the fact that successful first-time MD grantees were consistently less likely to obtain a subsequent R01 grant. This well-executed study concluded that physician–investigators consistently experienced higher rates of attrition and failure in spite of the original success obtaining an R01. One additional point made was that physicians proposing nonclinical research were more successful than those who submitted clinical projects.
One of the factually unsubstantiated, yet well formulated, “conspiracy theories” is the notion that although the NIH has long advocated for translational research projects involving physicians with a scientific interest and background, the money hasn’t always followed the rhetoric. The theory states that from the scientists’ viewpoint, physicians are well-compensated individuals whose commitment to research should be questioned because they are driven more by clinical pursuits (i.e., money) than by their interest in answering fundamental scientific questions that may or may not have clinical relevance. The level-headed, reasonably honest, and circumspect physician–scientist responds that a simple glance at the pertinent NIH study sections, notwithstanding the wholesale restructuring of the study section organization, reveals the presence of few MD-only degree holders in basic science or translational areas. This patent partiality against MD representation on important study sections reflects a schism at the most crucial level of scientific review and awarding. On the other hand, there may be sound fundamental reasons for the evolution of this state of affairs.
The Current Climate
One very interesting and perhaps unanticipated ally to the physician–scientist mission is the American taxpayer. Recently, accountability has become a major concern for those of us who pay taxes and have been looking for a return on our investment. In response to Clinton administration initiatives to double NIH spending over five years, the NIH budget reached $27.7 billion in 2004.3 President Bush acknowledged the importance of this project and, along with Congress, continued to maintain the goodwill. Around that time, the newly installed director of the NIH, Elias A. Zerhouni, MD, unveiled the NIH Roadmap and said, “As the 21st century unfolds, discovery in the life sciences is accelerating at an unprecedented rate. As science grows more complex, it is also converging on a set of unifying principles that link apparently disparate diseases through common biological pathways and therapeutic approaches. NIH research needs to reflect this new reality.”4,5
The hope among physician–scientists was that this new approach to problem solving would involve those individuals closest to the problems being addressed (i.e., physicans). The evidence for improvement on this front is scant. Parochial and partisan concerns over terrorism, recent conflicts in Iraq and Afghanistan, as well as the post-Katrina reconstruction have made the climate for would-be investigators much more daunting for the short term. The current (FY 2007 first and second funding cycles) payline for percentiled R01 projects is the 12.0 percentile. Recognizing the need to encourage new investigators to participate, the payline for applicants considered as first-time R01 investigators will be paid with the extended percentile payline up to the 18.0 percentile. These numbers are close to historic lows.
In truth, it is very easy to become discouraged about the status of the physician–scientist, particularly the one who holds an MD degree only. However, it is the individual’s commitment and fortitude that leads to success. And success must not only be measured by the number of R01s a person accumulates. Often, we tend to forget or ignore the bounty of foundation, government, society, and pharmaceutical grants that are available to worthy investigators. Dr. Goepfert’s well-articulated vision of what needs to be done in order for our society to realize the benefits of its huge financial and personal investment in medical advancement stands as his greatest legacy, and one that we would all be well advised to heed.
Rest assured that the physician–scientist model is alive today. It is producing dedicated individuals who stay committed to the ideal that as physician–scientists they possess a unique appreciation for a particular disease process and that their interest in combining their clinical interests with their scientific ones will benefit all. There are many physician–scientists for whom the rewards might be hard to come by, but the satisfaction of accomplishment and recognition for their work are immeasurable and heartwarming. So yes, the physician– or surgeon–scientist ideal is present and working well in our specialty. Hopefully you will look around and identify those in your ranks who fit the bill and recognize that many discoveries have been made that have changed the way we understand our specialty and the diseases we treat due to their efforts.
- Goepfert H. Hayes Martin Lecture. Training the head and neck surgeon-scientist. Am J Surg 1995;170(5):410–5.
- Dickler HB et al. New physician–investigators receiving National Institutes of Health research project grants: a historical perspective on the “endangered species.” JAMA 2007;297(22):2496–501.
- Kaiser J. Appropriations. House bill signals the end of NIH’s double-digit growth. Science 2003;300(5628):2019.
- Mayor S. NIH announces new strategy for research. BMJ 2003;327(7418):765.
- McLellan F. NIH director reviews first year on the job. “Roadmap” calls for reorganisation of basic and clinical research. Lancet 2003;362(9381):381–2.
©2007 The Triological Society