PHYSICIAN-SCIENTISTS: What’s the solution to the looming shortage?
Since the late 1970s, physician-scientists — scientists with medical degrees who are engaged in biomedical or clinical research — have been labeled a dying breed.
“In almost every decade since that time, various leaders have predicted their demise, and with greater and greater urgency,” said Wishwa Kapoor, Falk Professor of Medicine, who spoke June 11 on “The Looming Shortage of Physician-Scientists and What Academic Medical Centers Can Do” and received a medallion in recognition of his appointment as Distinguished Service Professor of Medicine. (See Aug. 29, 2013, University Times.)
Kapoor is chief of the Division of General Internal Medicine and vice chair of the Department of Medicine. He holds secondary appointments in health policy and management and clinical and translational science.
He is director of the Institute for Clinical Research Education and of the Center for Research on Health Care and is co-director of the RAND-University of Pittsburgh Health Institute and of Pitt’s Clinical and Translational Science Institute (CTSI).
Kapoor came to Pitt as an assistant professor in 1979 after earning his MD degree at the Washington University School of Medicine and completing his internship and residency at the University of Miami. He earned a master’s degree in epidemiology at Pitt in 1986.
He was promoted to associate professor here in 1985 and rose to full professor and Falk Professor of Medicine in 1994.
Kapoor said he was recruited to Pitt as a physician-educator, which provided both the opportunity for teaching and for seeing patients. Observations from his clinical practice led him to research the evaluation and management of patients with syncope, or sudden loss of consciousness. His proposed evaluation strategies led to clinical guidelines that remain in use today. He later led a large study on outcomes in patients with pneumonia. That research led to care recommendations that have been put into practice.
“When you get your first paper published in (the Journal of the American Medical Association), you get hooked on research,” he quipped, adding that when he became division chief, one of his major interests focused on developing research faculty, “particularly physician-investigators.”
“Physician-scientists are very important in academic medicine,” said Kapoor, noting that they are well represented as Nobel laureates, Lasker award winners, National Academy of Science members, pharmaceutical companies’ chief scientific officers and directors of NIH institutes.
And while they haven’t been driven to extinction, as some have feared, their numbers are not growing.
“The physician-scientist workforce is older than a decade ago; 75 percent are white, 20 percent are Asian. African Americans and Hispanics are underrepresented. Women remain underrepresented,” said Kapoor, adding that, as a percentage of the overall biomedical workforce, the ranks of physician-scientists have declined.
“As today’s physician-scientists exit the workforce, there may not be a robust replacement,” he said.
A National Institutes of Health (NIH) physician-scientist workforce working group’s 2014 report found disincentives for MD students who want to become physician-scientists, including financial concerns over work-life balance, increasingly complex training, balancing clinical pressures and research activities, the availability of research funding, and how to pay off medical school debt on a research salary.
“Having a lot of debt presents a barrier,” Kapoor said, noting the average debt for MD students who graduated in 2013 was $175,000.
Adding to the strain, the average age at which MDs or MD/PhDs receive their first NIH research grant has risen to 44.
The problem has not gone unnoticed. The Association of Professors of Medicine (APM), a professional organization for chairs of departments of medicine in medical schools, has called for retaining promising physician-scientists, transforming mentoring, advancing and retaining women as physician-scientists and identifying and preparing investigators with an enduring commitment to research careers.
NIH took heed of the trend decades ago, establishing a panel in the mid-1980s to find ways to bolster the physician-scientist workforce. Its recommendations — all of which have since been implemented, Kapoor said — called for maintaining proportional levels of NIH funding for clinical research; developing mentored clinical research for medical students as a pipeline for research careers; establishing training grants (NIH’s K30s for developing didactic courses, K23s for junior investigators and K24s for mentors); including more physicians in patient-oriented research study sections; implementing loan repayment programs; undertaking diversity efforts, and encouraging collaboration among clinical investigators and basic scientists — together with pharmaceutical and biotech companies.
Pitt has received funding through various mechanisms including 25 positions initially funded in 2005 through the Roadmap K12 program. The awards continue today, under NIH’s Clinical and Translational Science Awards (CTSA) program, he said. In addition, Pitt’s Clinical and Translational Science Institute (CTSI) was funded in 2006 with funding renewed in 2011, he said.
NIH has a “great mechanism” for the entire pipeline, with a variety of awards, loan repayments and research project grants including R01 funding, Kapoor said. “We think of success as moving in a horizontal direction toward the R01,” but the pipeline remains a leaky one, with physician-scientists leaving for careers in industry, non-academic or government jobs, or for clinical practice.
“Interventions have been started but they have not stemmed the tide. And the process has been exacerbated by the challenges that are facing academic medicine, including financial pressure on clinical revenues and difficulty in NIH funding,” said Kapoor.
Pitt’s efforts to support physician-scientists touch on many of the recommendations: The University offers academic programs including a PhD in clinical and translational science, as well as master’s degrees and multiple certificates; there is support for mentoring, and there are career development programs, including some for underrepresented minorities.
What can academic medical centers do? “I think the issues are really difficult,” he allowed.
One part of the solution lies in building the pipeline, Kapoor said. “Getting medical students stimulated to do research, I think, is really very important.”
He commended the NIH funding model of T32 training grants to career-development K awards to research R awards, adding that some universities, as well as some divisions at Pitt, are using it successfully.
“We should be using T32s as much as possible to train our trainees in a culture. Building a culture of writing grant proposals, building their skill, methods, grant-writing opportunities, medical writing training and professional development and other career development training — and actually getting some of the best trainees to write grants, and get them on K01s,” he said. Supporting K awardees through their transition to R awards also is important.
The bigger challenge, he said, comes in sustaining the careers of established investigators. “We have bridge funding, which has been successful,” he said, adding that writing K24 (midcareer investigator) awards may help.
Other pieces to the puzzle may include exploring opportunities for scientists to work with industry or health systems, or to band together as part of a research center or group, so they can support each other through tough funding times as part of a team, he said.
Advocating for increased NIH funding is another strategy.
“I think it’s a very complex problem,” Kapoor said. “I’m not sure anybody has a solution.”
—Kimberly K. Barlow