The Physician as Medical Researcher

Less than a decade ago in this period of flourishing biomedical science, the contribution of physician-scientists to research was progressively declining to the point where the species seemed endangered. Although recent data from the National Institutes of Health suggest a reversal of this trend, the fact that the decline occurred at all has prompted me to think about the singular and perhaps critical role of the physician in research. The very origin of biomedical science owes much to the contributions of physicians. Challenged by disease, physician-scientists such as Schwann, Golgi, Ludwig, Cohnheim, Bernard, Koch and Erlich developed the basic technology for the staining of diseased and normal tissues, the measurement of physiologic processes and the cultivation of bacteria. In so doing they opened the door not only to the scientific study of disease but also to the understanding of normal cell structure and function. The continuing potential of the physician for making fundamental contributions to science is evidenced by the Nobel Prizes in Physiology or Medicine, more than half of which have gone to physicians since 1970. But the M.D. degree does not a scientist make. Indeed, some might say that the designation "physician-scientist," like "military intelligence," is a contradiction in terms. Physicians acquire a large number of scientific facts in the course of a medical education, and they use the technology of science daily in treating patients. Physicians also employ the scientific method in accepting or rejecting alternative diagnostic hypotheses. But physicians cannot be defined as scientists unless they undertake systematic research with the aim of solving problems and producing new knowledge. With the present reduction of much research to the molecular level, physician-scientists are at a competitive disadvantage unless they acquire the bench skills of the more selectively trained Ph.D. Although combined M.D.-Ph.D. training programs have met part of the need for physicians who know how to exploit biochemical approaches to disease, most have no room for the late bloomer whose motivation to investigate disease is fired only after first making contact with patients. At that time, the physician's investigative zeal may be damped by the societal pressures of family commitment and medical school debt. Only those with the strongest motivation and greatest ability will persevere to try to understand the experiments of nature they see in every patient. What the Physician Can Offer Given the attributes of dedication and ability, does the medical school graduate have anything special to offer in biomedical research? I think so, and that contribution is as likely to be in basic as in applied research. Just as a geneticist relies on the mutant for the definition of normalcy, the physician-scientist illuminates normal physiology by study of its aberrations. When at the bedside, the physician is a field scientist with the opportunity for making firsthand observations. A classic example is Garrod, who established the field of biochemical genetics after noting the black urine of alkaptonuria and its familial occurrence. No matter how intensely specialized a physician may be, a medical background is a reminder that "the foot bone's connected to the leg bone," as the song goes. No less fascinated with the current reductionist search for a molecular basis of disease than other scientists, the physician remains profoundly aware that DNA is contained within the millions of cells in various combinations that constitute the complex entity of the human being. If physician-scientists do have unique contributions to make, how can their recruitment be facilitated? Changing criteria for admission to medical school to favor creative rather than accomplished students may help, as will enrichment of fellowship support and higher academic salaries. Physician-scientists must be increased in number if they are to perpetuate themselves by serving as examples and preceptors to the young. I don't know what the critical number is, but I do know that just as important as the answers to medical problems are the questions that lead to their study. Some of these questions can be asked best from the perspective of the physician. Kilbourne is Distinguished Service Professor at the Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029.

The Physician as Medical Researcher

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