A Breed Apart: The M.D./Ph.D.

As the United States health-care system braces for upheaval, young Americans continue to apply to medical school in droves. But academic administrators and others say that the parameters students assess in making their career choices-- to become practicing physicians, laboratory researchers, or both--will be among the changes wrought by reform. Biomedical career decisions have never been easy. It's typical for a bright young student assessing the options to go through a period of self-examination, according to doctors and scientists interviewed for this article. Such introspection generally focuses on questions like: "Do I need to care for sick people in order to be professionally fulfilled, or would I be happier doing basic research, which ultimately could benefit millions of people?" "Will I be able to repay my medical school debts if I focus on patient- oriented research rather than a private practice?" "Do I really have the commitment to stick with an M.D./Ph.D. program? pp.7 A young person with a high commitment to research on human disease is likely to find great rewards in undergoing the grueling amount of training involved in a combined M.D./Ph.D. program, research administrators say. M.D./Ph.D.'s are "by far the most successful group at getting grants funded," according to Salvatore Pizzo, head of the M.D./Ph.D. program at Duke University Medical Center. "They can write good grants because they know a lot about human disease; they have a unique focus because they've been through both kinds of training." An unpublished 1985 study by the National Institutes of Health found that the chance of an M.D./Ph.D.'s being funded was approximately 1 in 2, as opposed to about 1 in 3 overall, says Lee Van Lenten, administrator of NIH's Medical Scientist Training Program (MSTP), which supports M.D./Ph.D. training. However, he notes, these are old data, and current success rates are much lower than the 1985 figures. Getting the two degrees requires a minimum of six years of graduate education--and perhaps as long as eight or nine. This is followed in many cases by a residency. Students opting for this course of study "are making a decision in their early 20s for a commitment of 12 years," says Pizzo. "This is a driven bunch of students." NIH's MSTP program makes the road a bit easier for M.D./Ph.D. candidates by providing individual students with an allowance for tuition and fees plus a stipend for up to six years; funds for the remaining years come from the schools. As of July 1, NIH was funding 837 full-time training positions at a total of 33 schools. Additional students are funded by money supplied by their institution. But the so-called institutional slots are "coming under increased pressure," says Institute of Medicine president Kenneth Shine, noting that such funds are drawn from a pool that must also support research and education, faculty recruitment, equipment purchases, and, increasingly, administrative costs. What happens to M.D./Ph.D.'s once they finally finish their training? A study conducted by researchers at Washington University School of Medicine in St. Louis (C. Frieden, B.J. Fox, Academic Medicine, 66:162-4, 1991) found that 95 percent of 148 MSTP graduates had gone into residencies rather than postdoctoral fellowships. Of the 72 who had completed residencies or postdocs by 1990, 89 percent took positions in academia or at NIH. Those in academic institutions were primarily in clinical departments; most said they were devoting much of their time to basic research. A similar study by researchers at Johns Hopkins University School of Medicine (D.A. McClellan, P. Talalay, Acad. Med., 67:36-41, 1992) found that of 42 Hopkins M.D./Ph.D. graduates, 81 percent were in full-time academic posts, 14 percent worked in research institutes, and 5 percent took positions in biotechnology firms. All 42 graduates were actively involved in research, and 67 percent had clinical responsibilities. Pizzo can see changes on the horizon. "A potentially larger number of graduates will be pursuing careers with biotech companies," the Duke administrator forecasts. "Have we seen a lot of that yet? A little bit. Right now that's a shaky proposition, because companies are not doing ragingly well in the stock market, but it's a trend to watch." Another potential change, Pizzo says, is for "students [to] go into a translational research career [rather] than pure research," using their knowledge of molecular immunology and molecular biology to make diagnoses or provide treatment, such as in gene therapy. Third, while today "medicine and pathology are the classic disciplines [M.D./Ph.D. graduates] go into, I wonder if it will stay that way. As students start trying to find more niches that are going to be supportable, [they may] look at more disciplines." --B.S. Over the next few years, with terms like "managed competition" becoming part of the national vocabulary and federal research funding still unable to keep up with the proliferation of investigators, the questions will become even more complicated. While for more than a decade researchers have been worrying about obtaining support for their projects, now phyisicians, too, are asking themselves, "Will my skills continue to be in demand?" "Our industry is facing a major overhaul," says John Noble, director of the Center for Primary Care at Boston University School of Medicine. "I don't think anyone can anticipate the extent to which things are going to be reorganized." For the moment, however, students' decisions do not appear to be radically altered by the prospect of reform. Young people "know something is going to happen," says William Jacott, assistant vice president for health sciences at the University of Minnesota, Minneapolis, and a member of the American Medical Association's board of trustees. "But their pipeline could be anywhere from eight to 12 years. It's hard for them to visualize what things are going to be like 12 years hence." Although radical changes in the practice of medicine may well be in the offing, evidently they are not deterring students from applying to medical school: According to the Washington, D.C.-based Association of American Medical Colleges (AAMC), medical school applications reached a record high in 1993-94 (see accompanying table). "The people who are very unhappy [about pending changes] are people already in practice, who are looking at a significant decrease in their income," says Kenneth Shine, president of the Institute of Medicine (IOM). "If you're a young person who's never lived that lifestyle, the [post-reform] salaries look pretty good." An aspect of the proposed reforms that many medical students are welcoming, Shine says, is the promised reduction in paperwork and bureaucracy attendant in the current insurance system. "I think it' possible that health-care reform could increase career opportunities in research," suggests Roy Silverstein, president of the American Federation for Clinical Research (AFCR) and chief of the division of hematology and medical oncology at Cornell University Medical College in New York City. If a plan were enacted that included a provision for increased research funding, Silverstein says, the effect might be "narrowing the difference in incomes between the research and clinical community--sort of leveling the playing field. But [reform] could be a disaster, too." Practical considerations have an influence on career decisions, especially for minority students, according to Benjamin Carson, director of pediatric neurosurgery at Johns Hopkins Medical Institutions, who has been a mentor to many of these students. "Academic medicine traditionally is not something minorities have gone into, particularly for financial reasons," he says. Students from lower-income backgrounds, he explains, generally have to take out more medical school loans than their more well-to-do counterparts, and "by the time [they are] ready to practice, the major consideration is, `How am I going to pay all this stuff back?' Most of them really don't have a choice; they have to go into private practice." But opening a private practice is rarely a viable option these days. Shine notes that in 1988, more than half the medical school graduates took salaried positions in health maintenance organizations and other such arrangements. "Solo private practice opportunities are drying up," he says. Even the once-vaunted option of medical specialization is no longer considered the key to job security. A recent study in the Journal of the American Medical Association (J.P. Weiner, 272:222-30, 1994) forecasted that by the year 2000-- even if there were to be no reform at all--the U.S. will have an overall surplus of about 165,000 patient-care physicians, and that "virtually all of this surplus will consist of specialists." "Medical schools are trying to reorganize their curriculum to restore a balance between generalist and specialist [training]," says BU's Noble, whose institution has received a grant from the Princeton, N.J.-based Robert Wood Johnson Foundation to establish a generalist physician training program. This restructuring makes a research career--the struggle for funding notwithstanding--seem stable by comparison. "I'm really happy to be where I am right now [when compared with] my colleagues in private practice or tertiary care," says James Wilson, an M.D./Ph.D. researcher who is director of the Institute of Human Gene Therapy at the University of Pennsylvania. "In a day, their boss changes or the hospital ownership changes." As a case in point, he cites two Boston-based hospitals affiliated with Harvard University, long considered a "bastion of stability." In March, Massachusetts General Hospital combined with Brigham and Women's Hospital to form a new entity called Partners HealthCare System Inc. According to officials at the system, an operating plan for the united institutions is now under development, with repercussions for the staff yet to be announced. Such sweeping changes in the practice of medicine are among a number of trends identified by medical school administrators and others as likely to drive biomedical careers in the future. MEDICAL SCHOOL APPLICANTS[Source:Association of American Medical Colleges] CLASS YEARAPPLICANTSACCEPTED APPLICANTS 1987-8826,12317,027 1988-8926,72117,108 1989-9026,91516,975 1990-9129,24317,206 1991-9233,30117,436 1992-9337,41017,464 1993-9442,80817,362 M.D.'s who do patient-oriented research are concerned about a potential shortage of physician investigators in the near future. "There is an increasing differentiation of faculty into those who do research and those who take care of patients; fewer and fewer people do both," says IOM's Shine. "The community is very worried, and I think they've got every reason to worry." A primary reason that clinical research has lost its luster is the difficulty of obtaining funds for such studies, some say. E.H. Ahrens, Jr., a professor, emeritus, of biochemistry and medicine at Rockefeller University, found that only 7.4 percent of National Institutes of Health R01 (investigator-initiated) awards in 1987 were devoted to patient-oriented research (Perspectives in Biology and Medicine, 36:194-209, 1993). He attributes this paltry figure in part to the decline in the number of M.D.'s serving on NIH study sections. "There is a concern in the research community that there is something inherently unfair about the way research on human beings is reviewed," says AFCR's Silverstein. He knows of several qualified M.D.'s who have never been asked to serve on study sections. And many physicians who are asked must decline the invitation because they are overloaded with responsibilities in the clinical ward or operating room, he adds. "The physician community has to do their share" of grant reviewing, Silverstein acknowledges. By the same token, the task could be made less of a burden if the reviewing process were altered to accommodate doctors' schedules, he proposes. NIH deputy director Ruth Kirschstein says the agency's Division of Research Grants has convened an advisory committee to examine peer review of clinical research projects. She adds that NIH is attempting to encourage more physician research through various fellowship training programs as well as its Medical Scientist Training Program (MSTP), which supports M.D./Ph.D. students (see story on page 7). "We're scratching our heads and trying to think of new possibilities," she says. But the MSTP is not necessarily the solution to this problem. In his book The Crisis in Clinical Research: Overcoming Institutional Obstacles (New York, Oxford University Press, 1992), Ahrens reports on a 1990 literature search of publications of 82 MSTP graduates in three research-intensive medical schools. He found that "of the 82 double-degree graduates, only 11 were engaged mainly in some type of clinical research," and only two were directly studying whole human beings. "There will always be new diseases--AIDS is a case in point," Ahrens notes. "If we don't have physician-scientists capable of addressing them, then we will be impoverished." Shine says that, with increased pressure on institutions to subsidize indirect costs, a smaller percentage of their patient-care income is available to finance faculty research (as well as other institutional expenses, such as education). Consequently, medical scientists are trying to take as much of their salaries as possible from NIH grants; those who cannot are finding it necessary to see more patients, devoting less time to research. In five years, Shine predicts, "only the very, very best scientists will be getting most of their salaries from grants. "From my perspective, unless the federal government and, in some cases, states are willing to take up [a greater amount of] the shortfall, there will be a significant decrease in the number of opportunities for research careers and the amount of research." Uncertainties about pricing regulations under health-care reform are causing clinical research funds from another source--the biotechnology and pharmaceutical industries--to dry up, according to Silverstein. "They seem to be scaling back somewhat," he says. "The unknown is always a threat, particularly in the business world." A recent National Research Council (NRC) report entitled The Funding of Young Investigators in the Biological and Biomedical Sciences found that applications for R01 grants from investigators age 36 and under dropped from 3,040 in 1985 to 1,389 in 1993, a 54 percent decrease. Shine speculates that the decline could be attributable to several phenomena: Young researchers may have to take multiple postdoctoral appointments before they are able to get their own labs and apply for grants; they may be forsaking academic research for the biotechnology industry; or they may be discouraged from applying for grants in today's tightly constrained funding environment. (NRC is planning a follow-up study to determine the causes.) "The investigator cadre is aging," says John Diggs, AAMC's vice president for biomedical research. "The more senior investigators are going to drop out of the system in five to seven years." Diggs cites a need for the biomedical community to "[do] something to assure that we have a science intellectual base that is going to carry us into the next century." Although trends cited by health-care policy-watchers and scientific administrators indicate that biomedical science is no longer a source of unlimited job opportunities, top- notch researchers should have no trouble finding work, according to Edward O'Neil, an associate professor of family and community medicine at the University of California, San Francisco, School of Medicine and executive director of the Pew Scholars Program in the Biomedical Sciences. "There's still an enormous amount of opportunity out there, but the probability of success may not be as high as in the past," he says. As an example, O'Neil describes the career outlook for a young person he knows. "There's a rising fourth-year medical student at Stanford [University] who wants to become a transplant surgeon," he says. "On one hand, I can show her numbers that say there's an oversupply of transplant surgeons. But I can also show her numbers that say she's precisely the kind of person that transplant surgery is going to need in the future [because of her] skills and accomplishment in molecular medicine. I don't think her future could be any brighter."

A Breed Apart: The M.D./Ph.D.

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