The Problems Of Physician-Scientists

Are the difficulties of doing both clinical and basic research hampering the progress of medical science? Sir David Weatherall is a worried man. When the Muffield professor of Medicine at Oxford University gazes out at the unsolved problems of medical science, he sees deadly diseases like cancer and circulatory problems still killing people by the millions around the world. And he fears that the diseases may remain scourges because of a failing of the scientific community. "The reason that we know so little about the pathophysiology of the common killers in the Western world may be that we are short of physician-scientists," says Weatherall. The Oxford don is not alone in his worries. In Britain especially there is anxiety about shortages of scientists who can do both basic and clinical research. The fears have prompted a number of new programs designed to train students in both areas. But even as a new generation of researchers with M.D.'s and Ph.D.'s begins to emerge, many scientists are wondering if it really is still possible to straddle the two worlds. As Norman Kreitman, a psychiatrist and director of a research unit in Edinburgh, says: "It's becoming more and more difficult to be both a clinician and a scientist because both jobs are becoming ever more specialized and complex." The shortage of physician-scientists is difficult to measure. But all of the researchers contacted by The Scientist agreed that it has the potential for slowing the pace of biomedical research. Steve Reeders, a scientist and physician working at Yale University, for example, explains that physician-scientists are vitally needed as "a bridge": "Excellent basic scientists don't necessarily know which are the important questions in biomedical research," he says. "A constant dialogue is needed between the ward and the lab. It's not enough just to have meetings between clinicians and scientists. You need somebody who understands both disciplines and talks both languages." Weatherall adds that "it's also a matter of emotional commitment. Those who spend time with patients are committed to answering clinically important questions." And Carol Seymour, a senior lecturer in the department of medicine in Cambridge and a hepatologist who runs a basic science laboratory, argues that physician-scientists are vital for training medical undergraduates and for keeping the whole profession in contact with science. Certainly, as scientists like Weatherall and Reeders point out, many biomedical advances - for instance, in molecular genetics - have resulted from the work of physician-scientists. The central figure in the discovery of the molecular basis for the hemoglobin disorders, in which Weatherall played an important part, was Herman Lehmann, a physician-scientist. The research led to an understanding of the molecular pathology of single gene disorders and prenatal diagnosis. Another recent example is the Nobel Prize-winning work of Joseph Goldstein and Michael Brown at the University of Texas Health Science Center. Their discovery of the receptor for low-density lipoprotein (one of the "packages" in which cholesterol is carried throughout the body) required a high degree of clinical acumen. Without the perspective of the physician, says Weatherall, Goldstein and Brown would not have known to begin their studies on very rare patients with homozygous hypercholerterolaemia (a condition causing sufferers to have high cholesterol concentrations in their blood and, as a result, heart attacks when very young). "Their work required both clinical insights and superb basic science," says Weatherall. Similarly, says Weatherall, the elucidation of the cause of one form of muscular dystrophy by Louis Kunkel of Boston's Children's Hospital "would never have been done in a basic molecular biology department. It had to be done by somebody with enough knowledge of the clinical aspects of the disease." But are there enough "somebodies" like Kunkel, Goldstein, and Brown to uncover the underlying mechanisms of other diseases? Scientists in the British government are doubtful. So this year, the Medical Research Council, the government-funded body that supports biomedical research in Britain, is introducing clinical fellowships that will pay for medical school graduates to spend three years in a basic science unit and four in a clinical unit. About 50 applicants are expected for the five to 10 fellowships that will be awarded each year, beginning in 1989. At the same time, the medical school at Cambridge University is trying to introduce an M.D.-Ph.D. program. In these programs, which have existed in the United States since 1964, students train simultaneously in medicine and science. Not everyone at Cambridge supports the idea; the board of graduate studies, for example, is worried that students may be put under too much pressure. But Cambridge Medical School still hopes to take its first students in October 1989. For a successful model, Cambridge University has only to look across the Atlantic. While some academics in the U.S. doubted the value of M.D.-Ph.D. programs when they first began, says Lee Van Lenten, the National Institutes of Health's director of support for the programs, "nobody doubts their value now." Indeed, the programs are now highly prestigious. Medical schools compete intensely for funds to support the programs, for the most able applicants, and to hire the graduates. Tom Caskey, director of the Institute for Molecular Genetics, Baylor College of Medicine, Houston, for example, takes only M.D.-Ph.D.'s into his laboratory. "They are," he says, "simply the best." NIH now supports 726 M.D.-Ph.D. students at 29 different schools. Getting into the programs is difficult; about 50 students apply for each place, says Van Lenten. Evaluation of the programs has shown that about four-fifths of the newly minted M.D.-Ph.D.'s make their careers in academic posts, that as a group they win more than their share of prizes, and that their grant applications to NIH have a higher than average success rate. Still, Van Lenten and other scientists recognize that M.D.-Ph.D. programs are not the perfect solution to the shortage of physician-scientists. They point out that a number of students who might have simply gotten their science doctorates go for joint programs because of the added prestige - and the higher earning power. Some of the dual-degree graduates "have no intention of practicing as physicians," says Yale's Reeders. But for those who intend to straddle both worlds, the biggest hurdle is the sheer difficulty of becoming - and staying - both scientifically and clinically competent. All of the physician-scientists interviewed by The Scientist agreed that their professional lives would have been much easier if they had chosen one of the two paths. Indeed, the first response of some was that being a physician-scientist is "impossible." So what are the difficulties they face? Baylor's Tom Caskey finds the physician-scientist route to be easier than many of his colleagues do. Part of the reason is that he, unlike his British counterparts, does not have to cope with a collapsing health service. He spends 10 months of each year on basic research and is one of the central players in the human genome project. For the other two months, he spends three to four hours a day working in clinical genetics, which is, he says, enough to remain competent. He concedes, however, that this division of time wouldn't work for specialties that demand manual skills or the care of desperately sick patients. "Those who work in `hem-onc' (hematological oncology) have a hard time with their research because they're always having to cope with patients whose platelets have dropped to nothing," he says. And it is probably because surgical competence depends on regular hands-on experience that so few M.D.-Ph.D.'s specialize in surgery. The same problems have affected those in cardiology, prompting the National Heart, Lung, and Blood Institute to make a special effort, in part by funding more M.D.-Ph.D. programs, to increase the physician-scientists in this particular specialty. The life of hepatologist Carol Seymour of Cambridge University is typical for a physician-scientist. She spends six months of the year on the wards at Addenbrooke's Hospital in Cambridge covering all medical conditions. During that time, her research - on liver disease - is restricted to evenings and weekends. For the other six months, she works three and a half days a week in her lab and consults only in her specialty. If her research enters a particularly rich phase, she takes leave to devote all her time to research. She says that it is necessary to spend at least a third of her time doing science "to remain at all viable." David Weatherall probably has even more on his plate than does Seymour. Not only does he run a laboratory and see patients, he also helps with the administration of the medical school at Oxford and serves on the Regional Health Authority. Nationally, he also serves as president of the British Society for Haematology and as chairman of the Medical and Scientific Advisory Panel of the Leukemia Research Fund. In fact, Weatherall hasn't been able to always work as both physician and scientist; he attributes much of his scientific success to five years he spent at Johns Hopkins doing research almost entirely. "After such a long time away from patients," he says, "it was hard to return to clinical work." To stay on top of both the clinical and scientific worlds, says Reeders only half-jokingly, "it is necessary to spend about 60% to 70% of the time doing science and a similar proportion as a clinician." Something clearly has to give, especially when most academics must teach and administer as well. And so, scientists say, biomedical research is in the grips of a catch-22. A shortage of physician-scientists is hampering progress, and yet the shortage is being fueled by the increasing difficulty of being a successful clinician and basic researcher. The answer, says Peter Barnas, another of Britain's physician-scientists, is for the biomedical community to recognize that this is an important problem - and to launch a special effort to foster and promote those who choose to follow the difficult and lonely path of a physician-scientist. Richard Smith, a physician, is assistant editor of the British Medical Journal.

The Problems Of Physician-Scientists

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