Training models: Introduction
Clin Invest Med 1997;20(4):249-250
The first set of papers describes 2 training models for clinician scientists. To guide the reader, some relevant background information is provided below. It is important to note from the outset that these 2 models should not be viewed as mutually exclusive but, in a sense, complementary. Some medical schools may choose one or the other as the best; however, there are advantages in having both models available to capture the brightest prospective trainees at different "entry levels" in their medical training.
The MD/PhD program
This program is designed for individuals with a 4-year undergraduate degree, with a major in some basic biomedical science, who wish to enter medicine and have already made a decision to pursue a medical career in which research is a major, if not primary, activity. The typical MD/PhD student applicant has an outstanding academic record as measured by grade point average and has extensive research experience, usually including publication of his or her research. Some students enter the program after having obtained a Master's degree.
MD/PhD programs have been existence in the United States for some 30 years; they are funded by the National Institutes of Health (NIH) through the Medical Scientist Training Program (MSTP).
Dr. Bert Shapiro, current director of the NIH MSTP, was invited to present the experience with the program. His paper provides an overview of the program and also touches on preliminary follow-up data on graduates of the US MD/PhD programs and their success as future clinician scientists. A much more comprehensive follow-up study of MSTP graduates is now under way; this study will involve detailed telephone interviews and accumulation of data from all MSTP graduates including their current position, percentage of time devoted to research, research funding, publications, etc. The intent is to compare their career development and success as clinician scientists with a control group (i.e., non-MSTP graduates).
In Canada, interest in MD/PhD programs has been increasing. A summary of the current status of the MD/PhD training programs on the Canadian scene is included, based on a survey conducted by Sandy McGugan, Administrative Coordinator of the University of Toronto MD/PhD Program.
It is important to place the MD/PhD program in context as a preparation for the clinician scientist career track. Graduates of MD/PhD programs have achieved a strong foundation but require continued opportunities to pursue research and develop clinical specialty/subspecialty skills during postgraduate clinical training. In the US system, graduates of MD/PhD programs are eligible for clinical/research residency programs specifically targeted to them. These clinical/research residencies are designed so that, upon completion, the candidate becomes "board eligible" in his or her chosen specialty/subspecialty and has also completed a minimum 2-year postdoctoral research experience. In the Canadian system, such formal clinical/residency programs have not yet been developed, but there are indications that certain departments in some medical schools are making special efforts to accommodate the needs of MD/PhD graduates under the umbrella of the newly introduced Royal College Clinician Investigator Program (CIP).
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Surgical scientist programs
The traditional training model for clinician scientists consists of a variable period of research "apprenticeship," usually 2 to 3 years as a research fellow after completion of all of the clinical requirements for specialty and subspecialty training. In 1984, a somewhat different version of this traditional model -- the so-called Surgical Scientist Program -- was introduced at the University of Toronto by Dr. Bernard Langer, then chair of the Department of Surgery. What was new about this program was that, for the first time, research training for MDs was embedded in the postgraduate clinical training period, and the research training was more formal, with the requirement that the candidates undertake a rigorous training program and commit to at least a Master's degree. The Surgical Scientist Program thus achieved an integration of research and clinical training in the postgraduate phase (i.e., post-MD phase) analogous to the integration of undergraduate MD and PhD programs in MD/PhD programs.
The academic and administrative infrastructure for the Surgical Scientist Program at the University of Toronto was made possible through a partnership between the Department of Surgery and the Institute of Medical Science (IMS). To appreciate the context of the training program, it is necessary to describe the IMS at the University of Toronto.
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Institute of Medical Science
The IMS, an institute within the School of Graduate Studies, serves as a graduate unit for all clinical departments in the Faculty of Medicine, with the exception of the Department of Laboratory Medicine and Pathobiology. It was established to foster graduate education and scholarship in the clinical departments. Implicit from the outset was the understanding that the IMS had a special role to play in training clinician scientists. Embedding the Surgical Scientist Program in the context of IMS graduate programs has been mutually beneficial: the surgical scientists have benefited from the culture and rigour of the graduate studies milieu provided by the IMS, and the IMS has benefited from the presence of a large and increasing group of highly motivated, bright and dedicated surgical trainees who are interested in acquiring research training for a future career in academic surgery as clinician scientists.
Many fields in the IMS (such as cardiovascular sciences, membrane biology and signalling) are well established and have a clearly defined infrastructure and history of graduate education. Other programs (such as psychopharmacology/schizophrenia) are in an earlier developmental stage. These developing programs generally reflect new fields of scientific inquiry that are being actively encouraged by the Faculty of Medicine and affiliated teaching hospitals and that offer unique opportunities for multidisciplinary graduate education.
The IMS faculty is heterogeneous, drawing its members from the full breadth of medical sciences. What distinguishes its faculty from that of other graduate programs are (1) the strong emphasis on multidisciplinary collaboration and (2) the direct link between research and investigation of disease mechanisms. As a result, there is a unique culture and theme within the IMS, which reflects a "bench-to-bedside" paradigm. In every field, whether the approach involves molecular methodology, integrative biology or health outcome studies, there is invariably a strong link to disease mechanisms. This is perhaps the strongest distinguishing characteristic of IMS graduate programs compared with other graduate units.
The IMS has experienced tremendous growth over the last 7 years, with a 230% increase in the number of students and a corresponding 260% increase in faculty complement. Of the students, approximately 45% are in the PhD program and 55% in the Master's of Science program. The ratio of MD to non-MD students has remained relatively constant at 2 MD students to 3 non-MD students.
The IMS students can be divided into 3 training streams: molecular/cellular (42% of the student body), integrative biology (35%) and clinical investigation (23%). The number of MDs and non-MDs is equal in the molecular/cellular and integrative biology streams, whereas the ratio of MDs to non-MDs in the clinical investigation stream is approximately 1 to 5.
In a preliminary follow-up of IMS graduates since 1989, of MD graduates, 38% are still in training, 4% are in industry or self-employed, 15% are in clinical practice and 43% are in academia. Of non-MD graduates, 45% are still in training, 25% are in industry or self-employed, 10% are in practice and 20% are in academia.
This introductory and background material should allow a better appreciation of the next few papers, which describe in detail the various training models available to clinician scientists. These models are described in the chronological order of student entry, i.e., first the MD/PhD (undergraduate) model, followed by the surgical scientist (postgraduate clinical) training models.
