Clinical/research residency programs for the clinician scientist
Eliot A. Phillipson, MD
Clin Invest Med 1997;20(4):260-1.
Dr. Phillipson is Professor and chair of the Department of Medicine, University of Toronto, Toronto, Ont.
About 6 years ago I received a call from the then chair of the Department of Medicine, who was in negotiations with a candidate for director of one of the subspecialty divisions in the department.
"He wants a commitment for the recruitment of 4 clinician scientists to his division," the chair told me.
"Offer him 8 positions," I replied.
"But we can't afford even 4 positions," the chair protested.
"That's okay," I responded, "he won't be able to find even 2, so be generous and offer him 8."
Although my response was, of course, in jest, it contained an element of truth, and speaks to the problem of finding well-trained clinician scientists whom we can recruit to clinical departments in our faculties of medicine. In this regard, it is of note that only 6 applications were submitted from across the country in the 199697 competition for new Phase 1 Clinician Scientist Awards offered by the MRC. An important element in the production of clinician scientists, and one that may now act as a deterrent to potential trainees, is the prolonged, expensive and often disjointed training pathway they must traverse in becoming qualified as clinician scientists.
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Background
Clinical and research training in clinical departments has traditionally followed a series model in which the trainee first completed 5 to 6 years of clinical training in a specialty and subspecialty, followed by a research training program of 3 to 4 years that may or may not have led to a graduate degree. Although this model serves clinical departments well, it has several disadvantages:
- It requires a total of 8 to 10 years for completion, a commitment that many potential clinician scientist trainees are unable to make, given competing demands to make a living and to devote appropriate time to family life.
- It does not meet the needs of MD/PhD students for a postdoctoral experience that is continuous with graduate training and that allows them to remain at the cutting edge in their field of research.
- It means the loss of potential clinician scientist trainees who could have been attracted to research careers early in their postgraduate medical training years had they been exposed to the appropriate opportunity and stimulation but who, after 5 to 6 years of clinical training, are no longer interested in pursuing a research training program (or, indeed, any other type of additional training).
- It removes trainees from their clinical discipline for 3 to 4 years after residency training, during which time their clinical skills may deteriorate considerably and may leave them with compromised clinical credibility.
- It has not mandated the structured and rigorous research training experience that is inherent in a formal graduate program, thus compromising the trainees' eventual competitiveness in capturing research funding when they assume a faculty position.
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Considerations for training programs of the future
If we are to increase the effectiveness of clinician scientist training programs, the following elements must be addressed:
- the rigour of the selection/admission process. Specifically, given the limitations in resources, entry into research training programs during the years of residency must become considerably more rigorous than has generally been the case in the past. This requirement is based on the assumption that it is preferable to invest more resources in a smaller number of high-calibre trainees than to risk squandering resources on a larger number of trainees with lesser chances of success.
- the need for earlier initiation into research training after graduation from medical school. This requirement is based on the notion that residents are more likely to enter a research training program if they are exposed to the excitement of research early in their careers rather than at the end of clinical training.
- better integration of clinical and research training years. Specifically, there is a requirement to develop a clinical and research training curriculum that is driven by educational requirements and that might allow appropriate reductions in the total number of training years. Possible models for such integration are outlined in Table 1 and reflect the proven success of the model followed by the SSP of the University of Toronto.
- the need for a minimum of 3 years of research training in a formal graduate program for trainees who do not already hold a graduate degree. The rationale for this element is to ensure, as much as possible, that the research training will be as rigorous and focused as that of PhD scientists, with whom clinician scientists ultimately compete for research grants.
- the need for guaranteed and adequate salary support for the duration of the clinical and research training. Many medical graduates and clinical residents emerge from their years of study with debts loads that may be prohibitive and that may prevent them from further prolonging the training period. Hence, it is critically important that clinician scientist training programs provide at least sufficient funding to preclude the need for further loans.
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Conclusions
The declining number of MD applicants for research training awards should serve as a wake-up call to the academic medical community to address the factors that may deter potential clinician scientist trainees from entering and successfully completing a research training pathway. It is important that we act collectively and promptly to either implement the proposed solutions or develop even more innovative approaches to the training of future clinician scientists.
