Survival of clinician scientists
Claude C. Roy, MD
Clin Invest Med 1997;20(4):283-8.
Dr. Roy is the Interim Director of Programs Branch, Medical Research Council of Canada, and Professor Emeritus, Department of Pediatrics, Université de Montréal, GastroenterologyNutrition Service, Hôpital Ste-Justine, Montreal, Que.
Contents
Le problème de notre temps est que l'avenir n'est plus ce qu'il était. -- Paul Valéry
Introduction
Introduction
These words are not from Yogi Berra, the celebrated contemporary sage, but from the 19th century romantic poet who enlightened the tumultuous adolescent years of my generation. Society is in a state of change that some claim is as dramatic as the Industrial Revolution.1 In the twilight of this century, our cherished health care system has undergone profound changes, dictated by fiscal pressures to downsize and by patients' demands for access to new technologies.
Academic medicine, the cornerstone of the health care system, is particularly threatened by these changes.2 The decline in federal transfer payments, large decreases in provincial budgets for universities and their teaching hospitals and a substantial reduction in the core budget of the MRC are imperilling the scientific performance of Canada, jeopardizing the future of an emerging generation of talented investigators and driving away from a research career as clinician investigators young physicians needed for the changing of the guard.
A chorus of alarm has been raised in the US about the depleted ranks of physicians in academic medicine and their diminishing role in biomedical and health sciences research.35 This paper identifies factors that have contributed to a similar situation in Canada and proposes solutions.
Difficult times for biomedical and health sciences research
Federal and provincial governments have recently moved directly and strongly to control the growth of health care expenditures. Reductions in federal transfer payments, compounded by large provincial cuts, have led to dramatic reductions in university and teaching-hospital budgets, a concomitant drop in academic jobs,2 as well as widespread erosion of research infrastructure.6 In this restructuring, the public and decision-makers alike recognize mainly the teaching function of universities and fail to understand the crucial synergy between teaching and research as well as the pivotal role of university-based basic research in the national research enterprise.6
It is well known that Canada's expenditures on research and development (R&D) as a percentage of gross domestic product are less than those of all our major competitors except Italy. The 14% reduction in the budget of the granting councils (MRC, the National Science and Engineering Research Council and the Social Science and Humanities Research Council), which amounts to 25% in constant 1990 dollars, has been particularly devastating in view of the fact that university-based research absorbs close to 25% of Canadian R&D dollars, a proportion higher than that in most countries of the Organization for Economic Cooperation and Development.7
As biomedical and health sciences research accounts for 50% to 65% of university-based research, the 10% reduction made in MRC's base budgets for 1995, 1996 and 1997, to be followed by a further 3% reduction next year, is putting enormous pressures on MRC's grants and awards program at a time when competing nations are continuing to increase their research budgets (Fig. 1). Although it is true that total biomedical and health research investments have doubled in the past decade, MRC, traditionally the principal source of funding for university-based research, is no longer the single major contributor. Fig. 2 shows that the MRC's share of funding has dropped from 21% to 14% between 1986 and 1996, while that of the industry, which funds discovery-driven research and development, has moved to first place.
Canada's performance in biomedical and health sciences research is critical for the future of our country. Yet hundreds of productive investigators are either underfunded or are forced to close their laboratories. As a result of a shrinking academic marketplace, few university positions are available, and there is poor support of young faculty, postdoctoral and graduate students. These factors have created a climate of gloom and of great insecurity for the university research community. As financial resources are disproportionately small compared with the wealth of ideas and the means of carrying them out, frustration and a crisis in scientific morale are destroying our ability to attract the "best and the brightest" to a research career.
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The manpower problem
Over the past 5 years, federal and provincial governments have instituted strict manpower policies as another means of controlling the growth of health care expenditures.
Admissions to medical schools: Since 1988, admissions to medical schools in Canada have decreased by 15%; in Quebec, the decrease is greater, at 17%. The consequences are already being felt in the form of a decreased pool of talent. Furthermore, medicine may no longer attract the most talented. Finally, the budgetary impact of reduced admissions leads to fewer academic jobs at a time when labour-intensive, problem-based curricula require more teachers. The end result of reduced admissions to medical schools will be a decrease in the output and quality of research.
Access to residency positions: Although reductions in the total number of graduate training positions have been relatively modest, the large shift from specialty training to family medicine constitutes a major problem for the recruitment of clinician scientists. As pointed out recently, governments do not base their manpower policies on the needs of teaching and research.2 Certain specialties have been particularly affected by limited entry. As an example, in Quebec the number of PGY1 slots in pediatrics has decreased by 50% in the last 10 years.
Strict limits on international medical graduates (IMGs): A decade ago, 25% to 30% of academic physicians in Canadian medical schools had graduated outside of the country. Canada was able to attract the cream of IMGs to its training programs and highly qualified IMGs to all levels of its academic ranks. A sizable proportion of our world-class clinician scientists were IMGs who either came to Canada for their training and stayed on or were recruited as promising young investigators or as seasoned researchers to play key roles in the scientific community. Canada has cut itself off from the international marketplace of talented and dedicated physician scientists. Some years ago, the very successful Quebec program providing access to IMGs from French-speaking countries and, more specifically, from France under les Ententes France-Quebéc, has been discontinued. Furthermore, the assembly of Quebec rectors (CREPUQ) is no longer authorized to select a limited number of IMGs for academic positions. Until 2 years ago, these physicians were given practice privileges by le Collège des médecins du Québec and authorized to bill for clinical services.
Interprovincial movement of physicians: At a time when a critical mass of investigators with different backgrounds and approaches is promoted as an essential ingredient for progress and application of knowledge in the biomedical and health sciences, it seems incongruous that provincial governments would limit the interprovincial movement of physicians. Canadian academic medicine is seriously disadvantaged by these ill-conceived, isolationist policies.
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Disaffection of MDs for research careers
Ahrens and many of the academic luminaries have noted that the percentage of physicians holding National Institutes of Health grants is decreasing dramatically. The Canadian data show that the proportion of physicians holding MRC operating grants has decreased by close to 33% between 1986 and 1996 (Fig. 3).
Awareness of the problems inherent in the use of the same peer-review committees for health professionals (MDs, PhDs, DVMs), as for PhDs, and of the need to attract the former to a research career, led the MRC to create separate peer-review committees and several research training and salary support programs especially designed for health professionals.
Progressive disaffection of MDs for the Fellowship (research training awards) and Clinician Scientist (3 to 6 years of salary support for training and for the initial 3 years on faculty) programs has been noted for both (Fig. 4, Fig. 5, and Fig. 6). There was a decrease of 58% and 73% in the number of applications for Fellowships and Clinician Scientists Awards, respectively, between 1989 and 1996. The drop in applications from health professionals started in 199293 for Fellowships and in 199091 for Clinician Scientists. These data illustrate the fact that Canada will be facing an increasing shortage of clinician scientists. Further evidence of this disaffection is provided by data on Scholarship (5-year salary awards to new faculty within 24 months of their first appointment) applications, which have decreased by 70% between 1989 and 1996 (Fig. 6).
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Drop in the funding rate of MRC operating grants proposals
Over the past 10 years there has been a progressive drop in the rate of funding by the MRC. This decrease began years before the budget cuts of the past 3 years. Fig. 7 demonstrates that it occurred despite the fact that, in constant dollars, up to 199293 there was a modest increase in the core budget of the MRC. The drop has been more marked since 199495, but it would have been much more precipitous if the MRC had not elected to impose budget cuts of 15% to 20% to fund a larger number of investigators.
It has been particularly sobering to look at the decreasing approval rate of applications from young faculty taking up their first appointment. Since 1994, the rate of funding for MDs and MD/PhDs has run at around 20%, while that for PhDs has varied between 25% and 30%.
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Proposal for action
It has become increasingly clear that clinician scientists constitute an "endangered species."3 Well-trained physician scientists are uniquely qualified to investigate the pathogenesis of disease8 using a full spectrum of approaches from the most basic to patient- and population-oriented research. Without clinical investigators "the relevant scientific questions that feed back into the biomedical system will not be asked."9 The present drought of clinician scientists at a time when there is a decreasing lag between precept and practice10 undermines the translation of insights gained from basic research into new and improved therapies that improve patient care, as well as into effective preventive strategies for the public.
A rigorous plan of action must be urgently developed to recreate the model of the clinician scientist and regenerate its pool. Some of the strategies proposed below have already been implemented; others are the result of personal reflections from someone who is now at the adjudication and distribution end of research funds after a professional lifetime of deriving them from many sources.
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Training programs
Crucial to the national future of clinical research is the vigorous development of highly skilled clinician scientists who, as stated by Dr. Langer, are equally at ease at the bench and at the bedside.11
Medical school and residency: Insufficient exposure of medical students and residents to research must be remedied. There is good evidence that residency training programs, in which research is a requirement, produce graduates who are subsequently more productive.12 Furthermore, the publication of papers during the residency years clearly constitutes the best predictor of a successful academic career.13
The current shortage of residents and their decreased exposure to clinician scientists will further aggravate the problem. The shrinking academic ranks impose greater demands on clinician scientists, who need to spend more time than ever in research if they are to remain competitive. As research fosters a scientific problem-solving culture, the Royal College and provincial accreditation bodies should make exposure to research a requirement of all training programs. The recent creation of the Clinical Investigator Program is a step in the right direction.
Research training: Although programs need to be tailored to each mission area, they should be lengthy, in-depth and of high quality. Although there is little evidence that MD/PhDs fare better in MRC competitions than applicants without a PhD, the consensus is that course credits should be acquired to satisfy at least the requirements for a Master's degree.
Universities should make an effort to accredit research teams for the training of clinician scientists. These teams should have a critical mass of productive investigators at the forefront of their field using emerging technologies and approaches. It is also critical to identify within these teams highly competent and accessible mentors likely to become role models, who will inspire and guide research trainees.
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Early career development
Team-based recruitment is a sine qua non, since the chances for survival of solo investigators are increasingly slim. Nurturing junior faculty is problematic in view of present university budgetary constraints. The recent creation of the Canada Foundation for Innovation (CFI) holds much promise for rebuilding university infrastructure by providing investigators with appropriate equipment and facilities. However, the first and last scientific instrument, the one that must be used in every experiment, is the clinical scientist's brain. Therefore, protected time for young investigators is imperative. Salary support should be commensurate with the earnings of colleagues in a department with a practice plan culture. Mentoring is also a critical component of nurturing.
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Research funding
Increasing funding opportunities through the creation by the MRC of several partnerships and through other initiatives by not-for-profit foundations and the private sector have been exploited mainly by well-established investigators with a track record.
Launching a research career is a major challenge and is perceived as an unsurmountable obstacle by medical students, residents, fellows and young faculty. The MRC has responded to this by ensuring that, within the new grant category, first applications filed shortly after taking up an initial appointment have a set approval rate of 25%.
The last 2 federal budget speeches sent a clear message to the scientific community that the federal government is convinced that public funding for research is essential for the health and economic growth of the country. The message which some may interpret as still subliminal is that the government will shortly restore the budget of the 3 granting councils.
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Advocacy
Biomedical and health research scientists are increasingly accountable to society and have more fully assumed a role of advocacy for increased public funding. Both the Association of Universities and Colleges of Canada and the Coalition for Biomedical and Health Research have played a key role leading to the creation of CFI. All investigators should take on the responsibility for fund-raising at their own institutions. Nothing impresses potential donors and our political masters more than an investigator who takes them through his or her laboratory and explains the implications of his or her work for human health and economic growth.14
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Conclusions
Canadian academic medicine, an undisputed treasure, finds itself defending its very existence. It is a sign of the times that the National Forum on Health does not mention academic medical centres once in its voluminous report. Furthermore, research is only mentioned in the context of the investigation of the nonmedical determinants of health.
Nevertheless, the general political climate is favourable. There is hope that help is on the way for the core budget of the MRC, which needs to be rapidly restored. The performance of Canadian science has not yet been affected by the lean years. However, the current disaffection of young Canadians for careers as clinician scientists will have large-scale consequences in a decade or so, even if we are successful in regenerating the pool of clinician scientists by recreating the model, by recruiting the best and the brightest and by surrounding them with a nurturing environment.
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References
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- Lessin MS, Klein MD. Does research during general surgery residency correlate with academic pursuits after pediatric surgery residency? J Pediatr Surg 1995;30:1310-3.
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