AAMC Reporter: September 2008

Averting a Gathering Storm: Research Education Back Stage in Medical Schools

E. Albert Reece, M.D., Ph.D., M.B.A., Vice President for Medical Affairs, University of Maryland John Z. and Akiko K. Bowers Distinguished Professor and Dean, University of Maryland School of Medicine

We have witnessed in recent years historic advances in biomedical research, including the complete sequencing of the human genome and almost daily breakthroughs in understanding the basic biology of stem cells. Advances in biomedical engineering, molecular biology, and immunology also are coming at a record pace.

Meeting the challenge of "translating" such basic science insights into effective therapies for patients, however, is not as easy as it might seem. It requires the creation of a robust translational research enterprise.

The foundation for this enterprise is currently being built. According to several reports, however, its full realization is likely to be hampered by a shortage of physician-scientists to carry on this important work. This is a gathering storm, indeed.

Traditionally, physician-scientists have had the greatest success in moving basic science findings from the laboratory into the stage where they can be tested in clinical trials. This is because their specialized skills allow them to work at the interface of basic and clinical sciences and to serve as an intermediate between the two.

Over the years, many academic medicine programs have established combined M.D.-Ph.D. degree programs that train physician-scientists. A long-standing and even more common route is for individuals who already have their M.D. degree to pursue a research fellowship after their undergraduate medical education.

Unfortunately, not enough medical students and physicians currently are entering either of these pipelines. According to a 2002 article in the New England Journal of Medicine, in 1983, the total number of physicians in the United States was 479,439, and the number of physician-scientists was 18,535 (3.9 percent of the total); by the late 1990s, the total number of physicians had increased to 707,032, whereas the number of physician-scientists had fallen to 14,479 (2 percent of the total).

Not only is the physician-scientist population in the United States becoming an "endangered species" compared to 25 years ago, it is also significantly older. Since the mid-1980s, the percentage of total research project grants awarded by the National Institutes of Health (NIH) to investigators older, than 50 years has, gradually increased for M.D., Ph.D.s, and M.D.-Ph.D.s.

One beacon of hope in this otherwise disturbing picture is the NIH's Clinical and Translational Science Awards (CTSA) program. To date, the CTSA has funded about a dozen academic medical centers to include clinical and translational research training and career development in their overall programs. Yet, this represents less than 10 percent of U.S. academic medical centers. Although the NIH plans to fund 60 CTSA centers altogether by 2012, the future of this critically important training program is not guaranteed. According to various estimates, the NIH budget has been slashed by 10 percent to 16 percent in real dollars over the past five years, and budgets for some newly funded CTSA centers have been trimmed by as much as 50 percent.

There are many possible reasons why medical students and physicians are eschewing research careers, including accumulated debt, the long training period, and the uncertainty of success. However, according to recent reports, the most important factor involves the initial decision of whether to pursue a research career, a decision that often comes early in their training.

Only a major restructuring of medical education in which training in research methods takes center stage throughout the curriculum can avert this gathering storm. Weaving research training into medical education curricula would require developing a new paradigm for how we educate and train our doctors—one where every future physician receives thorough instruction in the basic principles of research methods, from the first day of medical school to the last and throughout their residency training.

To make such training mandatory, the two major accrediting bodies for undergraduate and subspecialty medical school training—the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME)— would need to mandate training in research as one of the core competencies for medical school and residency program accreditation. Both organizations have taken steps to do so following a 2006 report from the AAMC's Clinical Research Task Force II. That group, in which I participated, strongly recommended changing standards to emphasize research education.

Even if medical students later decide against a full-time career in research, there still are many ways for them to contribute, either as part-time researchers, associate investigators, part-time clinical consultants, or even as members of an IRB or data safety monitoring committee for a clinical trial.

Accelerating training in research through a careful modification of medical school curricula would allow trainees who decide to become independent physician-scientists to do so much earlier in their careers. The AAMC's clinical research task force included such recommendations in its report. The current average age at which a new investigator receives his or her first NIH R01 grant is now 42 years old for a Ph.D. and 43 years for an M.D. This clearly must change.

Reversing this trend not only would avert the impeding storm, but would also permit graduates to begin contributing to science during their years of highest creativity. Furthermore, providing trainees with opportunities to develop a record of accomplishment would significantly enhance their ability to obtain faculty appointments. Ultimately, I believe such a trend reversal would translate into much-needed therapies reaching patients far earlier.

Only when we begin to teach young, aspiring physicians the true value of research from the outset will we be able to maximize the potential of these talented individuals. More importantly, it will greatly improve our ability to fully reap tomorrow the benefits of today's unprecedented research findings.

Editor's Note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.