After spending nearly 15 years in biomedical science laboratories in two different countries with publicly funded health systems, I finally feel able to write down some thoughts on the explosion of physician scientists being trained across the world. I think we have been on a very dangerous path for some time now and need some bold moves at the level of the university, hospitals and granting agencies to address several key problems.
Before I start losing friends over what I write, I hope that a few disclaimers will soften the blow. First and foremost, I think that medically trained scientists are a critical component of our biomedical research community – I am not advocating for fewer medically trained scientists and I am certainly not advocating for stopping people from being involved in both arenas. Secondly, I think that basic scientists benefit enormously from regular interaction with the clinical problems that need addressing – far too often, scientists will chase something that already has a relatively easy solution in the clinic or they ignore the most outstanding question in a disease.
Disclaimers aside, it is high time that we stopped investing in MD/PhDs as if they were a special class of worker entitled to more than someone with “just a PhD.” I’ve outlined the main issues and some possible solutions.
Getting paid differently for doing the same job
The risks and liabilities within the medical profession are substantial. Most non-MD scientists understand this and are perfectly happy to see physicians compensated accordingly. The problem comes when you look at the balance of time spent in the hospital compared to in the lab. Some MD/PhD laboratory heads spend very little time actually in the hospital yet they take home considerably more pay than their colleagues with only a PhD.
This is particularly acute in the United Kingdom where many medical doctors who run scientific research groups have 10 to 20 percent hospital time but draw a substantially higher salary all of the time. Moreover, the U.K. National Health Service gives “merit awards” to medical doctors who undertake research which at the top level can result in an extra £75,000 (CAD $123,000) on top of normal salary. Yet, researchers at the same hospital who make outstanding contributions see no such reward. This imbalance permeates training programs as well (e.g., PhD and postdoctoral fellows) which often have little to no clinical duties associated with them so these medical doctors are literally doing the same job as another PhD student (often with less training in laboratory science) and take home up to 50 percent more salary. I don’t have as strong a sense of the imbalances in Canada but a quick scan of publicly disclosed salaries seems to support the idea that the same trends are present.
I often hear the justification that doctors would not undertake PhDs if they weren’t paid more, and I find this really difficult to swallow as a reason. I’ve met many motivated scientists who happen to have an MD, and salary is not the driving force for them. If we happen to lose a few people along the way who are only in science or medicine for the salaries, prestige and career progression, then so be it.
Possible solution: Pay people for the job they do and not for the letters after their names. If you run a research lab, you get paid like other people running research labs.
Poor return on training investment
One of the worst outcomes for the public purse is people who get trained in medicine (very competitive, very expensive), shifting over to research early (at a higher salary than a science graduate), and never returning to clinical practice (or only returning part-time). Not only have these people cost the system an incredible amount of money, but they have also taken the position away from someone else.
Possible solution: Require a minimum number of clinical hours post-training, either in the form of years of service or hours per week.
Medical training gives “a” way of looking at science, not “the” way
One of the reasons cited for needing more MD/PhD laboratory heads is that they bring a medically relevant perspective to the research. This appears as the epitome of translational research: a doctor sees a patient, maybe collects a sample or two, and then scurries back to the lab to develop a cure for that patient. It ticks all the boxes that the granting agencies are looking for but it is critical to remember that this is a single perspective and scientific research draws on many such perspectives to move forward. A developmental biologist or a chemist also brings a different perspective to the table.
Squeezing basic scientists out of jobs will not end well
The push by funding agencies toward “translational research” is being felt internationally. Since clinically related projects – often run by clinician scientists – are quite justifiable in this respect, they naturally have an advantage and when funding is tight and the basic scientists lose out. A telling example is the recent round of CIHR grants where applications based primarily on model organisms like worms, flies and fish had a success rate of less than five percent. We need to remind ourselves that transformative breakthroughs in biomedical research are often from projects without an overt “translational” goal. New DNA sequencing technologies are a good example where the scientists playing around with single molecule chemistry did not realize the application of their research until many years after the actual discovery. If we don’t invest in discovery science, we will regret it many years down the road when the pipeline of novel basic research dries up.
Possible solutions: Separate evaluation panels to compare apples with apples, and set funding targets for basic and applied research.
If publicly funded, national research and healthcare systems are to survive, they cannot afford to make mistakes with the distribution of resources among our best and brightest – such institutions absolutely need to get good value for money.
I’ll close by advocating for the collection of outcomes data which I think would be an essential resource for guiding the balance of training and career progression. What are the career outcomes are for MD/PhD trained people – do they go back into clinical work with a knowledge of basic science? Do they run laboratories and clinics simultaneously? Do they stop practicing altogether? Does the order in which they train matter – MD followed by PhD or vice versa?
Dear Dr. Kent,
An interesting article clearly written with passion and courage.
I am a physician-scientist who learned of your opinion piece through a MD/PhD student in Canada.
It contains many kernels of truth, flickers of frustration, good suggestions, but also a general omission of the fact that dually trained professionals on average put in twice as many years of training in order to position themselves to make significant contributions. I wholeheartedly support your suggestion to collect, analyze and publish longitudinal outcome measures in countries that offer integrated curricula for physician-scientist trainees. I would add that readouts of their contribution to our societies should be included.
In the 1970s, Drs. Brown and Goldstein had already pointed out the multiple phenotypes that exist among physician-scientists, and the different ways by which they can deliver on the investment made by the public (in that case, the federal government of the U.S.) of having trained them. Here in Canada, we hope that the future leadership of our federal funding body (CIHR) will actively demonstrate two things: one, the enormous value that both discovery science and translational science hold in modern societies, as pursued by researchers from multiple backgrounds; and two, the significant role that a small segment of scientists plays in these societies, who are fluent in the languages of both science and medicine.
Michael Schlossmacher, M.D.
Director, Program in Neuroscience
Ottawa Hospital Research Institute
Director, MD/PhD Program, Univ. of Ottawa
Ottawa, ON., Canada
Hi Dr. Schlossmacher,
First of all, thank you for your comments. It is actually incredibly nice to see that the articles are being read/spread so widely. I’m also glad that we agree on the need for discovery science in concert with translational science and the need to gather more data, the best planning always comes from a good understanding of the system that needs changing. I will also have a good look through the articles by Brown and Goldstein (thanks for the tip).
A couple of comments on your comment:
1) In the UK, medicine is often taken as an undergraduate course with the result of non-lab trained medical doctors entering labs with fewer lab skills than a BSc scientist and getting paid more for the rest of their career – living here for the last 7 years has definitely influenced the article.
2) Medically-fluent scientists are a rare breed (and often top my list of role models) – but I guess I see those people as having invested similarly as scientifically fluent physicians yet the rewards systems are not equal.
Overall though, I’m sure you can appreciate the need in a format such as a blog to be a little more blunt and opinionated. I’m obviously working every day with incredible physician scientists here in Cambridge and my work would not be nearly so doable without them – so as mentioned in the article, I’m not advocating for a reduction in MD/PhDs. My biggest concern is that we over-support one cadre and as a consequence under-support the other.
Anyhow – thanks again for your comments – if you’d ever be interested in writing something for the blog, we’d be happy to host your opinions.
I’ve recently heard that “this” lab is under investigation for numerous abusive issues.
I have recently heard it happened in Ottawa, efforts of scientist are often exploited, given an interesting contract so that “this” person won’t get sued. Which is totally against the constitution of law.
One of the true scientist who has both MD. And PhD had to suffer from horrible harassment by a MD scientist.
MD and PhD Scientist’s training it self is completely different.
Sometimes people don’t know how hard it is to do one experiment.
MD are Trained as MD.
PhD training has to be done by someone who holds PhD.
It doesn’t make sense MD to train PhD.
It makes sense MD PhD( in biology) to train PhD.
I won’t tell much at this point, but soon it will come out in public.