Crises in academic medicine.

Significant attention is being paid to the decline in research involvement of physician-scientists (M.D.s primarily involved in research) in this country. For an excellent recent review, see the article on this subject in the FASEB Journal (1). In the FASEB review, which generally reports information between the 1970s and 1980s to 1997, data are provided to document the decline in all of the following: 1) Number and proportion of physicians listing research as a major professional activity with the AMA; 2) Number of M.D.s in basic science departments who are NIH grant holders; 3) Proportion of M.D.s in clinical science departments who are NIH grant holders; 4) Number of M.D.s who review grants for NIH; 5) Proportion of medical students who have strong research career interests; 6) Financial status of medical students with a great increase in debt of medical school graduates; 7) The number of younger M.D. NIH principal investigators; 8) Number of M.D. trainees in both individual and institutional training grants; and 9) The application rate of M.D.s for NIH grants, relative to the great increase in NIH funding and in Ph.D. application rates. A little good news is mixed in with all this bad news in the FASEB report. There is the aforementioned increase in NIH funding, an increase in NIH K08 awards which offer mentored fellowships to M.D.s at a higher stipend than traditional fellowships, the continued success of the Medical Scientist Training Program (MSTP) which funds training toward concurrent M.D./Ph.D. degrees, and the information showing that M.D.s have a success rate comparable to Ph.D.s for NIH grant awards. The report points out, however, that the K08 awards do not nearly make up for the decline in M.D.s involved in training grants or individual fellowships, so that there is an overall decline in M.D.s receiving training to enter research careers. This is at a time when NIH support is increasing rapidly, and the explosion of knowledge in genetics and other fields requires more, not less, in the way of medical translational research. The FASEB report suggests several remedies which focus on various ways of enhancing the choice of career and improving the careers of physician scientists. These latter run the gamut from better role models in medical school to debt-forgiveness programs. These are well thought out proposals and I support them. I think if they were experimented with and then adopted, they would go a long way towards mitigating the problem of not enough M.D.s involved in research. However, I believe there are two crises in academic medicine (hence the plural in my title). These are: 1) The aforementioned decline in research involvement of physician-scientists; and 2) The decline in patient-oriented research (clinical research) by physicians. The remedies in the FASEB report will be very helpful to the first problem, but in my opinion they do not sufficiently address the second. For example, the report calls for expansion of the M.D./ Ph.D. (MSTP) programs, but within the report, data are provided that at one major institution, 85% of MSTP graduates go into basic research while only 11% have careers with significant patient-oriented research. I think the experience elsewhere is similar. The MSTP program trains primarily “bench” scientists, not “bed” scientists or “bench-tobed” scientists. I’m not saying that M.D./Ph.D.s who do basic research are not an important component of the medical research and medical education enterprises. It is good to have researchers who have detailed knowledge of human biology and an informed perspective on the important questions in medi1 To whom requests for reprints should be addressed at Department of Human Genetics, 4909 Buhl Bldg, University Of Michigan, Ann Arbor, MI 48109-0618. E-mail: brewergj@umich.edu