The “health” and future of the physician-scientist in hepatology
Authors: Gyongyi Szabo
Journal: Hepatology (2008)

Discoveries in biological and medical sciences have been the basis for advances in medical practice for centuries. A great historic example of application of clinical observations to practice and scientific knowledge is the discovery of the importance of hand washing with chlorinated lime solutions in obstetrical clinics to prevent childbed fever by Ignaz Semmelweis (1818-1865) and the "translation" of this knowledge to experimental explanation through the "germ theory of disease" by Louis Pasteur (1822-1895). Discoveries of basic research provide understanding of pathophysiologic mechanisms of disease, development of novel therapeutic agents, and strategies for disease prevention. If basic research is the fuel for medical sciences, translational research is the engine that moves medical knowledge to practice. However, none of this could happen without the skilled driver, the physician-scientist. During the evolution of medicine from the traditional empirical and practice-based approach to evidence-based science, the pioneering role of physician-scientists has never been as important as now, in the era of discoveries promised through advanced translational research. AAMC, Association of American Medical Colleges; AGA, American Gastroenterological Association; GI, gastroenterology; NIH, National Institutes of Health. What is translational research? While for many the term "translational research" means translation from "bench-to-bedside", the spectrum of translational research encompasses three key components of medicine and health care delivery.1 T1 research is defined as translation of basic research discoveries to human diseases, the classical "bench-to-bedside" translation. T2 is research designed to bring advances in clinical trials to be proactive in the community, also referred to as "translation to patients". T3 research designates research on dissemination of already established practice-based findings and implementation of research to the communities, termed "translation to practice". These definitions are not exclusive but help to understand the broad spectrum and mission of translational research. In recent years, the National Institutes of Health (NIH) Roadmap heavily emphasized the benefits of translational research approaches and promoted development of infrastructures at the national level to support all stages of translational research. Introduction of the Clinical and Translational Science Awards (CTSA) grants programs facilitated redesigning vision, infrastructure, and training priorities in support of clinical and translational research at the level of competitive academic institutions. Funding opportunities have been initiated to promote various stages of translational research. Hepatology research has greatly benefited from initiation of large-scale clinical trials supported by the National Institute of Diabetes and Digestive and Kidney Diseases such as the HALT-C clinical trial in hepatitis C virus infection, the DILIN Network, the NASH Network, and the recently initiated hepatitis B virus clinical trials that all serve to advance translational research in hepatology. Although these national and institutional efforts support reshaping medical research, the "health" and "pipeline" of physician-scientists, who are the fundamental drivers of translational research, are in danger. Numerous articles written in the last few years have drawn attention to the disappearance of the young physician-scientist in the United States.3-5 There has been a 25% decline in the number of physician-scientists on medical school faculties compared to two decades earlier.3 In a recent article, Neilson lists several reasons including heavy accumulation of debt, the difficulty of providing useful research experience in the modern training curriculum, lack of true understanding of what it means to be a physician-scientist before career choices are made, the concern about earning a living from academic life, and concerns related to the admission process for the M.D./Ph.D. track.3 It has been recognized that the time, effort, cost, and personal sacrifice to become a well-trained clinical scientist is grand. Current well-established career development pathways include formal M.D./Ph.D., M.D./MPH programs and clinical fellowships with strong research training. The various NIH-supported career advancement awards such as K awards are geared to complete research training for clinician-scientists in the junior faculty phase. The ultimate goal of all of this prolonged training is to become an independent investigator and to establish a funded, independent research program. However, achievement of this basic goal has become increasingly difficult in recent years. Perhaps the most alarming data comes from statistics on NIH funding for new investigators. The average age at which researchers receive their first NIH research grant had been increasing for decades and now it is age 42.2 In 1980, the average age of a first-time NIH grant recipient was 37. The number of RO1-like research grants (RO1) going to first-time investigators slipped to 1354 in 2006, the lowest level in 9 years.2 All these concerns apply to physician-scientists in hepatology. Most institutions struggle with recruitment of academic hepatologists and have difficulties in retaining the best minds to conduct research for several reasons. First, there is already a shortage of well-trained and funded academic hepatologists. Second, the immediate and long-term success of physician-scientists in academic hepatology largely depends on federal grant funding that has been under a major shortage for the last several years ever since the completion of the doubling of the NIH budget in 2005. Third, hepatologists for the most case are board-certified gastroenterologists and are affected by the market forces of not only the jobs in hepatology but also in general gastroenterology. Considering the relative shortage of gastroenterologists and the attractive salaries particularly in private practice gastroenterology, recruitment and retention of academic hepatologists is becoming increasingly difficult. A recent survey of graduates of the gastroenterology (GI) fellowship program at Mayo Clinic-Rochester from 1990-2003 showed a more encouraging picture, where 65% of graduates accepted academic positions whereas 35% pursued private practice.6 In general, gender-related issues also affect career choices and satisfaction in gastroenterology. Based on a recent survey sponsored by the American Gastroenterology Association (AGA) Institute, significantly more female than male gastroenterologists perceive that gender has affected their career advancement. Female gastroenterologists reported less overall career satisfaction and promotion than male academic gastroenterologists.7 Women were more likely to chose private practice over academic careers because of easier part-time options in the private practice setting. Overall, there are several signs that lend support to an optimistic view on the future of the physicians-scientist in hepatology. The 2007 entering class to U.S. medical schools was the largest in the nation's history, according to data released by the Association of American Medical Colleges (AAMC). The number of first-year enrollees totaled almost 17,800 students, a 2.3% increase over 2006. This represented an increase both in the applicant pool and in the size of the entering class in most medical schools. Based on the predicted steady increase in the number of baccalaureate degrees conferred annually, the AAMC predicts that the number of applicants to medical school will continue to steadily grow until 2015.8 There has been a steady increase in the number of medical schools that offer combined M.D./Ph.D. degree programs to provide students the opportunity to earn both M.D. and the Ph.D. in areas pertinent to medicine. The National Institute of General Medical Sciences (NIGMS) also support combined M.D./Ph.D. programs through the Medical Scientist Training Program (MSTP) that provides support to M.D./Ph.D. programs at 43 U.S. medical schools.9 There are several other ways to foster career choices along the physician-scientist path in hepatology. GI fellowship programs can take advantage of the "Clinical Investigator Pathway" approved by the American Board of Internal Medicine to support individuals interested in research to allow the option for postgraduate trainees to combine extensive research training with residency and/or GI-Hepatology fellowships. Some medical schools took this a step further and offer special programs to obtain the Ph.D. degree in combination with clinical residency/fellowship training (UMass, UT San Antonio). The AGA Institute and American Association for the Study of Liver Diseases host an annual Academic Skills Workshop to attract M.D./Ph.D. students into GI-Hepatology fellowships to improve the pipeline of academic hepatologists. The NIH is also committed to support junior investigators; according to an interview with departing NIH Director Elias Zerhouni, for the first time since 1995, new investigators and established ones submitting new applications had nearly the same success rate (19%) in funding in 2007.2 The NIH has several new initiatives to support junior investigators, to tilt the field in favor of early career scientists. The goal is to adjust for the recently discovered fact that only about 55% of investigators who receive their first NIH grants are at an early stage of their career.2 These NIH initiatives, with continued investments into training of young physician-scientists and the commitment of the individual mentors and institutions, provide substantial reality in increasing the "health" of our physician-scientist hepatologists and to maintain the "pipeline" for the future benefit of translational liver research. It is our responsibility as the active members of academic medicine to support the future of physician-scientists to maintain the supply of these drivers of medical science, as our field takes a leap toward new discoveries of translational research through biomarkers, systems biology, gene therapy, stem cells, and personalized medicine in hepatology.