Rescuing the physician-scientist workforce: the time for action is now

The 2014 NIH Physician-Scientist Workforce (PSW) Working Group report identified distressing trends among the small proportion of physicians who consider research to be their primary occupation. If unchecked, these trends will lead to a steep decline in the size of the workforce. They include high rates of attrition among young investigators, failure to maintain a robust and diverse pipeline, and a marked increase in the average age of physician-scientists, as older investigators have chosen to continue working and too few younger investigators have entered the workforce to replace them when they eventually retire. While the policy debates continue, here we propose four actions that can be implemented now. These include applying lessons from the MD-PhD training experience to postgraduate training, shortening the time to independence by at least 5 years, achieving greater diversity and numbers in training programs, and establishing Physician-Scientist Career Development offices at medical centers and universities. Rather than waiting for the federal government to solve our problems, we urge the academic community to address these goals by partnering with the NIH and national clinical specialty and medical organizations.In June 2014, the NIH Physician-Scientist Workforce (PSW) Working Group completed a year of data collection and deliberation, and released a report about the status of the PSW (1). The report is a combination of good news and bad news. The good news is that, despite the decline in the NIH budget, the size of the PSW has remained relatively stable. The bad news is that the current demographics, diversity, and career progression of this workforce raise concerns about the future. For a start, although apparently stable in size, the PSW is even smaller than many of us realized, and the apparent stability has hidden important demographic trends. In American Medical Association surveys of the nearly 1 million (and rising) MD physicians in the United States, only 14,000 (1.5%) consider research to be their primary focus (1). Even fewer have NIH grant support; only 8,200 physicians are principal investigators on NIH grants, split evenly between MDs and MD-PhDs (1). The number of extramural NIH-funded physician-scientists with research program (R series) awards has been essentially constant for the past 20 years, while the number of nonphysician (PhD) NIH-funded investigators has increased by half over the same period, reaching 19,400 in 2012 (1). As a result, the percentage of NIH awardees who are physicians has fallen to 30%. Although public policies have encouraged an increase in the number of medical schools and medical students in the US, and medical school admission policies have placed value on undergraduate research, the percentage of physicians focused on research has fallen.At the same time that the PSW has remained stable in size, data in the report show that the average age of the workforce is rising, as older investigators remain employed and younger investigators have not emerged in sufficient numbers. The average age at which a physician-scientist received his or her first NIH R01 grant in 2011 was 44 years for MD-PhDs and 45 years for MDs: approximately 10 years older than in 1980 (2). R01-funded investigators (physicians and nonphysicians) younger than 37 years have all but disappeared, and the time from graduating medical school to obtaining a first faculty position has increased to over 10 years for MD-PhDs and even longer for MDs without a PhD. Women and minorities are underrepresented, having opted not to enter or remain in the workforce. Thus, gathering places for physician-scientists look mostly like clubs for older white men. Without corrective action, the PSW appears headed for a population crash as older investigators retire. We recognize that younger physician-scientists have not entirely disappeared; they just take longer to obtain faculty appointments and independent NIH grants. This situation creates an extended waiting period that we call the holding zone, which contributes to the disturbing demographics (Figure 1).Open in a separate windowFigure 1The physician-scientist pipeline: long and leaky.The figure highlights a number of issues, including career attrition at every stage and the existence of a protracted period when well-trained physicians in their 30s are serving in subordinate positions awaiting the next step in their career progression. To draw attention to their plight, we call this period the holding zone. The illustration is based on the experience of MD-PhD program graduates, but many of the issues reflect the obstacles for any would-be physician-scientist. Attrition rates from MD-PhD programs are low, with most of those who withdraw completing medical school or graduate school. Very few MD-PhD program graduates (5% or fewer) choose to forego postgraduate clinical training as residents and fellows. In our experience, career attrition takes many forms and becomes cumulative at each stage, reflecting the proportion of individuals who either never return to research, opt for full-time clinical practice outside of academia, join academia as an assistant professor but spend their time caring for patients, or are appointed to the tenure track but end up devoting minimal time to research (1). A declaration of success depends in part on the definition of success. Outcome data show that approximately 80% of MD-PhD program graduates are working in academia, industry, or research institutes — including the NIH — but not all are doing research (3). Data on NIH award rates, conversions from K grants to R grants, and the proportion of individuals appointed to MSTP T32 grants can be found in the PSW report (1). The NIH continues to track principal investigators on grants but is just starting to track physician-scientists who play essential roles as other key personnel.