1. The Vanishing Physician-Scientist? Andrew I. Schafer Chairman, Department of Medicine Weill Cornell Medical College Indiana University School of Medicine April 26, 2011

2. Physician-Scientists Conduct medical research along entire continuum Conduct medical research along entire continuum Devote majority of effort to research Devote majority of effort to research Vital and unique role in medical research enterprise Vital and unique role in medical research enterprise

3. Original “endangered species” article:

5. Evolving Role of Physicians in Medical Research The 19 th Century and Earlier Physicians make most major contributions to medical knowledge Physicians make most major contributions to medical knowledge

6. Evolving Role of Physicians in Medical Research The 19 th Century and Earlier Physicians make most major contributions to medical knowledge Physicians make most major contributions to medical knowledge Andreas Vesalius(1514-1564) Founder of Modern Human Anatomy Foundation of medicine as “observational science”

7. Evolving Role of Physicians in Medical Research The 19 th Century and Earlier Physicians make most major contributions to medical knowledge Physicians make most major contributions to medical knowledge William Harvey (1578-1657) Foundation of medicine as “functional science”

8. Evolving Role of Physicians in Medical Research The 19 th Century and Earlier Physicians make most major contributions to medical knowledge Physicians make most major contributions to medical knowledge Claude Bernard (1813-1878) Founder of modern experimental medicine

9. Evolving Role of Physicians in Medical Research The 19 th Century and Earlier Physicians make most major contributions to medical knowledge Physicians make most major contributions to medical knowledge Rudolph Virchow (1821-1902) Cellular basis of disease

10. Evolving Role of Physicians in Medical Research The 19 th Century and Earlier Physicians make most major contributions to medical knowledge Physicians make most major contributions to medical knowledge Robert Koch (1843-1910) Germ theory of disease

11. Evolving Role of Physicians in Medical Research The 19 th Century and Earlier Physicians make most major contributions to medical knowledge Physicians make most major contributions to medical knowledge Louis Pasteur (1822-1895) (Chemist) Germ theory of disease

12. Evolving Role of Physicians in Medical Research 1890s - 1930s Dramatic rise of science and research in medicine Dramatic rise of science and research in medicine Science becomes integral to medical education Science becomes integral to medical education Inspired by clinical observations “bedside to bench” Inspired by clinical observations “bedside to bench” Research labs located in hospitals Research labs located in hospitals

13. Evolving Role of Physicians in Medical Research 1930s - WWII Dramatic therapeutic advances heighten glamour of medical research Dramatic therapeutic advances heighten glamour of medical research Rising public opinion of medical research Rising public opinion of medical research Philanthropy Philanthropy Physicians (and increasing number of PhDs) doing basic research that is becoming more detached from clinical relevance Physicians (and increasing number of PhDs) doing basic research that is becoming more detached from clinical relevance Interrupted by WWII, when researchers support war effort by returning to applied work Interrupted by WWII, when researchers support war effort by returning to applied work

15. Evolving Role of Physicians in Medical Research WWII – 1970s “Golden Age” “Golden Age” Vannevar Bush: primacy of fundamental research Vannevar Bush: primacy of fundamental research

16. Vannevar Bush

17. SCIENCE: THE ENDLESS FRONTIER Vannevar Bush A Report to the President by the Director of the Office of Scientific Research and Development United States Government Printing Office, 1945

18. Evolving Role of Physicians in Medical Research WWII – 1970s “Golden Age” “Golden Age” Vannevar Bush: primacy of fundamental research Vannevar Bush: primacy of fundamental research Burgeoning of NIH: strong basic sciences orientation Burgeoning of NIH: strong basic sciences orientation

19. Dedication of the New NIH Campus in Bethesda 1940, FDR

20. Evolving Role of Physicians in Medical Research WWII – 1970s “Golden Age” “Golden Age” Vannevar Bush: primacy of fundamental research Vannevar Bush: primacy of fundamental research Burgeoning of NIH: strong basic sciences orientation Burgeoning of NIH: strong basic sciences orientation PhDs flood medical research arena PhDs flood medical research arena Age of “triple threat” MD Age of “triple threat” MD

21. Evolving Role of Physicians in Medical Research 1970s - Basic and applied research becoming polarized Basic and applied research becoming polarized Mounting pressure from Congress and public advocacy groups for practical payoff in conquest of disease Mounting pressure from Congress and public advocacy groups for practical payoff in conquest of disease “Bench to bedside” “Bench to bedside”

22. Evolving Role of Physicians in Medical Research 1980s - Rising concern about future of physician-scientist Rising concern about future of physician-scientist IOM, NIH, AAMC reports on “clinical” research IOM, NIH, AAMC reports on “clinical” research

24. Percentage Increase in First Time R01 Applicants (1998-2003) PhD

25. Percentage Increase in First Time R01 Applicants (1998-2003)

27. 1980 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

28. 1981 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

29. 1982 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

30. 1983 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

31. 1984 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

32. 1985 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

33. 1986 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

34. 1987 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

35. 1988 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

36. 1989 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

37. 1990 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

38. 1991 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

39. 1992 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

40. 1993 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

41. 1994 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

42. 1995 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

43. 1996 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

44. 1997 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

45. 1998 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

46. 1999 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

47. 2000 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

48. 2001 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

49. 2002 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

50. 2003 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

51. 2004 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

52. 2005 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

53. 2006 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster

54. 2006 September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty Sources: IMPAC II Current and History Files and AAMC Faculty Roster 1980

55. Attrition of NIH-Funded MD-Scientists First-time unsuccessful MD applicants for an R01 grant are consistently less persistent than PhD applicants in reapplying. First-time unsuccessful MD applicants for an R01 grant are consistently less persistent than PhD applicants in reapplying. MD applicants with an R01 grant are less likely than PhD applicants to apply for a subsequent R01 grant. MD applicants with an R01 grant are less likely than PhD applicants to apply for a subsequent R01 grant. At every point in the early life cycle of NIH funding, MD-scientists are more likely than PhD-scientists to leave the R01 grant application pool. At every point in the early life cycle of NIH funding, MD-scientists are more likely than PhD-scientists to leave the R01 grant application pool. Dickler, JAMA, 2007 Dickler, JAMA, 2007 About 40% of MDs with K08 (mentored clinical scientist development) awards do not even apply for a subsequent R01 grant. Kotchen, JAMA, 2004 About 40% of MDs with K08 (mentored clinical scientist development) awards do not even apply for a subsequent R01 grant. Kotchen, JAMA, 2004

57. Chasm between Basic Science and Clinical Practice

58. Chasm Between Basic Science and Clinical Practice Scientific Scientific

59. Bridging Bridging the Chasm

60. Bridging the Scientific Chasm between Basic Science and Clinical Practice Integrationism of systems biology Integrationism of systems biology Translational research Translational research Evolution of physicians as members of research teams Evolution of physicians as members of research teams

61. Chasm Between Basic Science and Clinical Practice Scientific Scientific Cultural Cultural

62. Cultural Barriers Separate Clinical Medicine from Basic Science (from Barry S. Coller) Need for Immediate Action Avoiding Rush to Judgment Adherence to standards of practice Encouragement to challenge existing paradigms

63. Respect for hierarchy and expert authority Critique, challenge accepted wisdom Errors as mortal threats Errors as inevitable manifestations of creative process Cultural Barriers Separate Clinical Medicine from Basic Science (from Barry S. Coller)

64. Focus on unique Focus on generalizable principles Commitment to the Physician’s Oath Commitment to Search for the Truth Cultural Barriers Separate Clinical Medicine from Basic Science (from Barry S. Coller)

65. Bridging Bridging the Chasm

66. Bridging the Cultural Barriers between Basic Science and Clinical Practice Vive la différence Vive la différence Institutional leadership to cultivate a climate of mutual respect and trust Institutional leadership to cultivate a climate of mutual respect and trust Research team building Research team building MD trainees experience laboratory research MD trainees experience laboratory research PhD trainees experience clinical medicine (e.g. HHMI “Med Into Grad” Initiative) PhD trainees experience clinical medicine (e.g. HHMI “Med Into Grad” Initiative)

67. “Young MDs and PhDs have much to teach each other from two different vantage points…led me to wonder whether young MDs and PhDs are not ideally equipped to train each other.” -Edward H. Ahrens, Jr. The Crisis in Clinical Research, 1992 The Crisis in Clinical Research, 1992

68. Major Contemporary Issues in Physician-Scientist Career Development 1. Women physician-scientists

69. Women Physician-Scientists Gender Distribution of Matriculated Medical Students

70. Why Women Find Physician-Scientist Careers Less Attractive Than Do Men Concerned that it will be impossible to combine a successful career with childbearing and family life Concerned that it will be impossible to combine a successful career with childbearing and family life Feel that they have to be better than their male counterparts to be considered equal Feel that they have to be better than their male counterparts to be considered equal Receive little encouragement to become physician-scientists Receive little encouragement to become physician-scientists Lack compelling role models Lack compelling role models - Andrews, NC. Nature Med, 2002.

71. Major Contemporary Issues in Physician-Scientist Career Development 1. Women physician-scientists 2. Generation gap in expectations

73. “There’s a tremendous generation gap between what the current generation of junior faculty want and what the current generation of senior faculty perceive as correct.” -Junior male faculty MD-scientist, Duke Faculty Focus Group Duke Faculty Focus Group

74. Male executive survey question: “I want job options that let me have more personal time” Somewhat agree Somewhat disagree Strongly agree Strongly disagree Source: Jody Miller, “Get a Life!” Fortune, November 28, 2005

75. Source: Benko C, Weisberg A. Mass Career Customization: Aligning the Workplace with Today’s Nontraditional Workforce, 2007. Years Changing Family Structures Years

76. “What about the wife and babies if you have them? Leave them. Heavy are the responsibilities to yourself, to the profession and to the public. Your wife will be glad to bear her share of the sacrifices you make.” William Osler (NYT 4.2.11)

77. Memorandum from Einstein to Mileva Einstein-Maric 18 July 1914 A. You will see to it that: 1.My clothes and laundry are kept in good order; 2.I will be served three meals regularly in my room; 3.My bedroom and study are kept tidy, and especially that my desk is left for my use only. B. You will Relinquish all personal relations with me insofar as they are not completely necessary for social reasons. Particularly, you will forgo my: 1.Staying at home with you; 2.Going out and traveling with you. C. You will obey the following points in your relations with me: 1.You will not expect any tenderness from me, nor will you offer any suggestions to me; 2.You will stop talking to me about something if I request it; 3.You will leave my bedroom or study without any back talk if I request it. (reference: Collected Papers of A. Einstein, Vol. 8, p. 32) (reference: Collected Papers of A. Einstein, Vol. 8, p. 32)

78. The New Workforce Imperative Corporate Ladder: Traditional hierarchy Linear path upward Move or stop moving Fits traditional family structure Assumes workers’ needs remain consistent over time Corporate Lattice: Multiple, individualized paths upward Move faster, slower; change directions Personalized career-life fit Adjusts as workers’ needs change over time Adapted from Benko, Weisberg: Mass Career Customization, 2007.

79. Off-Ramps and On-Ramps: Keeping Talented Women on the Road to Success Two thirds of highly qualified women have discontinuous or nonlinear careers Two thirds of highly qualified women have discontinuous or nonlinear careers 93% of women who stepped out of the workforce want to return to their careers 93% of women who stepped out of the workforce want to return to their careers Most organizations are ill equipped to make reentry possible, let alone easy Most organizations are ill equipped to make reentry possible, let alone easy (Harris survey of 2400 “highly qualified” professional women and 653 men ages 28-55) -Hewlett SA, 2007

82. Flexible Faculty Policies Related to Tenure and Promotion 1. Extend length of the probationary period 2. Tenure (promotion) clock-stopping policy 3. Less than full-time employment while on a tenure-eligible track

83. Probationary Periods ≥ 8 Years for Basic Science and Clinical Faculty in the U.S. Medical Schools 1983-2008

84. Evolving Workplace Flexibility for Medical School Tenure-Track Faculty (Bunton SA, Corrice AM, Acad Med, 2011) Despite the existence of these policies, results bring into question the acceptance of their use in the culture of academics Despite the existence of these policies, results bring into question the acceptance of their use in the culture of academics Many institutions may have developed flexible policies but implicitly or explicitly discourage faculty members from using them Many institutions may have developed flexible policies but implicitly or explicitly discourage faculty members from using them In fact, some faculty members may fear retribution for using these policies despite their availability In fact, some faculty members may fear retribution for using these policies despite their availability There is a disconnect between the existence of policy and faculty knowledge about or willingness to use it, which may reflect lingering employment norms There is a disconnect between the existence of policy and faculty knowledge about or willingness to use it, which may reflect lingering employment norms

85. Major Contemporary Issues in Physician-Scientist Career Development 1. Women physician-scientists 2. Generation gap in expectations 3. Mentoring

87. Characteristics of a Mentor Mentor Teacher Sponsor Advisor Role Model Coach Confidant

88. Characteristics of a Mentor Mentor Teacher Sponsor Advisor Role Model Coach Confidant NoviceMenteePupil Protégé Advisee Trainee Communicator TeacherSponsor Advisor Coach Confidant

92. Major Recommendations 1.Attention and resources should be directed at repairing the “leaking” physician-scientist pipeline.

93. Major Recommendations 2.Major changes should be made to the contemporary approach to mentoring physician-scientists.

94. Major Recommendations 3.Institutions should proactively promote the advancement and minimize the attrition of women in physician- scientist careers.

95. Major Recommendations 4.The physician-scientist workforce should be strengthened by earlier and more coordinated efforts to identify and prepare successful future investigators who have a more enduring commitment to research careers.