The Physician-Scientist: an Endangered Species
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Promoting Cardiovascular Education, Research and Patient Care THE OFFICIAL BULLETIN OF THE INTERNATIONAL ACADEMY OF CARDIOVASCULAR SCIENCES Editorial Team VOL. 3 · NO. 2 · Pages 13-24, 2004 Editor: Ivan Berkowitz MBA The Physician-Scientist: Assistant Editors: Ian Dixon PhD An Endangered Species Lorrie Kirshenbaum PhD by Burton E. Sobel, Burlington, Vermont Editorial Board: fessional responsibility of a physician-scientist is per- Lois DeBakey PhD forming research, most physician-scientists play piv- Otoni Gomes MD otal roles in teaching. Suresh Gupta PhD Keld Kjeldsen MD Physicians of diverse types fulfill valuable responsibil- Tom Kottke MD ities in our academic medical centers. Master clini- Ricky Man PhD cians provide optimal care. Physician administrators Dennis McNamara PhD provide leadership and implement strategic plans. Bohuslav Ostadal MUDr, DrSc Clinician educators and scholars teach clinical skills Damaris Osunkwo MD and enhance clinical decision making. Clinical trial- Arie Pinson PhD ists help to validate advances in diagnosis and treat- Grant Pierce PhD ment. Nevertheless, the physician-scientist is an Pawan Singal PhD important element. Because of their immersion in sci- Rajendar Suri PhD entific pursuits and its impact on their own thinking, Nobuakira Takeda MD physician-scientists are, perhaps, uniquely able to Burton E. Sobel hone hypothesis generation and refinement, healthy In This Issue scepticism, and critical thinking in their students at all levels (2). 13 The Physician-Scientist an Endagered Species Almost a century ago, Flexner revolutionized medical hat Is a Physician-Scientist? 16 Cardiac Research - Past, education. He differentiated academic medical cen- Present and Future WSeveral characteristics define a physician-sci- ters from institutes about which he noted the follow- ing: “The creation of such institutes does not relieve 17 Bruce McManus wins entist. Being a physician is but one. Some physician- Nagano Award scientists are Ph.D.’s as well as M.D.’s. All spend most the university of its research function; for if it be true that higher teaching cannot be efficiently prosecuted 18 International Symposium of their time performing fundamental laboratory research, disease oriented research, or patient orient- except in the atmosphere of scientific inquiry, then the 19 Current list of Academy existence of research institutes does not alter the edu- Fellows ed research (1). The physician-scientists who are the focus of this commentary perform investigator initiat- cational situation.” He indicated that medical facul- 20 A Revolutionary Initiative ties continue to be charged with the responsibility to for Young Investigators ed research frequently reflected by acquisition of peer- reviewed, competitive grant support from agencies advance, disseminate, and apply medical science. His 21 Academy Journal Expands such as the National Institutes of Health (NIH), the analysis transformed the nature of medical schools in 22 German Physiological National Science Foundation, the American Heart the United States and Canada and led to the integra- Society Meeting Association, the American Diabetes Association among tion of research and education on the one hand and 23 Heart Failure Reviews is numerous others. They publish their work in peer- the development of a contingent of physician-scien- an Official Academy reviewed journals and, if successful, produce a corpus tists on the other (3). Journal of work that moves a field. Although the primary pro- 23 A Book Review continued on pg. 14 24 Special Announcements EDITORIAL OFFICE: Institute of Cardiovascular Sciences, St. Boniface General Hospital Research Centre, Faculty of Medicine, University of Manitoba 3006 - 351 Taché Avenue, Winnipeg, Manitoba R2H 2A6 Canada · Tel: (204) 228-3193 · Fax: (204) 233-6723 e-mail the Editor: [email protected] · Academy web site: www.heartacademy.org The International Academy of Cardiovascular Sciences gratefully acknowledges the generous support of THE WINNIPEG FOUNDATION towards the publication of CV NETWORK Growth and Decline of the Contingent of Throughout a nearly 30 year interval, physician- thinking through hypothesis generation and Physician-Scientists scientists have become a progressively smaller refinement predicated on acquisition of data minority of scientists seeking and obtaining rather than resort to authority or dogma. Skills A robust core of physician-scientists was support from the NIH (5). More disturbing is conveyed through such teaching enhance the spawned by the aftermath of WWII and the the decline in the number of first time physi- capacity of “students” including medical stu- explosive evolution of the NIH. Various “great cian applicants for NIH support. It has plum- dents, house officers, clinical and research fel- society” programs undertaken by President meted recently, by 31% between 1994 and 1997, lows, as well as graduate students, postdoctoral Lyndon B. Johnson’s administration fueled a without a compensatory increase in applica- fellows, and faculty to embrace critical think- continual accretion of highly trained, profes- tions from MD/PhD’s. Since 1992 a 51% ing. The quality of the diagnostic assessments sional scientists. Their expertise, support and decrease has occurred in the total number of and therapeutic decision making of such stu- facilities, and commitment made research MD postdoctoral trainees being supported by dents who care for patients is augmented. careers competitive and progressively less the NIH (5). The number of MD‚s applying for Physician-scientists are valuable mentors not available to part-time investigators (4). A par- the prestigious Howard Hughes Medical only because of the thought processes they uti- adigm evolved in which clinician scholars and Institute Postdoctoral Fellowships declined by lize in their investigational pursuits but also physician-scientists in academic medical cen- 57% between 1996 and 1998 (5). because the scientific questions they attack fre- ters traveled parallel paths. However, threats quently derive from their experience in taking The Role of the Physician-Scientist to the physician-scientist contingent emerged care of patients. beginning about 20 years ago (5). They reflect- Physician-scientists are dedicated to discovery, ed a social transformation of American medi- A Prescription for Preservation of the but paradoxically, discovery may not be their cine (6) driven by profound political and eco- Physician-Scientist most important contribution. Examples of pro- nomic forces. found discovery abound. In the late 18th cen- The financial pressures on academic medical No society has been able consistently to sustain tury Jenner‚s research on cow pox and docu- centers are unprecedented. As pointed out by total health care costs in excess of 12% of its mentation of its efficacy led to its widespread Barker (10), “Typically, even public state-sup- gross domestic product (7). The accelerating use and established vaccination (vacca means ported centers must now generate 85% to 95% costs of biomedical research in our society cow in Latin) as the preferred means to prevent of their annual operating funds through patient could not be sustained either. The notion that smallpox and led to the discontinuation of vari- care revenues, research grants, tuition, and “we must make sure that no life-saving discov- olation, an earlier and more toxic approach. In philanthropy...Patient care revenue from hospi- ery is locked up in the laboratory” (8) led to a the late 19th century Koch identified the bac- tal and physician services typically makes up proliferation of expensive systems such as those terial cause of tuberculosis, discovered most of a center’s total operating revenue.” used in electron beam computed tomography, anthrax, and formulated his powerful postu- Such sources of revenue are stringently con- magnetic resonance imaging, and positron lates. Development of cardiac catheterization trolled by third-party payers including public emission tomography. Expensive procedures by Forssmann, Cournand, and Richardson; the and private insurers. Not only the academic evolved including percutaneous coronary inter- discovery of oncogenes by Varmus and Bishop; medical centers and the physician-scientist ventions, dialysis, interventional radiology, and elucidation of causes and consequences of that populate them but also physicians who do endoscopy. Economic competition led virtually hypercholesterolemia by Brown and Goldstein; not participate in them but who might other- every community hospital to acquire and development of vaccines for polio by Salk and wise have been attracted to careers as physi- employ these technologies. Thus, expense Sabin; and development of artificial organs and cian-scientists face unprecedented financial mounted. Political pressure became a threat as development of kidney dialysis by Kolff are pressures. The debt incurred by medical stu- well. It led to portrayal of the pharmaceutical more recent cogent examples. These and innu- dents has skyrocketed, now frequently exceed- industry as “public enemy number one.” The merable other examples illustrate the diverse ing $100,000 by the time of graduation. Careers industry provided a juicy target for candidates disciplines in basic and clinical science in in research provide considerably less remuner- who implied that a vote for them was a vote to which physician-scientists engage and the ation compared with those in clinical disci- curtail pharmaceutical expense thereby saving diverse medical