The disappointing Physician-Scientist Workforce Working Group Report

Did the authors of the recommended actions in the Physician-Scientist Workforce Working Group Report read the rest of the report?

The report: was released last month. First, some excerpts:

This set of facts about physician-scientists was interesting:

• Over the last 25 years, 37 percent of Nobel Laureates in Physiology or Medicine had an MD degree. 
• Over the Lasker Awards’ last 30 years, 41 percent of the Basic Awards and 65 percent of the Clinical Awards have gone to MDs. 
• 69 percent of NIH Institute Directors have an MD degree. 
• 60 percent of the National Academy of Sciences Class IV (Biomedical Sciences) members have an MD degree. 
• 70 percent of the chief scientific officers at the top 10 pharmaceutical companies have an MD degree.

A key focus of the Working Group was determining why the supply of physician-scientists is falling. The uncertainty of grant funding was, not surprisingly, a top concern cited by the students, junior faculty and medical school deans interviewed.  Here is a sample of excerpts from the body of the report:

• Qualitative research undertaken by and on behalf of the PSW-WG indicated that the uncertainty of funding is by far the biggest concern of young physician-scientist faculty; its importance cannot be overestimated. (page 40; emphasis mine here and below)

• The uncertainty of research funding was the major challenge to a career in research articulated by both dual degree students and single degree students interested in pursuing a research career. By far, the largest concern from students interested in research is the issue of funding and the uncertainty of the funding. Job stability is very concerning to those who wish to pursue careers with research components. (page 80) 

• The [MP/Ph.D.] students admired successful physician-scientists, who are able to continue getting funded for research. . . . On the other hand, these students described the older physician-scientists who are running a lab, being a mentor, and an academic teacher/advisor, as looking tired. Each student in the focus group verbalized that the uncertainty of research funding was the major challenge to a career in research. Financing a career in research and the perceived politics of government funding makes each one nervous about being able to sustain a career as a physician-scientist. (page 91) 

• Most [MD] students respected and admired those who are physician-scientists, but they were not particularly interested in navigating the grant funding process. . . . “And it is almost like being, to me, how artists have to go out and get gigs and do that whole thing. I feel like researchers have to like go out and find grants, find funding, find people who believe in them, and it just seems really, really tedious.” From a student who has aspirations to do research: “I think the funding environment now is something that is pretty scary."  

• [Medical school deans] identified the most important factors that they believe influence students’ career decisions. The stability of research funding and ability to sustain a career as a physician-scientist was frequently mentioned as an important factor, since students are observing their professors losing research funding and complaining bitterly about it. (page 111) 

• Most [young faculty] expressed fear and frustration about the possibility of not being able to continue their research  careers if they are not able to secure an R award. They expressed the fear that they have invested so much of their adult life preparing to do scientific research and it could all be ended by not being successful with an R award. They have sacrificed both a lucrative clinical salary, as well as precious time in the hopes of being able to continue to build a research career. (page 117)

Within the body of the report can be found all the key concerns that deter qualified individuals from embarking on a career as a physician-scientist and that threaten the morale of those already engaged in such a career. This leads one to wonder, then, whether whoever devised the list of recommended actions actually read the report.

Trainees contemplating embarking on a career as a physician-scientist and those (like myself) who have already committed to such a career are worried about the overall stability--short-, medium- and long-term--of careers in biomedical science. Incredibly, the recommendations listed at the conclusion of the report are entirely comprised of the standard fare of training programs, fellowships, new investigator privileges etc that we have seen discussed, tested and/or implemented ad nauseum up to now. As before, these all would serve to continue to front-load the pipeline and do not concern what was clearly the chief concern identified: the highly uncertain stability and desirability of physician-scientist positions downstream.

Trainees are not dumb: the report shows that they are not only thinking a year or two or three ahead. They are looking ahead to what happens after that first K award or after they get their first R01: when they are no longer young investigators; perhaps when they have kids, a mortgage, college tuition to pay. The fact that the authors of the recommendations, ignoring the findings presented in the report, think that they can alleviate the shortage of physician-scientists by luring young investigators with goodies up front and hoping that they will forget about increasing pressures, stress and instability downstream is astonishing.

Tacky

Some non-physicians think physicians are overpaid. This physician disagrees, but does think that a number of specialties are way overpaid (I'm looking at you radiology, dermatology and some others--you know who you are).

After walking through a university parking lot while on a visit recently, I had these thoughts:
1. If you are in a highly paid specialty, there is no need to drive to work in a late model Ferrari. This is in bad taste in a time of great concern about health care costs.
2. Even if you feel that you need that Ferrari and need to drive it to work, you do not necessarily need vanity license plates that announce you paid for the vehicle by billing for your grossly over-compensated medical service.
3. All of the above is doubly true if you work for an academic medical center.

Part of a dying breed

The DrugMonkey blog is laden with the type of practical, career advice that I wish I had been given early on. I was thinking recently about a post from last year:

So noob, you put in one grant, it didn't get funded and you feel mopey? . . . .
It is not about what anyone else or the "typical" person has done. It is about doing whatever you possibly can do until that Notice of Grant Award arrives.
My stock advice right now is that you need to have at least one proposal going in to the NIH for each standard receipt date. If you aren't hitting it at least that hard, before you have a major award, you aren't trying. If you think you can't get out one per round.... you don't really understand your job yet. Your job is to propose studies until someone decides to give your lab some support.
My other stock advice is take a look at the payline and assume those odds apply to you. Yes, special snoflake, you.
If the payline is 10%, then you need to expect that you will have to submit at least 10 apps to have a fighting chance. Apply the noob-discount and you are probably better off hitting twice that number. It is no guarantee and sure, the PI just down the hall struck it lucky with her first Asst Prof submission to the NIH. But these are the kinds of numbers you need to start with.
Once you get rolling, one new grant and one revised grant per round should be doable. They are a month apart and a revision should be way easier. After the first few, you can start taking advantage of cutting and pasting a lot of the grant text together to get a start on the next one.

And also, in the same vein, this:

In the face of budgets which allow the funding of only a subset (a third? quarter?) of the grants which are excellent and interesting and impactful and all that jazz, review becomes variable. Meaning the difference between making it into a fundable score and just missing a fundable score takes on the appearance of chance. The only way to beat such odds is to give yourself more chances at the game. This means writing and submitting multiple applications (on different topics, of course).

And I was castigating myself: "how come I'm not doing this? I obviously need to submit more applications; why can't I find the time?"

And then it occurred to me: I was thinking this while I was writing a medical clearance letter on behalf of a patient.  And just before that, I was reading about an unusual case I saw in clinic on UpToDate. And I have my half day clinic the day after tomorrow, which, if you include associated documentation, follow-up, reading and responding to patient queries, really takes up a full day. And the month before, I was on the hospital consult service, which breaks up the day and eats up time. On top of that, I have the same responsibilities as DrugMonkey and most of his audience: stay up to date on the science literature, run a lab, write papers and, oh yes, write grant applications.

Another thing about DrugMonkey is that, as far as I can tell, he does not have kids at home. The thing about having kids is that when they're not driving you crazy--which, fortunately, tends to be more than 50% of the time--you want to spend time with them; and your spouse, also. In fact, now that I think about it, by virtue of being single, divorced or old enough to have adult kids, many (most?) of the investigators I know who are thriving in the current environment do not have kids at home.  Hmmm.

Medical students are smart. They can put two and two together: soft money salaries + historically low NIH grant success rates=job insecurity and potential for high stress.  "Fixes" for the system thus far proposed generally involve pumping more physicians into the system through training grants and lower barriers for initial R01 grant awards. Proposed measures seem to never involve increasing downstream job security. Our society idolizes youth. This includes the NIH: trainees and new investigators are loved.  Once you've been sucked into the system and you're trying to get your grants renewed, you're on your own buddy. Think the PhDs reviewing your grant applications or tenure file give a fig that you are a physician-scientist? Think again. Physicians in training--and this goes for MD-PhD students also--aren't blind: they see what is happening.

There: I've solved the puzzle of why medical students are less inclined than ever to do what I do for a living: of why predictions that physician-scientists are a "endangered species" are coming true.

Annals of ineptitude: NIH grant planning edition

Still clearing my desktop.

The April 4th issue of Science has a ten page section up front regarding the current travails of U.S. grant-funded researchers: "Chasing the Money".

The NIH funding situation has been getting progressively worse over the past few years. Meanwhile, over the years, the NIH has kept coming up with new schemes to direct funds to new investigators in order to pump fresh blood into the system.

Now, read the following excerpt from the lead article:

• The agency makes it easier for new investigators to get funding, for example, but it doesn't know how they fare 5 years out, when their first big grant is up for renewal. "We want to make sure we're not setting them up for failure," says Sally Rockey, NIH's deputy director for extramural research. The agency plans to start tracking these people, to gauge whether they're headed for dire straits.

Now read it again.

Note the words "plans to start." Plans. To. Start. Plans to start. Now? Now?(!) 

Two things: 1) when starting a program, it's good to think through the outcomes beforehand. Especially when your enticing people into a career and investing heavily in them. Especially when their livelihood while pursuing that career is dependent on your organization. Similarly, it's good to try to ascertain results/outcomes in as timely a fashion as possible. 2) Sally Rockey and her colleagues should read "Chasing the Money" in the April 4th edition of Science as well as the many other articles out there about the current funding environment. They might learn something. Why would these new investigators not be headed for dire straits?

File this away under the NIH subsection of government ineptitude. 

Clearing my desktop part 2. Medicine-the ABIM piles on

Two recent articles of interest concern medicine, and specifically how burdens unrelated to patient care continue to accumulate in a cruel fashion.  I want to highlight one quotation from each article. These quotations perfectly echo my sentiments about one particular new aggravation .

The first article can be found here.  The following quotation is in regard to one new initrusion that I and many, many of my colleagues find outrageous. The American Board of Internal Medicine (ABIM) continues to ratchet up the monetary and time burden of recertification with no evidence that anyone, aside from the ABIM itself, will benefit: 

• doctors also face board recertification in the various medical specialties that has become time-consuming, expensive, imposing and a convenient method for our specialty societies and boards to make money."

The second article--also dealing with new cruelties inflicted on physicians who would rather just be providing patient care--is here.  And here is the quotation: 

• Almost comically, the response of medical leadership—their solution— is to call for more physician testing. In fact, the American Board of Internal Medicine (ABIM)—in its own act of hostage-taking—has decided that in addition to being tested every ten years, doctors must comply with new, costly, "two year milestones." For many physicians, if they don't comply be the end of this month, the ABIM will advertise the doctor's "lack of compliance" on their website. 

Physicians would not be up in arms about these dictates from the ABIM if there were any shred of solid evidence that they improved patient outcomes. But there isn't. There is just yet more intrusion on the schedule, budget and sanity of physicians; yet more paperwork.

Clearing my desktop part 1. Science-the broken research funding system.

I have not written here for a while. Some of the key problems with the biomedical research enterprise that I have been thinking about of late have been described by prominent scientists in widely-circulated articles. What I would have written--at least regarding the descriptions of the problems, if not the solutions--would have been redundant.

Here is an example of one of these articles (in the op-ed section of the Wall Street Journal). Regarding the authors' description of the problems with grant review, I can only say "amen."  (The article, unfortunately, may be behind the Journal's paywall.)

Here is another example. Again, regarding the overview provided and the descriptions of the problems with the current system of research funding: "amen."

Whew, another three sentences written . . . I deserve a little break

Pro . . .cras. . .tin. . .ation

I do a lot of interesting reading while I'm in the midst of grant writing. The number of sentences I can write before "needing" a break is inversely proportional to the time remaining before the deadline, starting at about three and increasing exponentially beginning a few days before the deadline. If not for grant and manuscript writing, my knowledge of history, philosophy, Consumer Reports ratings of refrigerators, the 10 best places to retire, the 10 worse things to say on a first date, the Freedom-class littoral combat ship and Amazon.com's selection of V-neck undershirts would be infinitely smaller.

Recently, I ironically found myself reading this on my iPad, having stumbled upon this article while lounging on the living room couch, surfing the net and diligently avoiding completing a grant application due the next day. The article, "Why Writers Are the Worse Procrastinators," was strangely reassuring. I'm a professional writer in a way. Here I have been beating myself up about my chronic procrastination, but it turns out that, if you're a writer, it just comes with the territory.

Much of my training occurred before the advent of online grant submission. Evidence that a lot of my colleagues were fellow procrastinators? Scientists and administrative assistants waiting eagerly by the FedEx pickup box to ensure pickup 5 PM on the day before major grant deadlines. Common knowledge in the local biomedical science community about where to take FedEx packages for the very last after-hours drop-off (I seem to remember that it was at the airport FedEx office). True story: when I was in training, my lab's Principal Investigator missed the last FedEx and UPS pickups the day before a major NIH grant was due. I remember the frantic copying and stapling: even more panicked than usual the day before grants were due. The PI's solution: buy a ticket for a transcontinental  flight that very night to Washington DC, put a postdoctoral fellow on the plane with the application (and all 14 copies, or whatever it was back then) in hand, and send him off to hand-deliver the application to the NIH.

A tip for those of you whose procrastination leads to self-flagellation and misery: read this essay on Structured Procrastination by John Perry, emeritus professor of philosophy at Stanford, and his follow-on book, The Art of Procrastination: A Guide to Effective Dawdling, Lollygagging and Postponing.  They're both witty, easy reads and, importantly, many people (including me) find that Perry's way of looking at procrastination makes a huge difference in how they think about their procrastination and themselves. My only slight concern is that maybe these writings have lulled me into too much complacency about my procrastination and have perhaps forestalled my eventual self-"cure."