Robert Lembo, MD, Executive Director, Graduate Medical Education from the National Institutes of Health, turns the spotlight on training physician scientists and clinician investigators through the process of graduate medical education in the U.S
In support of the National Institutes of Health (NIH)’s research mission, the NIH Clinical Center – the 200- bed research hospital located on the NIH campus in Bethesda, Maryland – is committed to both excellence in scientific discovery and the clinical care of patients with rare, complex or refractory diseases enrolled in human subject research protocols.
Since 1953, the Clinical Center has supported both the professional growth and development of a cadre of physician-scientists and clinician-investigators to improve the Nation’s public health. That commitment began in the 1950s with the innovative Clinical Associate Program (CAP) – which fostered the development of many medical school faculty and academic department chairs, ten National Medal of Science Awardees and nine Nobel laureates – and continues today with a variety of clinical and translational research training programs within the NIH Intramural Research Program (IRP) and functioning within the Clinical Center.
Graduate medical education
The CAP model recruited research-naïve physicians from across the Nation who had completed two or three years of clinical post-graduate medical education to engage in laboratory or patient-oriented research under NIH Senior Investigator mentorship while providing clinical care to patients who were enrolled in research protocols at the Clinical Center. At inception, it was the prototype for training in “bench-to-bedside” research.
Despite the favourable impact of the CAP on the advancement of academic medicine nationally in the 1970s, interest in the Program waned in subsequent years. Factors leading to this decline included the progressive increase in the number of funded dual degree (MD-PhD or DO-PhD) programs training physician-scientists at medical schools and the requirement for research or scholarly activities within accredited residency or clinical fellowship training programs. How- ever, even with an expanded portfolio of research career development opportunities nationally, the number of physicians pursuing research-intensive academic careers has not increased and there has been a decline in the number of grant-supported, independent physician-investigator over time. Contributing to this decline are factors including level of educational debt; length of time in training to achieve clinical competence and subspecialty certification in the context of research training; decreased availability of and increased competition for funding support; insufficient protected time to conduct research; family responsibilities; and balancing clinical, research and education responsibilities within academic settings.
Research training
Since the phase-out of the CAP, the NIH IRP has developed several approaches to mitigate prospective physician-scientists or clinician-investigators becoming an “endangered species” within the U.S. healthcare workforce. These include research-intensive training pro-grams targeted to medical, dental or veterinary students; graduate medical education trainees; and early career physician-investigators, which provide mentoring, tangible academic resources and financial support.
For pre-professional students, the NIH focuses on “early capture” mentored research training. The flagship offering is the Medical Research Scholars Program, a nationally competitive, stipend-supported, 12- month residential research career development experience on the NIH campus, which enrols approximately 50 medical, dental or veterinary students per- mitted a study “year out” from their degree-granting institutions. These students engage in mentored basic, clinical, or translational research projects that match their professional interests and career goals. The research experience is enriched with lectures focusing on the process of scientific discovery; journal clubs, and patient-oriented teaching rounds at the Clinical Center. The success of this approach is reflected by the most recent MRSP graduates, who published 64 peer-reviewed manuscripts, presented 112 research abstracts; and received nine awards for outstanding research achievement.
For medical school graduates, the NIH approach is to combine both clinical and research training within structured speciality or subspecialty graduate medical education programs. The Clinical Center sponsors 18 Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs leading to board certification in selected fields of Internal Medicine, Surgery, Pathology, Genetics, Neurology, Paediatrics or Psychiatry. These Programs combine prescribed clinical training with an additional one to three years of mentored, fully-funded research activities, which sets them apart from the standard national training model. Also, these programs offer loan repayment to defray educational debt and formal instruction in the design, conduct of bioethical and regulatory aspects of clinical research in a highly favourable clinical learning environment. Through a collaborative arrangement with Duke University, selected trainees submitting a thesis can earn a Master of Health Sciences degree in Clinical Research. The success of this model is exemplified by the NIH’s largest ACGME pro-gram, the combined Hematology-Oncology fellowship program, which trained a total of 65 subspecialty clinical fellows over the past five years and graduated 25% into faculty positions at academic medical centres, 50% as investigators at research-intensive institutions such as the NIH, and 11% in research-related positions in the pharmaceutical industry.
Also, for certified subspecialist physicians primarily interested in combining sub-speciality clinical training with research skills development, the NIH offers multiple non-accredited fellowship programs in many medical or surgical fields analogous to the CAP. In total, these “niche” research-oriented graduate medical education training programs are currently enrolling over 150 physicians on the NIH campus.
Closing remarks
Finally, to maintain physician-scientists or clinician- investigators who have completed clinical training in the research-intensive career pipeline, the NIH IRP offers the Stadtman Tenure Track Investigators and the Lasker Clinical Research Scholars programs. Since 2009, the Stadtman competitively recruits productive early-stage investigators, including MD- or DO-PhD graduates, to mentored, fully-funded tenure track positions in the IRP, focusing on a specific scientific area or innovative, high impact research. Since 2011, the Lasker competitively recruits physician-scientists to pursue fully funded independent research in the IRP for five years, with the option of continuing at NIH as a tenured senior investigator or to transition with NIH funding to a research-intensive university or research institution. While early in its evolution, the Lasker has enrolled 34 physician-scientists to date and four have successfully earned tenure as investigators at the NIH.
