National Institutes of Health Physician-Scientist Workforce Working Group Report June 2014 In a word, I consider hospitals only as the entrance to scientific medicine; they are the first field of observation which a physician enters; but the true sanctuary of medical science is a laboratory; only there can he seek explanations of life in the normal and pathological states by means of experimental analysis.1 Claude Bernard, 1865 1 Bernard, Claude, An Introduction to the Study of Experimental Medicine (Dover edition 1957; originally published in 1865; first English translation by Henry Copley Greene, published by Macmillan & Co., Ltd., 1927 i The Physician-Scientist Workforce Working Group David Ginsburg, MD, Co-Chair Rena N. D’Souza, DDS, PhD James V. Neel Distinguished University Professor and Dean, School of Dentistry Professor University of Utah Departments of Internal Medicine, Human Salt Lake City, UT Genetics, and Pediatrics and Communicable Diseases James G. Fox, DVM Howard Hughes Medical Institute Professor and Director of the Division of Comparative University of Michigan Medical School Medicine Ann Arbor, MI Professor, Department of Biological Engineering Massachusetts Institute of Technology Cambridge, MA Sherry Mills, MD, MPH, Co-Chair Director, Office of Extramural Programs Helen H. Hobbs, MD National Institutes of Health Investigator, Howard Hughes Medical Institute Bethesda, MD Professor of Internal Medicine and Molecular Genetics University of Texas Southwestern Medical Center Susan Shurin, MD, Co-Chair Dallas, TX Deputy Director, National Institute of Heart, Lung and Blood Ann R. Knebel, RN, PhD, FAAN National Institutes of Health Deputy Director Bethesda, MD National Institute of Nursing Research National Institutes of Health Nancy Andrews, MD, PhD Bethesda, MD Dean, Duke University School of Medicine Vice Chancellor for Academic Affairs Elaine Larson, RN, PhD, FAAN, CIC Nanaline H. Duke Professor of Pediatrics Anna C. Maxwell Professor of Nursing Research Professor of Pharmacology and Cancer Biology Associate Dean for Nursing Research Duke University Medical Center School of Nursing Durham, NC Professor of Epidemiology, Mailman School of Public Health Gordon R. Bernard, MD Columbia University Melinda Owen Bass Professor of Medicine New York, NY Associate Vice Chancellor for Research Director, Vanderbilt Institute for Clinical Vivian S. Lee, MD, PhD, MBA and Translational Research Senior Vice President for Health Sciences Vanderbilt University School of Medicine Dean, School of Medicine Nashville, TN CEO, University Health Care University of Utah Lawrence F. Brass, MD, PhD Salt Lake City, UT Professor, Department of Medicine Associate Dean for Combined Degree and Physician Scholars Programs University of Pennsylvania Perelman School of Medicine Philadelphia, PA ii Timothy J. Ley, MD David G. Nichols, MD, MBA Professor of Medicine and Genetics President and CEO Division of Oncology The American Board of Pediatrics Washington University School of Medicine Chapel Hill, NC St. Louis, MO. Leon E. Rosenberg, MD Richard P. Lifton, MD, PhD Professor, Department of Molecular Biology Chairman, Department of Genetics Princeton University Professor, Genetics, Internal Medicine and Princeton, NJ Investigator, Howard Hughes Medical Institute, Yale University School of Medicine Andrew I. Schafer, M.D. Haven, CT Professor of Medicine Weill Cornell Medical College David Meltzer, MD, PhD. New York, NY Associate Professor of Medicine Chief, Section of Hospital Medicine, Director, Center for Health and Social Sciences Susan VandeWoude, DVM University of Chicago Professor and Associate Dean for Research Chicago, IL Department of Microbiology, Immunology and Pathology Juanita L. Merchant MD, PhD College of Veterinary Medicine & Biomedical H. Marvin Pollard Professor of Sciences Gastrointestinal Sciences Colorado State University Professor of Internal Medicine and Fort Collins, CO Molecular and Integrative Physiology University of Michigan Ann Arbor, MI iii Acknowledgments The Working Group gratefully acknowledges the following individuals who served as ad hoc members of the Physician-Scientist Workforce Subcommittees and whose insights contributed to the discussion of issues and recommendations presented in this report: Ad Hoc Subcommittee Members Robert M. Califf, MD Harry W. Dickerson, BVSc, MS, PhD Professor of Medicine Professor Director, Duke Translational Medicine Institute Associate Dean for Research and Graduate Vice Chancellor for Clinical and Translational Affairs Research Department of Infectious Diseases Department of Medicine /Cardiology College of Veterinary Medicine Duke University The University of Georgia Durham, NC Athens, GA Janine Austin Clayton, MD Robert Dittus, MD Director, Office of Research on Women’s Professor of Medicine Health and Division of General Internal Medicine Associate Director for Research on Women’s Vanderbilt University Health Nashville, TN National Institutes of Health Bethesda, MD Mildred C. Embree, DDS, PhD Assistant Professor of Dental Medicine Barry Coller, MD College of Dental Medicine David Rockefeller Professor and Physician-In- Columbia University Chief New York, NY Laboratory of Blood and Vascular Biology The Rockefeller University Mark C. Fishman, MD New York, NY President Novartis Institutes for BioMedical Research Thomas O. Daniel, MD (NIBR) Executive Vice President and President Cambridge, MA of Research & Early Development Celgene Corporation Don Ganem, MD Summit, NJ G lobal Head of Infectious Diseases Research & Vice President Timothy DeRouen, PhD Novartis Institutes for Biomedical Research Professor of Biostatistics, Oral Health Sciences, Cambridge, MA and Global Health Director, Center for Global Oral Health School of Dentistry University of Washington Seattle, WA iv Peter J. Gruber, MD, PhD Willie M. Reed, DVM, PhD, DACVP, DACPV Johann L. Ehrenhaft Professor and Chairman Dean and Professor Department of Cardiothoracic Surgery College of Veterinary Medicine University of Iowa Purdue University Iowa City, IA West Lafayette, IN Michael Dale Lairmore, DVM, PhD Mike J. Welsh, MD Dean and Professor Roy J. Carver Biomedical Research Chair in Veterinary Medicine Internal Medicine and Molecular Physiology University of California Davis and Biophysics Davis, CA Professor of Neurosurgery, Director of the University of Iowa Cystic Fibrosis Jeffrey Myers, MD, PhD Research Center Professor Director of the University of Iowa Institute for Department of Head and Neck Surgery Biomedical Discovery The University of Texas MD Anderson Cancer Roy J. and Lucille A. Carver College of Medicine Center University of Iowa Houston, TX Iowa City IA External Reviewer Steven M. Altschuler, MD President and CEO The Children’s Hospital of Philadelphia Philadelphia, PA The Working Group also wishes to acknowledge the support and contributions of NIH staff who provided administrative support to the Subcommittees, and of the contractors who provided research support. NIH Staff Contributors Yvonne Lau, MD, MBHL, PhD Mercedes Rubio, PhD Executive Secretary Program Chief, Psychopathology Risk and NIH ACD Physician-Scientists Protective Factors Research Program Workforce Assistant Director, Individual Research (PSW) Working Group Fellowship Programs NIH Extramural Research Integrity Officer National Institute of Mental Health Office of Extramural Research/Office of Bethesda, MD Extramural Program National Institutes of Health Xiaodu Guo, MD, PhD Bethesda, MD Scientific Review Administrator Review Branch National Institute of Diabetes and Digestive and Kidney Diseases Bethesda, MD v Lynn Morin, MA Lisa Evans, JD Public Health Analyst Scientific Workforce Diversity Specialist National Institute of Alcohol Abuse and Office of Extramural Research/Office of Alcoholism Extramural Program Rockville, MD National Institutes of Health Bethesda, MD Mary L. Garcia-Cazarin, PhD Health Scientist, Office of Dietary Supplements Rosemarie Filart MD, MPH, MBA AAAS Science & Technology Policy Fellow Medical Officer National Institutes of Health Detail at Office of Research on Women's Health Bethesda, MD National Institutes of Health, Bethesda, MD Jennifer Sutton, MS Extramural Program Policy and Evaluation Staff of OERStats Officer Division of Statistical Analysis & Reporting Office of Extramural Research/Office of (DSAR) Extramural Program Office of Extramural Research National Institutes of Health National Institutes of Health Bethesda, MD Bethesda, MD Misty L. Heggeness, PhD Sarah Shane Labor Economist Executive Assistant to OEP Director Office of Extramural Research/Office of Office of Extramural Programs Extramural Program National Institutes of Health National Institutes of Health Bethesda, MD Bethesda, MD Contractors Contractor support for this report was provided under the NET ESOLUTIONS CORPORATION (NETE) NIH Prime Contract HHSN276201300089U. NETE was supported by its subcontractors, Thomson Reuters and Catalyst Research & Communications. Individual team members include: NET ESOLUTIONS (NETE): Sandeep Somaiya, Contract Program Manager; Meghan Hudson, Task Coordinator; Sydney Gomes and Chrissy Juarez, Graphic Designers. Thomson Reuters: Joshua Schnell, PhD., Subcontract Director and Task Lead; Elmer Yglesias, David Jones, Leo DiJoseph, and Di H. Cross. Catalyst Research & Communications: Glora Stables, PhD, RD, Subcontract Director; Donna Lloyd- Kolkin, PhD, Task Lead and Report Writer; Heather Handel, MHS, Researcher. Meeting support for this contract was provided by Palladian Partners under Contract HHSN2632012000201. Individual team members include Joel Yaccarino, Chris Guilfoy, Helena Mickle, Samantha Wright and Daniel Greenstein. vi Special Recognition Hershel Alexander, PhD Director, Data Operations and Services Association of American Medical Colleges Washington, DC Professional Organizations The PSW-WG also gratefully acknowledges the assistance of the following organizations in providing insights and/or data used in the analyses presented in this report: American Association of Colleges of Nursing American Association for Dental Research American Association of Medical Colleges American Board of Internal Medicine American Board of Medical Specialties American Board of Pediatrics American Dental Education Association American Medical Association American Physician Scientists Association American Veterinary Medical Association Association of American Medical Colleges Association of American Veterinary Medical Colleges Federation of American Societies for Experimental Biology Howard Hughes Medical Institute Merial Veterinary Scholars Program vii Executive Summary Dr. Francis Collins, NIH Director, convened and charged the Physician-Scientist Workforce Working Group (PSW-WG) with analyzing the current composition and size of the physician-scientist biomedical workforce and making recommendations for actions that NIH should take to help sustain and strengthen a robust and diverse PSW. The need for the PSW-WG emerged from the recommendations of the Biomedical Research Workforce Working Group for strengthening the biomedical workforce. Its June 2012 report concluded that the training and career paths of physician-scientists were different than that of the non-clinician PhD workforce and that further study of this important segment of the workforce was needed. Warning bells about the health of the physician-science workforce were sounded as early as 1979 when future NIH Director James Wyngaarden observed that the physician-scientist with a medical degree was becoming “an endangered species.” He had observed that MD applicants for NIH project grants represented a progressively smaller fraction of all applicants than previously, while the corresponding fraction of PhD applicants had increased dramatically. In 1996, NIH established a committee headed by David G. Nathan to make recommendations about the perceived shortfall of clinician scientists. The Nathan Committee recommended creating new career development grants for patient-oriented research and loan repayment programs to help young physician-scientists pursue research careers despite an increasing load of educational debt. In spring 2013, the PSW-WG met and established subcommittees to discuss issues confronting the physician-scientist workforce. To inform its deliberations, the PSW-WG directed quantitative analyses of NIH IMPACII and other relevant databases to answer key questions, and considered the findings from qualitative research based on focus groups and interviews with students, research deans, and early career investigators. The PSW-WG defined physician-scientists as scientists with professional degrees who have training in clinical care and who are engaged in independent biomedical research. The PSW thus includes individuals with an MD, DO, DDS/DMD, DVM/VMD, or nurses with research doctoral degrees who devote the majority of their time to biomedical research. The PSW-WG recognizes that the primary goal of professional clinical education is the training of a skilled clinical workforce in the respective areas of practice, and that the portion of such professionals devoted to research will be small. However, findings which lead to advances in practice are driven largely by the work of investigators with a variety of degrees, of whom those with clinical training contribute essential knowledge and skills. Key Findings NIH is the primary funder of biomedical research and research training in the United States. The strength of the physician-scientist workforce reflects the nature of the nation’s investment in this arena. NIH funding increased greatly in the late 1990s from $13.675 billion (1998) to $27.167 billion (2003). During this period, institutions expanded their research capacity and training programs, and the number of physicians and non-clinically trained researchers applying for NIH R01 grants increased. NIH’s budget growth came to a halt in 2004 and has since remained static. After adjusting for inflation using the Biomedical Research and Development Price Index, the 2013 NIH budget was 21.9 percent below its viii 2003 level. The 2008 recession also reduced research funding from other sources, including pharmaceutical companies. Size and Composition of the NIH-funded Physician-Scientist Workforce It is difficult to obtain accurate numbers about the total size of the physician-scientist workforce because the data are considered proprietary by the pharmaceutical and medical device industries, and because data are not available on the number of physician-scientists whose research is funded by non-NIH sources. PSW-WG analyses indicate that there were approximately 9,000 physician-scientists in the NIH-funded workforce during 2008-2012, including 4,192 with an MD, 4,086 with an MD/PhD, 341 nurse-scientists, 253 veterinarian-scientists, and 161 dentist-scientists. Though their percentage of the overall biomedical workforce has been steadily decreasing since the 1970s, the total number of physician-scientists with a medical degree has remained remarkably steady over the past few decades, with MDs and MD/PhDs each comprising about 50 percent of the physician- scientist workforce with a medical degree. At the same time the average age of entry into the independent workforce (marked by receipt of an NIH RPG) has increased steadily, as has the average age of the physician-scientist workforce. Nearly three-quarters of the MD RPG awardees were white and another one in five were Asian. Although there has been significant growth for Asian and Hispanic awardees over the past decade, there has been less growth for African-Americans and Native Americans. The lack of diversity of the physician-scientist workforce is a source of very serious concern to the NIH and to the professions. Other groups are addressing these difficult issues; the PSW-WG did not attempt to duplicate their efforts, and endorses strong investment in improving minority participation in scientific leadership. Female physician-scientists remain underrepresented in some segments of the NIH-funded physician- scientist workforce. For physician-scientists with a medical degree, the percentage of female MDs who are RPG grant holders has increased from 17 percent in the mid-1990s to 29 percent currently. However, for MD/PhDs, growth in women investigators has been slower, increasing from 17 percent in the mid- 1990s to 22 percent at the present time. Among veterinarian-scientists who receive RPGs from the NIH, men outnumber women by about three to one, despite the fact that the overwhelming majority (90 percent) of students enrolled in schools of veterinary medicine are women. In contrast, among nurse-scientists applying for and receiving RPGs from NIH, women outnumbered men by approximately nine to one, reflecting their numerical dominance in the profession. Among dentist- scientists, women received about one-third of the RPGs awarded, yet constitute only about one-quarter of the dental-research workforce. Challenges Confronting the Physician-Scientist Workforce Several challenges confront the physician who elects to pursue a research career. Increases in the cost of obtaining medical education can burden students with high amounts of debt, especially those who were not enrolled in an integrated MD/PhD program. The training required to obtain competency in clinical and scientific research continues to increase, resulting in a marked prolongation of the training process. The transition between finishing a clinical or post-doctoral fellowship and initiating an independent research position is a very vulnerable period in the career path of all physician investigators. Funding pressures have mounted with the decrease in NIH funding and physician-scientists are increasingly being asked to support a higher percentage of their income by seeing patients. Financial opportunities in ix