Culturing the Future of Medicine: The Imperative of Strengthening the Infectious Diseases Physician-Scientist Pipeline

Never in the history of infectious diseases has the intersection of medicine and scientific innovation been as dynamic and critical as it is today. The global coronavirus disease 2019 (COVID-19) pandemic has showcased an unprecedented acceleration in the development of vaccines and therapeutics [1]. In only 11 months, researchers transformed preclinical studies into practical solutions, leading to the creation of effective mRNA vaccines against the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pathogen. This remarkable achievement has not only saved millions of lives but also paved the way for new vaccine technologies to combat other diseases and the development of innovative therapeutics [2]. The advent of mRNA vaccines and RNA-based therapeutics is but one of many examples demonstrating how swiftly scientific discoveries can be translated into impactful solutions for management of infectious diseases at a population level.

At the heart of this translational process are physician-scientists, who, with their rigorous training in scientific discovery and clinical medicine, play a pivotal role in propelling medical innovation forward. Nevertheless, the last 4 decades have seen a troubling decline in the physician-scientist workforce [3]. A 2020 American Medical Association (AMA) survey, which has been administered annually since 1980, revealed that only 1.3% of physicians reported engaging significantly in research as a primary professional activity, a slow and steady decline from 1.6% in 2011 [4]. Despite the limitations of survey-based data, this decline is a worrisome trend considering the increasing complexity of medical challenges. With people living longer, the emergence and reemergence of infectious disease pathogens, and the far-reaching health implications of climate change, the need for effective diagnostics, treatments, and preventive strategies is more pressing than ever. A robust physician-scientist pipeline is not merely beneficial; it is a critical component in the public health response to infectious diseases. So, the question arises: How do we reverse the declining trend in physician-scientist representation in the biomedical workforce and ensure the sustainability of this vital segment?

THE CHALLENGES

To effectively bolster the physician-scientist workforce, we must first understand the barriers hindering the recruitment and development of these essential professionals (Figure 1). A primary obstacle is the scarcity of research opportunities during the demanding years of clinical training. Residents, often working 80 hours per week, find little time to develop the research skills necessary for a physician-scientist career. Even those who pursue the research career-oriented MD-PhD pathway, followed by physician-scientist training programs structured to merge clinical and research training, often have years of dedicated clinical requirements between their PhD thesis and postdoctoral research fellowship [5]. Moreover, funding for research-oriented trainees is limited at all stages. Over the past decade, fellowship awards and early career development grants (eg, T32, F32, K01, K08, K23, K12/KL2, K99/R00, etc.) have plateaued [6], exacerbating the difficulty for training institutions to provide dedicated research time to interested trainees. Striking a balance between focused time for research and not further prolonging already lengthy training times is essential. Expanding physician-scientist training programs, which offer accelerated and condensed clinical training while providing time for intensive research, is an option that institutions may consider, to support physician-scientist trainees.

Threats to financial wellness due to the escalating cost of medical education are another significant barrier. The median debt of medical school graduates with loans increased from $184 000 in 2011 to $200 000 in 2019, adjusted for inflation [7]. In the 2017 Infectious Diseases Society of America compensation survey, research-focused infectious disease physicians earned $20 000–$30 000 less per year, on average, compared with their clinically focused peers [8]. With longer training durations and stringent specialty certification requirements, physician-scientist trainees often face deferred loan repayments and extended transitions to research independence. Indeed, the median age for obtaining a first National Institutes of Health (NIH) R01 grant has risen significantly in the last 2 decades, from 39 years in 1995 to 46 years in 2020, illustrating the protracted pathway to research autonomy [4].

International medical graduates (IMGs), nearly a quarter of the US graduate medical education pool, encounter additional obstacles to joining the physician-scientist workforce. Being on training or work visas (J1 or H1B) and not having permanent US resident status or US citizenship are exclusion criteria for most federal training grants, limiting funding access for a significant portion of interested trainees. This lack of financial support hinders career progression for IMGs and leads many IMGs to opt for less restrictive career paths, primarily in clinical practice, representing a lost recruitment opportunity for the physician-scientist pipeline.

Another hurdle arises for those who persist on the physician-scientist path through training, as the transition to faculty and the early faculty years poses new challenges. The academic job market for newly qualified physician-scientists is fiercely competitive, with most positions contingent on securing career development awards. Without grant funding or adequate institutional support, many early career faculty physician-scientists face the tough choice of abandoning the physician-scientist track despite years of focused training or delaying faculty appointments while working in poorly defined, noncompetitive staff or instructor positions. This compounds financial unwellness at a time when many are looking to buy a home, grow a family, and begin saving for retirement. Alternatively, accepting a clinically demanding faculty role while pursuing research at the same time is unsustainable and often leads to burnout. Hence, the current model demotivates and hinders the retention of talented physician-scientists.

LESS TALK, MORE ACTION: IGNITING AND SUSTAINING INTEREST IN PHYSICIAN-SCIENTIST CAREERS

Despite its challenges, the physician-scientist career path remains a rewarding and exciting endeavor. Trainees often enter medicine with an inherent curiosity about science, human health and disease, and the potential for improvement. Training as a physician-scientist nurtures this curiosity and also offers vast opportunities for scientific exploration and substantial impact on public health. Addressing the challenges in becoming a physician-scientist is achievable but requires proactive measures.

It is crucial to spark interest in the physician-scientist career throughout training, particularly in newly matriculated medical students. Providing positive insights into the richness and versatility of the physician-scientist career path can inspire and encourage trainees to view it as a viable and thrilling option. If trainees only perceive a cycle of grant writing and the struggle to sustain a research program, they may be deterred. Emphasizing opportunities for mentorship, multidisciplinary team science, advocacy, scientific discovery, and patient care highlights the numerous positives of a career as a physician-scientist. It is also important to recognize that, for some, developing interest in a research-focused career may come in later training years. Existing models must be adaptable to nurture the “late bloomer” phenotype with opportunities to acquire the necessary skills and integrate research training during the postdoctoral phase.

Once trainees are engaged, it is essential to provide the necessary resources to support and sustain their interest throughout their training. Expanding funding opportunities [9], such as NIH fellowship grants and institutional grants that allow institutions to protect trainees’ research time during residency and fellowship, is key and this support must extend into the vulnerable early faculty years. Streamlining the process for existing funding mechanisms, such as K-level career development grants, by reducing bureaucratic hurdles (eg, high burden of administrative paperwork and Institutional Review Board and Institutional Animal Care and Use Committee regulations) and increasing the transparency of grant review processes and compensation and hiring decisions, are also crucial. To enhance the effectiveness of grant review processes for training and career development grants, it is crucial that reviewers are well versed in standardized review criteria and offer constructive feedback to applicants. Doing so can significantly soften the disappointment experienced by promising candidates following unsuccessful initial applications, mitigating the tendency to become disheartened and abandon their pursuit of a physician-scientist career. Furthermore, widening the eligibility criteria for grants to include IMGs in research training would significantly expand the recruitment pool.

Loan repayment programs offset the financial burden of extended training, but they need to be better advertised and expanded to serve as a strong incentive. Additionally, academic institutions must commit to nurturing junior faculty physician-scientists, particularly when they are in the process of securing independent career development awards. The current paradox, in which new graduates need funding to protect their time for research yet are rarely hired without substantial funding already secured, leaves many in uncertainty and contributes to attrition from the physician-scientist workforce. Institutions that invest in developing junior faculty physician-scientists as they pursue independent funding can expect a return on their investment when career development and research project grants are ultimately awarded.

Addressing these challenges is a complex task for individual institutions, and a collective effort is necessary to enhance the recruitment and retention of physician-scientists. This collaborative approach should begin with a clear definition of the needs: What is the optimal number of physician-scientists required to meet current and future health care demands? What resources are necessary to train this target number? And crucially, how can institutions effectively advocate for and secure the funding needed to meet these goals? Having clear answers to these questions will be key for developing a strategic plan that addresses the gaps in the physician-scientist pipeline and ensures its vitality for the future (Figure 2).

CONCLUSIONS

The current biomedical challenges, especially in responding to the threat of infectious diseases, highlight the crucial role of physician-scientists as catalysts for translating scientific innovation into practical medical applications. However, the diminishing workforce poses a significant threat to effectively addressing the evolving complexities of health care challenges. The barriers we have outlined, ranging from limited research opportunities during clinical training to financial burdens and the competitive faculty job market, require a concerted effort from key stakeholders, including funding agencies, academic institutions, and medical training programs, to cultivate and sustain the physician-scientist pipeline. These challenges prompt deliberate actions that surpass mere rhetoric, emphasizing the improvement of opportunities for funding research while ensuring fair compensation for individuals passionately pursuing their professional calling and who will likely be the best line of defense in looming biomedical crises and future pandemics.

Notes

Author contributions. B. K. T., I. S., and B. S. conceptualized the content. B. K. T. drafted the manuscript and designed the figures. I. S. and B. D. S. revised all versions of the manuscript. All authors reviewed and approved the final manuscript.

Disclaimer. The views expressed are those of the authors and do not necessarily reflect the official views or policies of the NIH or the Department of Health and Human Services nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

Financial support. B. D. S. is supported by the National Institutes of Health (NIH) (grant numbers R01HL149883, R01HL153122, P01HL154998, P01AG049665, and U19AI135964). B. K. T. is supported by the Center for AIDS Research, Emory University (grant number P30AI050409); and NIH Building Interdisciplinary Research Careers in Women's Health Program (grant number K12HD085850). I. S. is supported by the intramural research program of National Institute of Allergy and Infectious Diseases, NIH.

References

Author notes