Ensuring the survival of the clinician-scientist.

Many forces threaten the survival of the clinician-scientist as an academic species, among them: (1) the changing health environment; (2) the complexity of and rapid advances in biomedical science, which necessitate that MD-PhD graduates "retool" after completing their clinical training; (3) the length and rigor of the research training required to train clinician-scientists adequately; (4) the scarcity of funding for subspecialty training positions; (5) the perception that the successful clinician-scientists in academic medicine are those who focus on basic, rather than clinical, research; (6) the indebtedness of young physicians when they complete medical schools; (7) the fierce competition for research funding; and (8) pessimism among senior faculty about the clinician-scientist's potential for survival. There are solutions to these issues that must be vigorously pursued to ensure the survival of the clinician-scientist: (1) Rigorous six- to seven-year programs (e.g., two in internal medicine, four to five in a subspecialty) for physicians must be established. They should include a minimum of three years of research and should lead to board certification in internal medicine, pediatrics, psychiatry, etc., board certification in a subspecialty, and a PhD in clinical science. (2) These programs must have a choice of three tracks, (a) disease-oriented basic research, (b) clinical investigation in patients, and (c) health services research. Such a program--the PhD in Clinical Science program--has recently been approved and begun at the University of Colorado. (3) Funding organizations such as the National Institutes of Health should designate their training resources primarily for programs with a minimum of three years of formal and rigorous research training. (4) These rigorous research training programs must be integrated with young-faculty awards for clinician-scientists to ensure continuity in their investigative careers. (5) Loan-repayment programs must be developed to repay student loans of clinician-scientists during their first five years as faculty members. (6) Against the background of these changes, senior faculty as mentors must articulate to emerging clinician-scientists the excitement of being involved in future discoveries in biomedical science.