A Global Perspective of Clinician Scientist Training Programs

INTRODUCTION

Clinician scientists (CS) are physicians who are well trained in clinical and biomedical research and are uniquely placed to bridge the gap between clinical care and research. They intend to develop a comprehensive understanding of the disease from the molecular level up to the clinical presentations and management. Hence, they can influence the translational aspects of research significantly.¹ It is now well known that very few physicians take the path of a CS career (only 5% in 1985 and declining to 2% in 2014),² and this has led to a sustained decrease in this spirited workforce in healthcare. It is not uncommon to see that the CS as a group is increasingly being referred to as an ‘endangered species.’ Several reasons are attributed to this decline, and many strategies are proposed to preserve the species.^1–5 One primary preservation strategy is the development of clinician scientist fellowship (CSF) or CS development or simply CS programs (CSP) across the globe. The programs are structured or unstructured and mainly driven by universities and other academic institutes with critical implications for healthcare.^1–13 Compared to an unstructured program, the CS ina structured program was found to be doing better with more grant applications, publications, and significant research positions.¹⁴ They are mainly funded by public programs through various funding schemes. The primary goals of CSF or CSP are twofold. One is to increase the dwindling numbers of CS in healthcare. Two, to strengthen the translational aspects of the research.

ADVANTAGES OF STRUCTURED CSF PROGRAMS

1. They help address the lack of proper training and mentorship for CS in their early careers.

2. Increases the workforce of CS in healthcare.

3. Improves the translational relationship between clinical practice and biomedical research.

4. Provides a protected time for research with more flexible training.

5. Improves the working conditions of CS during the program.

6. Incorporates advanced training curriculum for the CS.

7. CSF or CSP helps with collaboration, networking, and developing an identity as a clinician scientist.

MODELS OF CSF PROGRAMS ACROSS THE GLOBE

There are several structured and unstructured programs globally, and a few geographically representative ones will be discussed here.^3–27 There are many differences across the countries in relation to their medical education structure, opportunities to pursue MD/PhD programs, and long-term support for a CS career. The general curricular domains of the CSF or CSPs include scientific concepts, research designs, clinical study operations, data management and informatics, study and site management, product development and regulation, ethics and participant safety, professionalism, communications, teamwork, and leadership.¹¹

United States

The landscape of the CSF/CSP in the US is broad and comparatively well-developed than its counterparts across the globe. The MD/PhD programs have existed for more than 50 years. There are nearly 100 programs, half of which are funded by the NIH.⁵ However, it is unlikely to meet the predicted demand for a CS workforce.

An appreciable step that significantly supports the MD/PhD dual-degree students began in 1964 by the National Institute of General Medical Sciences (NIGMS), a component of NIH, which manages the Medical Scientist Training Program (MSTP). NIGMS provides MSTP grants to the institutions, which in turn also add their resources to support the CS trainees. While several critical issues may need to be addressed to improve this program,¹² its contribution to training nearly 15,000 CS trainees, so far, is envious.

The NIH K08, K12 and K23 training awards support early career clinicians toward the development of a research career.^3,12 Later, as an extension to the K08/K23, is the K02 award, which in some NIH institutes is restricted to an individual with a clinical degree.³ The NIH T32 training grants allow postdoctoral specialists to have blocks of protected time to develop their investigative skills so that the CS can move towards a career development award (CDA) and later acquisition of independent grant funding (e.g, from disease foundations and the ultimate R01 grant from the NIH).⁶

The Association of American Medical Colleges (AAMC) has had a committee since 2019 called ‘Training Opportunities for Physician Scientists’ (TOPS).⁶ The TOPS has developed a separate area on the AAMC website dedicated to Physician Scientist Training Programs (PSTP), which provides information, resources, webinars, and program listings to benefit the trainees and program directors.²⁶

Then, there are individual programs like the novel CS faculty mentoring program or FAME specifically developed for junior faculty CS.¹³ The main objectives were to provide research training for clinician-investigators, mentor lab-based CS, and increase collaboration between all strata of CS. The highlights of the curriculum included career development lectures, emerging technology lectures, CS-specific seminars, and grant writing workshops.¹³ This was found effective for small to mid-level institutions. Besides FAME, others, such as the Clinical and Translational Science Award (CTSA) programs, have been created to provide flexible curricula to diverse investigators working in interdisciplinary teams.¹⁵ The curricula include scientific, operational, and academic aspects of translational research, regulatory and commercial aspects of innovation, and intellectual property.¹⁵

Mentoring skills are rarely taught, and training of the mentors is one of the critical ingredients to running a robust CSF/CSP program. There are limited but well-designed programs to train mentors in the US. For example, a mentor training curriculum was implemented effectively in 16 US academic centres and demonstrably achieved the desired outcomes.¹⁶ The curriculum includes several key training measures like effective communication, establishing expectation, assessing the mentee’s understanding, promoting professional development, fostering independence, addressing diversity, and articulation of the mentoring plan.¹⁶ High levels of satisfaction, self-reported skill gains, and positive behavioural changes were reported by the research mentors and this augurs well for the future.

United Kingdom

In the pre-doctoral phase of the career, the UK has an option of an intercalated year of scientific training as a part of the BSc degree.⁶ There are also the MD/PhD integrated programs. However, a PhD training following medical graduation is not uncommon and is supported by the National Institute for Health Research (NIHR). The NIHR provides academic clinical fellowship (which help clinicians acquire the necessary requirements for a PhD application) and clinical lectureships (which help clinicians acquire postdoctoral positions following a PhD) to provide support and dedicated research time for clinicians during their training.⁵ Several funders from the UK (Wellcome Trust, Cancer Research UK, Medical Research Council) have robust programs to support pre-doctoral training and PhD and post-doctoral CSP funding. The National Clinician Scientist scheme was started in 2000 and is open to promising medical graduates who have completed a basic research fellowship and higher research degree (PhD) but still need to complete their specialist training.¹⁷ It is funded by the Department of Health, research councils, and higher education funding council to support awardees in completing their specialist training in combination with further research. Although well-structured and well-funded, the UK scenarios struggle with the later phases of a CS career - the establishment of an independent research career.^5,6 To promote the leadership amongst the CS, certain organizations like the Francis Crick Institute offer CS a 6 + 6 (6 years – renewable for 6 years) fixed appointments. Following completion of these terms, the individuals are expected to join the university hospital medical centers, which would enhance the prospects of future CS and overall benefit the community.⁶ Besides, the ‘clinical academic research partnership scheme’ of the UK Medical Research Council supports the research activities of fully trained specialists or NHS consultants.⁶

Canada

The Canadian system has options for an MD/PhD system or the Clinician Investigator Program (CIP). The MD/PhD integrated is typically taken during the undergraduate MD years. There is a provision for interrupting medical studies after two years to pursue a higher degree in research (PhD) and then complete the remaining medical studies.⁸ The CIP programs typically involve the completion of a PhD during the postgraduate/residency studies. There are also unstructured research training options without a formal research graduate degree.

A survey of CS performed in 2017 reported that 83% of the respondents were appointed as academic faculty, and 44% of them devoted 50% of their time to research.^19,27 Another nationwide survey demonstrated that compared to the CS trainees in the CIP system, more trainees from the MD/PhD system felt the need for additional training (clinical fellowships and post-doctoral research fellowship) outside the country. Additional training considerations were perceived chiefly for prestige and better quality of international programs. Improved funding sources internationally and better integration of clinical and research training were rated important by the CS trainees. Interestingly, hardly any programs besides the FRQS/MSSS provide funding for international CS mobility and salary support during this period.

Germany

Most university hospitals in Germany run the clinician scientist programs. The German Research Council (DFG) formulated the recommendations for the program in 2015.^7,8 The programs are at three levels:

1. Junior (BIH Charité) CSP targets physicians in their second and third years of residency.

2. Regular CSP targets physicians in the later part of their residency

3. Advance CSP for trained medical specialists.

Alternate CSP models have also been shown to be of high value. For example, the one by the German College of Psychosomatic Medicine (DKPM) wherein young postgraduate physicians can participate in a two-year program that has a reliable mentor, an individual research project, and five 3-day courses on research skills.⁹

The DFG has also introduced ‘Rotationsstellen’, whereby one can employ part-time replacement clinicians to free up the CS and allow them to focus on research. Besides the DFG, organizations like the EU and Max Planck Society increasingly support integrated MD/PhD programs.^7,8 Since much medical education is free in Germany, an MD/PhD completes the program with better financial status than his colleagues in North America. There has been a significant improvement in the numbers and structuring of the CSP since the formulation by DFG.

Australia

There is a lack of nationally sponsored CSF/CSP. However, similar to the US (but shorter duration), they have an integrated MD/PhD training program.^20–22 Some opportunities for CS career support are also provided by the National Health and Medical Research Council (NHMRC) and a few specialty training colleges. However, compared to US, UK, and Canada, the systems in Australia are ill-equipped to robustly support the CS and increase and sustain the CS workforce.^5,6,20–22

Singapore

There is not much data on CSPs from Asia. One emerging country in this aspect is Singapore, where efforts have been made to establish specific academic medical centers to provide a nurturing environment to CS.²⁵ To give a boost to the CS workforce, the National Medical Research Council (NMRC), in 2012, started a mentored award program called the transition award or the T-award.²³ This award is designed to support the early career CS who have a clinical qualification and are registered with the Singapore Medical Council. There is a provision for exceptions like PhD holders in human clinical research. The support is for 3-years and includes salary provisions and research funding for a specific project. When the awardees of this program were surveyed, it was noted that the majority (37.9%, n = 11) devoted 41–60% of their time to research.²³ However, the perceptions remained that organizations need to value research, and clinical responsibilities can be overarching at the cost of research. The surveyed CS strongly felt the need for adequate mentoring and streamlining of the administrative processes.

LIMITATIONS OF THE CURRENT CSF PROGRAMS

1. Challenges in creating new and target positions following the completion of the program to ensure continuity of the translational research and reduce attrition rates.

2. Lack of adequate cultural change within academic settings that rewards translation-focused research

3. Maintaining an appropriate balance between patient care, research, and education for CS still needs to be improved.

4. Lack of clarity regarding the long-term prospects and career for a CS. The CSF programs help the CS in their early career phase but not adequately in a sustainable long-term career.

5. Several CSF programs fall short of a good integration of clinical and research work. Many of the tasks performed by a CS in research remain variably separate from patient care, which may negatively influence the translational aspects.

6. Lack of diverse representation in the CS workforce

FUTURE DIRECTIONS

Personalized medical education is being increasingly discussed in intellectual circles. There are several proposals for alternate options of training without a full-time PhD. These include PhD integrated with clinics with blocks of protected time each week and combined residency and fellowship training to shorten its duration and adding bench research to it.³ However, these options are challenging to implement and have their own disadvantages. Certain academic centers have proposed additional measures to support the CS workforce, including debt forgiveness for residents and fellows, allocation of technical personnel, a dedicated and funded year of research during medical school, laboratory work support while entering and exiting clinical training periods, overlapping approaches for every level of training, individualized and multidisciplinary mentoring, and interventions targeting work-life balance.²⁴ The central strategy for the future is focused on early identification, early recruitment, providing comprehensive support, and retention till appointment to targeted positions.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Hyderabad Eye Research Foundation