Training Physician‒Scientists for Careers in Investigative Dermatology

Abstract

Physician‒scientists have made countless discoveries, and their dwindling numbers are a significant concern. Although dermatology has become an increasingly popular destination for physician‒scientist trainees, the proportion of trainees who pursue scientific research careers after training is among the lowest of all medical specialties. To investigate this problem, we surveyed a national cohort of dermatology educators, physician‒scientist track program directors, and National Institute of Arthritis and Musculoskeletal and Skin Diseases T32 directors for opinions regarding physician‒scientist training in dermatology. On the basis of these findings and to help address the issue, we propose a training practicum and provide a resource for funding opportunities to help guide trainees and institutions interested in supporting investigative dermatologists. We also discuss the important roles of department chairs and institutions in fashioning an environment conducive to physician‒scientist training. The information and recommendations provided in this paper may help to improve the recruitment, training, development, and retention of investigative dermatologists and future leaders in this field. Physician‒scientists have made countless discoveries, and their dwindling numbers are a significant concern. Although dermatology has become an increasingly popular destination for physician‒scientist trainees, the proportion of trainees who pursue scientific research careers after training is among the lowest of all medical specialties. To investigate this problem, we surveyed a national cohort of dermatology educators, physician‒scientist track program directors, and National Institute of Arthritis and Musculoskeletal and Skin Diseases T32 directors for opinions regarding physician‒scientist training in dermatology. On the basis of these findings and to help address the issue, we propose a training practicum and provide a resource for funding opportunities to help guide trainees and institutions interested in supporting investigative dermatologists. We also discuss the important roles of department chairs and institutions in fashioning an environment conducive to physician‒scientist training. The information and recommendations provided in this paper may help to improve the recruitment, training, development, and retention of investigative dermatologists and future leaders in this field. Physician‒scientists (also called clinician‒investigators) are medical doctors who harness the knowledge of physiology and disease to address questions in biology and medicine through scientific research. Physician‒scientists encompass individuals with a medical degree (MD) who may or may not also have a doctoral degree (i.e., PhD). Throughout history, physician‒scientists have been instrumental in advancing biomedical knowledge. James Shannon, the father of the modern National Institutes of Health (NIH), believed that the key driving force behind the physician‒scientist is the concept that diseases will only be cured when science provides a fundamental understanding of physiology (Goldstein and Brown, 1997Goldstein J.L. Brown M.S. The clinical investigator: bewitched, bothered, and bewildered--but still beloved.J Clin Invest. 1997; 99: 2803-2812Crossref PubMed Scopus (257) Google Scholar). The classical role of the physician‒scientist is to make discoveries regarding human disease and to translate those discoveries to the patient bedside. In the last century, a plethora of key discoveries were made by physician‒scientists, including up to half of Nobel Laureates in Physiology and Medicine (The Nobel Foundation, 2020The Nobel FoundationAll Nobel Prizes in physiology or medicine.https://www.nobelprize.org/prizes/lists/all-nobel-laureates-in-physiology-or-medicineDate: 2020Date accessed: August 29, 2020Google Scholar) who conducted ground-breaking research encompassing basic science, disease-oriented, and patient-oriented research. Examples of their fundamental discoveries include the discovery of DNA polymerase by Arthur Kornberg, ABO blood typing by Karl Landsteiner, and inborn errors of metabolism by Archibald Garrod. From 1964 to 1972, a cohort of nine physicians trained at the NIH, all of whom were awarded Nobel Prizes for seminal discoveries, including the low-density lipoprotein receptor by Michael Brown and Joseph Goldstein, cellular oncogenes by J. Michael Bishop and Harold Varmus, G proteins and G protein‒coupled receptors by Alfred Gilman and Robert Lefkowitz (respectively), prions by Stanley Prusiner, nitric oxide signaling by Ferid Murad, and odorant receptors by Richard Axel. These examples are merely a fraction of the transformative discoveries made by physician‒scientists in recent history. In addition to important basic science discoveries, physician‒scientists have played and continue to play a vital role in clinical research and in running clinical trials. Physician‒scientists have also played significant roles in dermatology. Nobel prize‒winning discoveries related to biochemistry, cell biology, developmental biology, and immunology have all played vital roles in our understanding of epithelial physiology and pathology. The use of phototherapy for modern-day dermatologic diseases can be traced back to Niels Ryberg Finsen, who won the Nobel Prize in 1903 for the use of electromagnetic radiation in patients with lupus vulgaris. The revolutionary treatment of melanoma using checkpoint inhibitors would not be possible without the Nobel Prize‒winning discovery of PD-1 by Tasuku Honjo. Physician‒scientists have also made important strides in understanding the molecular pathogenesis of epidermolysis bullosa, pemphigus, psoriasis, and atopic dermatitis (Rubenstein et al., 2002Rubenstein D.S. Blauvelt A. Chen S.C. Darling T.N. The future of academic dermatology in the United States: report on the resident retreat for future physician-scientists, June 15–17, 2001.J Am Acad Dermatol. 2002; 47: 300-303Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar). Many physician‒scientists continue to work to further our understanding of dermatologic diseases and their treatments. Despite their importance in advancing medical research, physician‒scientists represent an endangered species (Jain et al., 2019Jain M.K. Cheung V.G. Utz P.J. Kobilka B.K. Yamada T. Lefkowitz R. Saving the endangered physician-scientist - A plan for accelerating medical breakthroughs.N Engl J Med. 2019; 381: 399-402Crossref PubMed Scopus (56) Google Scholar). A 2014 NIH Physician-Scientist Workforce (PSW) working group report identified a distressing trend in the PSW (Physician Scientist Workforce Working Group, 2014Physician Scientist Workforce Working GroupPhysician-scientist workforce working group report. National Institutes of Health, Bethesda, MD2014Google Scholar). Since a peak in the PSW in the late 1980s and early 1990s, PSW numbers have stagnated, with a 30% proportional decrease in R01s obtained by the PSW relative to those obtained by nonphysicians (Physician Scientist Workforce Working Group, 2014Physician Scientist Workforce Working GroupPhysician-scientist workforce working group report. National Institutes of Health, Bethesda, MD2014Google Scholar). This time period also saw a significant decline in attendance at meetings of the American Society of Clinical Investigators (ASCI) and the Association of American Physicians, two organizations dedicated to the advancement of medical knowledge through research (Erzurum, 2018Erzurum S.C. Aging and scientific medicine: 60 is the new 40.J Clin Invest. 2018; 128: 4204-4207Crossref PubMed Scopus (1) Google Scholar; Goldstein and Brown, 1997Goldstein J.L. Brown M.S. The clinical investigator: bewitched, bothered, and bewildered--but still beloved.J Clin Invest. 1997; 99: 2803-2812Crossref PubMed Scopus (257) Google Scholar). As the current PSW ages, inadequate numbers of new physician‒scientists enter this career path (Milewicz et al., 2015Milewicz D.M. Lorenz R.G. Dermody T.S. Brass L.F. National Association of MD-PhD Programs Executive CommitteeRescuing the physician-scientist workforce: the time for action is now.J Clin Invest. 2015; 125: 3742-3747Crossref PubMed Scopus (116) Google Scholar). These challenges were the impetus for the recently established Physician-Scientist Support Foundation (www.thepssf.org). To understand this decline, we must understand the modern-day training pipeline of the physician‒scientist. In 1964, James Shannon carried out his vision of a PSW by supporting the creation of the Medical Scientist Training Program (MSTP) through the National Institute of General Medical Sciences (NIGMS). This program funded the training of a new workforce of physician‒scientists who graduate medical school with both MD and PhD degrees, a testament to their training in both clinical medicine and scientific research. There are currently 51 MSTPs in the United States that receive NIH funding through institutional T32 grants from NIGMS (National Institute of General Medical Sciences, 2021National Institute of General Medical SciencesMedical Scientist Training Program (MSTP) institutions.https://www.nigms.nih.gov/training/instpredoc/pages/predocinst-MSTP.aspxDate: 2021Google Scholar). Many schools without an MSTP also provide the opportunity for students to obtain both degrees. At any given time, there are over 5,000 students working to obtain their MD and PhD; each year, approximately 600 new students and graduate et al., and of of physician-scientist training in medical training Med. PubMed Scopus Google Scholar). 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The clinical investigator: bewitched, bothered, and bewildered--but still beloved.J Clin Invest. 1997; 99: 2803-2812Crossref PubMed Scopus (257) Google Scholar). This in an by et al., and of of physician-scientist training in medical training Med. PubMed Scopus Google that that training in both science and medicine the of the physician‒scientist career The physician‒scientist will not obtain their when their have been in the workforce for over a this is the at and in (Milewicz et al., 2015Milewicz D.M. Lorenz R.G. Dermody T.S. Brass L.F. National Association of MD-PhD Programs Executive CommitteeRescuing the physician-scientist workforce: the time for action is now.J Clin Invest. 2015; 125: 3742-3747Crossref PubMed Scopus (116) Google Scholar). In a of MD and students who in research the when to a career a physician‒scientist et al., et of physician-scientist MD and in research PubMed Scopus Google Scholar). challenges include in in on clinical and et al., and of of physician-scientist training in medical training Med. PubMed Scopus Google Scholar). these challenges in the career path and the trend in PSW significant must be to the training and action have been including the time to an research the of physician‒scientists, and the of physician‒scientist trainees at all (Milewicz et al., 2015Milewicz D.M. Lorenz R.G. Dermody T.S. Brass L.F. National Association of MD-PhD Programs Executive CommitteeRescuing the physician-scientist workforce: the time for action is now.J Clin Invest. 2015; 125: 3742-3747Crossref PubMed Scopus (116) Google Scholar). 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