EARLIER THIS YEAR, the Canadian Institutes of Health Research (CIHR) abruptly terminated funding for students entering the MD/PhD programs in Canada. No justifications for this decision or guidelines as to how trainees can procure other sources of funding were given. Much public outcry has denounced CIHR’s action and the Clinician Investigator Trainee Association of Canada (CITAC) is petitioning for continued support for its members.

To put things into perspective, in the last round of MD/PhD grants, CIHR allocated approximately $2.4 million, which represents just 0.24% of their total budget. This is equivalent to funding half of the MD/PhDs currently enrolled (see Fig. 1). The remainder of the trainees and stipends are funded through sources such as endowments and other government funds. The exact stipend, and how much of it comes from CIHR, varies depending on the institution; nevertheless, CIHR’s contribution serves as the major source of financial support for most MD/PhD students.

Figure 1. Breakdown of funding and enrollment for MD/PhD programs in universities across Canada. Image credit: Tim Guo & Kieran Manion.
Figure 1. Breakdown of funding and enrollment for MD/PhD programs in universities across Canada. Image credit: Tim Guo & Kieran Manion.

While budget cuts may limit funding, stipends for MD/PhD programs should continue to be a priority considering their intended mission of fostering clinically experienced researchers. The goal of publicly funded, health-oriented research should be to translate what is already known into tangible improvements in public health (see Box 1). For example, identifying the mechanism of action of a novel drug would be an important basic finding, but improving its pharmacokinetics would be more pertinent for treating a particular disease. Participants in the MD/PhD programs undergo costly and time-consuming training, but are ultimately uniquely positioned to engage in this type of research.Tim_MDPhD_box1

In contrast, researchers trained solely in biomedical science are hindered when it comes to translational research. The academic community focuses on fundamental discoveries as its main goal; after all, the purpose of basic research is to uncover the unknown. Gauging success through publication impact factors reflects and substantiates this mindset. Papers disseminating paradigm-shifting discoveries will be more influential and cited more often, whereas those describing incremental advances of a pre-existing finding towards translation garner less attention. Since the former propels scientific careers, there is little motivation for basic science researchers to undertake the latter. While priorities are starting to shift, the cultural emphasis of the vocation deters many scientists from dedicating resources to translational research.

Differences in technical expertise also pose a barrier. Problems that researchers try to solve at the bench within confined systems are fundamentally different from the problems seen in the clinic. In many cases, animal models do not accurately depict biological processes in humans, and being fully aware of the disparities requires in-depth training and exposure to both systems. “Every new patient we see is like a new mouse model,” says Dr. Marcus Butler, a clinician-scientist at the Princess Margaret Cancer Centre. “The clinic is a place to find good questions, which then you can isolate in the lab.” Given that translational research requires testing hypotheses based on observations of health and disease, those who directly observe patients should be the most qualified to generate clinically relevant hypotheses.

Despite having an advantage in translational research, clinicians face their own set of challenges. Established physicians typically abstain from research due to the burden of clinical responsibilities. The lack of job security as burgeoning scientists further discourages clinicians to initiate a research career. This factor would especially affect young practitioners with a sizable educational debt. One recent study found a negative correlation between the educational debt of American MD/PhD graduates and their likelihood of entering research, while the opposite was true for graduates who eschewed research to become full-time practitioners. Therefore, proper financial incentives could encourage promising individuals to commit directly to this arduous, yet vital role.Tim_MDPhD_box3

Investigators do not necessarily need both an MD and a PhD to perform translational research. Nor are MD/PhD programs the only way to attain both clinical and research skills. MD trainees can participate in clinician investigator programs (CIP) offered by many Canadian medical schools, which provide research training during residency. Similarly, research graduates can attend medical school, as many of those from our department have done. Nevertheless, students from each degree who continue on to obtain the complementary training are still the minority. In contrast, a 2010 study of MD/PhD programs in the United States revealed that the majority of these trainees do fulfill their intended roles as clinician scientists, with nearly all of those included in the study indicated to have at least some research activities as part of their occupation.

As a training path, MD/PhD programs are an effective way to generate clinician scientists while circumventing many of the issues pertaining to each degree. Financial support for medical tuition alleviates some of the debt burden that medical trainees experience as a roadblock to research, while employment in a clinical setting with different priorities from pure academia offsets some of the cultural restraints and technical blind spots of basic researchers. Given the value of clinician scientists, investment in Canadian MD/PhD programs should be continued to ensure that physicians-in-training with a penchant for science are equipped with the skills they need to thrive in the increasingly competitive research world. If we cannot reinvent the landscape of translational research by bridging the chasm between discovery and application, we should at least prepare individuals to trek across it.


References:

  1. Appleton, CT et al. Strength in numbers: growth of Canadian clinician investigator training in the 21st Clinical & Investigative Medicine 2013; 36: E163-169.
  2. CIHR cutting MD/PhD training program. CMAJ 2015. DOI:10.1503/cmaj.109-5124.
  3. Engaging basic scientists in translational research: Identifying opportunities, overcoming obstacles. 2012.
  4. Brass, EF et al. Are MD-PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD-PhD programs. Academic Medicine 2010; 85: 692-701.
  5. Bulter, D. Translational research: Cross the valley of death. Nature 2008; 453: 840-842.
  6. Jeffe, DB, and Andriole, DA. A national cohort study of MD-PhD graduates of medical schools with and without funding from the National Institutes of General Medical Sciences’ Medical Scientist Training Program. Academic Medicine 2011; 86: 953-961.
  7. Science The Endless Frontier. A report to the president by Vannevar Bush.
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Tim Guo

Tim is currently a PhD candidate in the laboratory of Dr. Naoto Hirano at the Princess Margaret Cancer Centre. The lab and his project explore new ways to engineer T cells for cancer immunotherapy. Outside the lab, he dabbles in the culinary arts and catches up on classic movies.
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