Robert C. Bowman, M.D.
It may be too late to restructure your program, but you may want to consider
how you might meet your goals to graduate more researchers and also might
graduate the different researchers that the nation needs.
From 1965 to 1978 several interesting thing happened.
NIH researcher choice increased to peak levels with most schools graduating
the most researchers by percentage of total graduates between 1975 - 1980.
In the 1980s there were limitations and declines in all the funding and emphasis
areas noted above. However the salaries of physicians, especially subspecialists,
continued to rise rapidly.
The NIH views the research decline as a matter of poor funding of NIH,
especially fellow development. It uses the decline along with medical schools to
lobby for more funding for research MDs.
When examining this situation, the reasons for research physician decline have
more to do with numbers. The research graduation likely medical schools, those
created before 1960, expanded only 15%. The newer schools that were more primary
care and public had a doubling of medical students and therefore a doubling of
those not likely to be choosing research. The research likely schools were FP
and primary care likely schools.
PhDs nationwide exploded beyond increases in MDs, especially in health and
science and bioscience. PhDs are also hungrier for jobs, since MDs have many
competitive careers. In some research orientation programs 95% of MDs end up
doing residency programs and the clinical or other academic tracks. It is not
uncommon for MD researchers to go out clinically, and come back to research.
Perhaps they were admitted too soon and needed more life experiences before
admission.
Declines in the ratio of MD to PhD in schools, on panels, in research grants
were inevitable given the demographics.
There were choices that could have been made to match the research with the
changing interests of medical students and the nation.
Instead of retooling NIH funding to be of interest to the huge numbers entering
primary care, there was no major change in NIH and there continues to be no
change in what NIH does to attract, train, suppor, and fund researchers. This
means great segments of the medical student population are unsupported in
research interests.
Now we have a crisis in translational research, fidelity research, workforce
research, efficiency, quality, and more.
The money has been there, the choices to use the money in effective and
efficient ways were not.
NIH continues to focus on basic science, MDs for basic science depts, and MDs as
researchers. They refuse to see PhDs as lower cost and almost as much bang for
the buck. The conflicts between MD and PhD are local, med ed, and national.
(Commonwealth Fund, Bench to Bedside, other reports)
I find the MD to PhD debates to be similar to the primary care vs specialty or
the midlevel vs FP debates and interesting to compare.
Also the choice of medical schools to graduate more researchers often represent
a mismatch with who chooses research. If medical schools truly wanted more
researchers they would focus on
What makes older students choose research at the highest levels of all students,
especially in the research elite schools (age 29 - 31 is the most likely to
choose research careers). Research By the
Ages
Why states with higher college and high school graduation rates graduate more
researchers
Why states with lower graduation rates graduate almost no researchers
Why students born in the most urban highest income areas, in major university
towns, and in research towns (Los Alamos, Bartlesville) tend to choose research
at higher levels (parent influences, education, income likely)
If the NIH and medical education leaders sound the alarm that the US is failing
in research, in higher education, and in future information superiority, then
the nation might listen. Lobbying for more NIH dollars will be seen as self
serving and may well not result in more researchers, which are determined by a
number of other areas.
Decreasing the salaries of the most highly paid physicians for clinical
subspecialty work would also improve research choice and distribute physicians
better. Interesting that this worked during health reform and managed care to
graduate more primary care physicians and fuel the best distribution in the
nation's history, but no one really considers income cuts or cuts in graduate
medical education positions that might force better primary care, mental health,
women's health, and research choices.
Choice of family medicine, research, psychiatry, and office-based primary care
in poverty locations would all likely improve with better investments in
education and facilitation of admission of older students via special tracks
Much of the time in medical school admissions as in research choices I feel that
"We are digging in the wrong place"
Stanford, Oregon, and Case have long admitted older medical students. Stanford
is the only elite top 25 research school to do so. Oregon is unique in that it
has moved up into the top 25 in NIH revenues recently, no mean feat. Stellar
recruitments and older student admissions are a part of their effort. They also
have a very successful effort in family medicine research and other newer areas.
Case has had older admissions that have collapsed in more recent years, likely
due to leadership changes. They should have looked at Stanford and Oregon's
example instead of US News and World Report. UTMB Galveston has a significant FP
research component and moved up well.
After a visit to Oregon, I really feel good about the solid efforts in
admissions to focus on maturity and experiences and character at Oregon. This is
very different than competing for the younger higher scoring students. In the
competition for researchers, it is important to remember that 21 medical schools
graduate half of the physician researchers. This means that they are able to
identify and select and train, and support them. For the other 105 schools, they
are choosing students much less likely to be research material. Attempting to
make researchers out of those with lower probability does not work. It also
leads to side effects for selecting for MCAT and sciences, like poor physician
distribution and poor people and communication skills.Side
Effects of Selecting
I wish there were enough in the nation to supply all of the research needs, but
we have a limited education and college system accessed by those who have income
and position. We may lose as many as 2/3rds of researchers before middle school
or at least before medical school admission. We clearly lose many young
professionals as well, those that we desperately need in teaching, in public
service, in rural locations, in inner city locations, and in family medicine.
Robert C. Bowman, M.D.
rbowman@unmc.edu
State Researcher Comparisons: Birth to Practice
Research in Rural Medical Education