AAMC Report...

[SaltySqueegee]

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Apparently we are in short quantity:

http://www.trainingmag.com/msg/content_display/publications/e3ic1TiVJ3oRtsPO0iNUQ3FyQ%3D%3D

https://services.aamc.org/Publications/index.cfm?fuseaction=Product.displayForm&prd_id=150&prv_id=176

And the AAMC is trying to change that... there are a few recommendations to the LCME for individuals going to medical school to have a Master's level education in tranlational research, or possibly an additional year of only research (doesn't Cleveland Clinic already have a five year program like this?).

There is also talk and recommendations of increasing translational funding for PSTP, to encourage future research. We all know that money, or the lack there of, plays at least a small factor in career decisions...

-Salty

 

[CCLCMer]

Apparently we are in short quantity:

http://www.trainingmag.com/msg/content_display/publications/e3ic1TiVJ3oRtsPO0iNUQ3FyQ%3D%3D

https://services.aamc.org/Publications/index.cfm?fuseaction=Product.displayForm&prd_id=150&prv_id=176

And the AAMC is trying to change that... there are a few recommendations to the LCME for individuals going to medical school to have a Master's level education in tranlational research, or possibly an additional year of only research (doesn't Cleveland Clinic already have a five year program like this?).

There is also talk and recommendations of increasing translational funding for PSTP, to encourage future research. We all know that money, or the lack there of, plays at least a small factor in career decisions...

-Salty

Hi,

I am a first-year student at the Cleveland Clinic, and yes, we do have a five year program with research integrated throughout the curriculum. Many of us are planning to get MS degrees along with our MDs, but it is not required. Even if you don't get the MS, you still do a fifth year of research after M2, and you still write a MS level thesis. But I think that most people will wind up getting official MS degrees in some kind of biomedical sciences, because it isn't that much extra work on top of the regular CCLCM curriculum. We just have to take a few extra classes and a seminar. We also have the option to get MS degrees in things like bioethics or business through Case, but you would probably have to stay for a sixth year to do those programs, because there is not very much overlap with the CCLCM curriculum.

If anyone wants to know more about CCLCM, feel free to post here or PM me.

-CCLCMer

 

[Neuronix]

I have a question for you CCLMer... What is the average student indebtedness at CCLM upon graduation? If there hasn't been a graduting class yet, what will that be expected to be?

There seems to be a push for additional MD programs and residency programs with required research tacked on, but I don't see how that improves anything when those programs don't address three factors:

1) Med school puts a tremendous and terrible debt burden on students, and this is usually not or barely mitigated by these extra year out type of programs. Even the NIH payback program only pays a maximum of $35,000/year for two years, which is often less than half the debt of a student from a private med school.
2) Grant competitiveness at this point is extreme, with funding only going to greater than 10th percentile.
3) Tenure is pretty much impossible to come by in clinical departments these days. Meanwhile, doing research cuts your potential salary in greater than half in many departments.

It boils down to, why beat yourself up for an unstable and poorly funded career in research with massive personal debt when you could go be a clinician, make a boatload, and have a stable job? If these issues aren't addressed, a great percentage physician-scientists vs. physicians will not appear, no matter how many people get extra years out for research. I'm an advocate for the MD/PhD because at least it sets one apart for jobs and eliminates the debt faced by medical students.

 

[Saluki]

It's difficult to say exactly what the average indebtedness for CCLCM students is going to be, but I anticipate it being extremely low compared to other private medical schools. I know that one of the reasons that some people mentioned as a motivation for coming here over institutions like Vanderbilt was the financial aid package. I have basically a full tuition grant that is all from need-based aid, and even people who didn't demonstrate need still received some grant money. So, I think that we'll be better able to enter those type of academic careers since our debt burden will be small.

 

[Neuronix]

Even with full tuition grants, the indebtedness at CCLM probably comes out to around $20k/year for living expenses * 4 = $80k. But, since most people are not on full tuition grants, it's probably more than that. That puts the level of debt at about the level of a state medical school.

I'm not convinced that properly addresses student indebtedness. If a reduced debt burden helped to produce more academics, one might expect more academics to come from state schools, but in general that doesn't happen. Students at state schools could easily take a year out for research if they wished to and get the same sort of training (maybe minus a class or two vs. an integrated program). In the end it comes down to there being a big difference between $0 of med school debt and $100k of med school debt.

I'm not trying to pick on CCLM in particular (the earlier post made it an easy topic of conversation), but rather I think the upswing in required research at medical schools and residencies and partial debt relief is a half-hearted approach.

 

[Gut Shot]

It boils down to, why beat yourself up for an unstable and poorly funded career in research with massive personal debt when you could go be a clinician, make a boatload, and have a stable job?

This pretty much sums it up.

Some of the faculty here were discussing the current state of affairs at conference last week. The consensus is that while NIH grants are damn nigh impossible to get, institutional money is relatively plentiful. In order to stay funded many folks have to move to new institutions and get new startup funds every few years. No thanks.

 

[CCLCMer]

I have a question for you CCLMer... What is the average student indebtedness at CCLM upon graduation? If there hasn't been a graduting class yet, what will that be expected to be?

No one has graduated yet, so there won't be any actual figures. I don't know what the official expected debt is, but I will try to find out this week and let you know. As far as your other points go, I would say the following:

1) Most state schools (with the possible exceptions of a few like U Mich and some of the CA state schools) are not focused on research. In fact, most state schools have as part or all of their mission the intention of educating clinicians who will practice in their state. It is possible to do research at state schools if students seek it out, but that's not the state schools' main reason for existing. So I would wager that students who are really into research are not as likely to attend state schools, and students who attend state schools are not as likely to want to go into research for a career. I think that this adequately explains why so few researchers come from state schools, in spite of their having a lower average debt load versus students who attend private but research-intensive schools like mine or yours.

2) The level of funding at CCLCM varies, but we have our own financial aid independent of the main Case program, and as Saluki pointed out, most people get generous packages. Ultimately, the school plans to fund everyone's tuition (although that probably won't benefit my class). There are also some people who are completely funded like MSTP students are.

3) Basically, I think the rationale for choosing a program like CCLCM over an MSTP comes down to how long people want to spend training, the backgrounds of students, and also what kind of research they would like to do. Statistically, most MSTP graduates go into basic science research. Our program is really aimed more towards producing clinical or translational researchers, although it is still possible to do basic science research here. In addition, our average student age is pretty old compared to the students in an MSTP. The oldest student in my class (M1) is 31, and I doubt there are too many people starting MSTPs in their thirties! Plus, two students came into our program already having their PhDs, and maybe half a dozen others already have MS degrees. These people would not be likely candidates for MSTPs because they already have graduate degrees. Six or eight people doesn't sound like much in absolute terms, but it is when you consider that there are only 32 of us total!

 

[Saluki]

Even with full tuition grants, the indebtedness at CCLM probably comes out to around $20k/year for living expenses * 4 = $80k. But, since most people are not on full tuition grants, it's probably more than that. That puts the level of debt at about the level of a state medical school.

I'm not convinced that properly addresses student indebtedness. If a reduced debt burden helped to produce more academics, one might expect more academics to come from state schools, but in general that doesn't happen. Students at state schools could easily take a year out for research if they wished to and get the same sort of training (maybe minus a class or two vs. an integrated program). In the end it comes down to there being a big difference between $0 of med school debt and $100k of med school debt.

I'm not trying to pick on CCLM in particular (the earlier post made it an easy topic of conversation), but rather I think the upswing in required research at medical schools and residencies and partial debt relief is a half-hearted approach.

Obviously, the MD/PhD program does result in you coming out with a lot less debt, but since an MD/PhD program takes a lot longer it should come even out in the end. You're right about the 80k in debt even with a full tuition grant, but I wasn't comparing it to the debt level at state institutions but rather at comparable private institutions where the average debt load is often above 200,000. Even if you continued at a resident's salary for the rest of your career, frugal living would allow you to pay off 80k. Most students at state schools aren't interested in careers as physician scientists (with the exception of the MD/PhD people...)and unless you live in California or Michigan, the reputation of the state schools often can't live up to that of private institutions. I don't see why you consider adding research oriented schools a half-hearted approach- programs like CCLCM aren't stealing people from MD/PhD programs but rather adding to the number of physicians with the capability and interest to do research.

 

[Neuronix]

I don't see why you consider adding research oriented schools a half-hearted approach- programs like CCLCM aren't stealing people from MD/PhD programs but rather adding to the number of physicians with the capability and interest to do research.

I never suggested that research oriented medical schools were stealing people from MD/PhD programs. The MD/PhD option has been getting more popular over the past few years!

Instead, I suggested it is half hearted because in my opinion it does not get to the real root causes of a shortage of physician-scientists. Those factors in my opinion are:

1) Med school puts a tremendous and terrible debt burden on students, and this is usually not or barely mitigated by these extra year out type of programs. Even the NIH payback program only pays a maximum of $35,000/year for two years, which is often less than half the debt of a student from a private med school.
2) Grant competitiveness at this point is extreme, with funding only going to greater than 10th percentile.
3) Tenure is pretty much impossible to come by in clinical departments these days. Meanwhile, doing research cuts your potential salary in greater than half in many departments.

To reiterate, I think that the following approaches are not half-hearted. If there really is a shortage of physician scientists and programs at every level want to fix that, the following should happen:

1) Medical schools must eliminate all debt for research-oriented students, just like it would be for a PhD student.

2) The NIH must put out more grants for MD/PhDs to establish and fund their research. The debt forgiveness for residents is a good start, however that program should be expanded to cover ALL debt, not just 70k of it. I also wonder how competitive those particular programs are...

3) Clinical departments that most MD/PhDs call home must give more stable jobs with reasonable funding and expectations in a difficult and uncertain funding environment.

Anything less than that from either medical schools, the NIH, or academic departments is half-hearted, again in my opinion.

 

[oldbearprofessor]

1) Medical schools must eliminate all debt for research-oriented students, just like it would be for a PhD student.

2) The NIH must put out more grants for MD/PhDs to establish and fund their research.

Neuonix - I am curious as to what your specific ideas would be related to these, especially the clause "fund their research" which implies post-training longer term support of academic careers. Beyond the current mentored grants which are widely used by MD/PhD's, do you suggest that the NIH create a special category of R01's, or R01 scoring for MD/PhD's? After all, when all is said and done, the R01 is the key grant phase and it is at that level that research careers rise and fall.

How would medical schools identify research-oriented students in a practical sense such that it could pay all of their costs. What would be the penalty for a student taking this money and not following through? What if it wasn't their "fault" - i.e. they submitted unfunded grant applications later in their career. Who would pay for this? I suspect the lure of $200,000 or more to pay all medical school costs would lead to a lot of students claiming they were "research-oriented", since for regular MD students, it wouldn't add multiple years to their education.

I am not trying to put down your suggestions, it is just that to be useful to policy-makers, they need to be spelled out in detail.

Regards

OBP

 

[malchik]

I think Neuronix's point is that the AAMC authors fail to see the cause of the problem. And I agree with the substance of Neuronix's position that the cause of low numbers of physician scientists is a function of the unappealing nature of the career. Forcing students/residents to participate in research does nothing to make the academic career more attractive. It is worse than half-hearted, it is probably even counter-productive.

The point is well-taken that proposed remedies need to be specific. I am probably not in a position to suggest specifics. But I do think clinical departments and medical schools will have to shoulder more responsibility to the research enterprise, instead of simply requiring all funding for research to come from NIH RO1s. What happened to the "hard money" of yester-year? Why don't departments invest in people anymore?

 

[Nuel]

How would medical schools identify research-oriented students in a practical sense such that it could pay all of their costs. What would be the penalty for a student taking this money and not following through? What if it wasn't their "fault" - i.e. they submitted unfunded grant applications later in their career. Who would pay for this? I suspect the lure of $200,000 or more to pay all medical school costs would lead to a lot of students claiming they were "research-oriented", since for regular MD students, it wouldn't add multiple years to their education.

We could apply your line of reasoning to straight PhD students. Would you say that prospective PhD PIs who had their grants rejected and decided to do something else wasted the hundreds of thousands of dollars that the government invested in their training? Who would pay for this? Eh, the government is STILL paying for PhD students.

I think Neuronix's case is very strong.

 

[CCLCMer]

Ok, just for everyone's info, I asked the financial aid office here what they expect the average student debt to be for CCLCM students, and they said they were not able to give me any numbers because no CCLCM students have graduated yet. All they would say is that the average debt for the university program (regular program at Case) students is $131,000, which does not answer our question. Sorry, but it doesn't look like we'll be able to find out anything more than that until 2009.

I personally think that one part of the problem is also that many people don't want to do 7+ years of post-college training, especially if there is another shorter route to becoming a research physician. Props to those of you who are doing it though. 🙂

 

[Neuronix]

I wrote a nice long response to obp and SDN ate it. Ah well, here's the concise version:

I agree with malchik's summary. Med schools, and especially clinical departments, just don't invest in people anymore. I think this has to do with the declining profitability of hospitals and tightening funding from the NIH. I'm now seeing all the MD/PhDs who have left my lab and neighboring labs going into private practice because they couldn't get any money for career development. When they're just out of fellowship, they're not given enough protected time, not given any startup money, and instead are given alot of incentives for doing more and move clinical work. This is supposedly one of the best places for a physician-scientist (at least that's what my PDs like to have us think), but yet it doesn't seem like they're getting the support they need. I guess med schools just simply don't care about supporting physician-scientists.

What can the NIH do? More career development money. I'm not really sure what already exists, but it doesn't seem to be enough after watching several MD/PhDs try and fail. I mean heck, only a small minority of institutes will potentially fund that F30 I submitted. The NIH will have to pick up the slack that clinical departments won't give to their investigators so that physician-scientist careers can get started. What ever happened to things like startup packages? I also think they should expand the loan repayment programs for clinicians doing research to more like $60,000/year for a maximum of 4 years.

What could medical schools do? How about this CCLCM. Why not set aside the money each student took in loans for tuition and living expenses? For each year they do research after they finish, forgive a year of that money. Sure, they could stop doing research after that, but at that point they've made a significant investment in their future research career.

BTW, don't worry about questioning me. I like the discussions we can have on here. The anonymity provides alot of safety to think about these things out loud.

 

[oldbearprofessor]

I wrote a nice long response to obp and SDN ate it. Ah well, here's the concise version:

I agree with malchik's summary. Med schools, and especially clinical departments, just don't invest in people anymore. I think this has to do with the declining profitability of hospitals and tightening funding from the NIH. I'm now seeing all the MD/PhDs who have left my lab and neighboring labs going into private practice because they couldn't get any money for career development. When they're just out of fellowship, they're not given enough protected time, not given any startup money, and instead are given alot of incentives for doing more and move clinical work. This is supposedly one of the best places for a physician-scientist (at least that's what my PDs like to have us think), but yet it doesn't seem like they're getting the support they need. I guess med schools just simply don't care about supporting physician-scientists.

What can the NIH do? More career development money. I'm not really sure what already exists, but it doesn't seem to be enough after watching several MD/PhDs try and fail. I mean heck, only a small minority of institutes will potentially fund that F30 I submitted. The NIH will have to pick up the slack that clinical departments won't give to their investigators so that physician-scientist careers can get started. What ever happened to things like startup packages?

Supporting training grants is a key aspect to developing physician scientists and a wide range of these grant programs already exist. Training grants, especially individual ones, such as K08’s, primarily fund the individual, not the research laboratory. This can be great for the institution, but doesn’t work to really develop a long-term career in and of itself. Ultimately, in my experience, the real point at which we lose physician-scientists is at the point of transitioning from mentored and other training grants to non-mentored grants and setting up ones own lab. The standard is and will likely to remain the R01 and it is the R01 holders who serve as mentors for the training grants, so enhancing the R01 mechanism is crucial to developing and supporting physician-scientists. I was only partly joking about different scoring for R01’s for physician-scientists. There needs to be true bridging money to get labs started. With the loss of the R29 mechanism, it’s difficult to jump to that first R01 from a training grant – usually much harder than getting a training grant.

At the present time, with all NIH funding, especially R01 funding, becoming more difficult to obtain, it is not surprising that institutions are pushing their junior faculty into revenue-generating clinical tasks. This is due to many things, including a lack of mutual understanding between clinical departments and basic science mentors about the time needs of starting faculty, the relative ease with which physician-scientists can have new clinical responsibilities eat into their time and, the agonizing process of writing grants. Few physician-scientists after a clinical fellowship would rather write a grant than take care of a patient. I’m really not trying to get the institutions off the hook here, just reflecting on the reality of the situation as I have seen it over many years and watching many, many unsuccessful starts to academic careers.

Institutions have a strong interest in getting physician-scientists funded as this brings in dollars, reputation and publicity. But start-up funds do not a career make. I’ve seen many folks go nowhere with institutional start-up funds. Institutions should provide this money – if they are not, it’s because they have seen a pattern of it not working in that department or institution or there is a very, very short-sighted department head. Personally, I have not seen institutional start-up funds be as useful as they could – I think the emphasis should be on getting the motivated individuals to submit NIH training grant applications and using institutional support primarily to increase the lab money for those who get the training grants. As I said, training grants are notoriously low in the amount they give for actual lab personnel and supplies. If a starting faculty is doing all their own lab work, they don’t have time to move forward quickly.

What are some solutions? Well, I don’t think they are simple at all. Ultimately, there must be a clear understanding for physician-scientists that the initial years of their career, AFTER residency are going to be primarily spent on research (including lots of grant writing-time) and little clinical work. The institutions must be willing to support this but they will only be willing if the people are well selected and they see a high success rate for those they support. I’m not sure this means MORE physician-scientists being trained via MD/PhD or research year programs– I think it might be better right now to support fellows and junior faculty who have clear evidence of successful initial efforts and a commitment to research. But, this is very hard to demonstrate – impossible at the medical school level.

I will pass for now on discussing the role of debt in limiting physician-scientists. A real issue, but I’d rather first discuss these other aspects of developing successful physician-scientists.

Regards

OBP

 

[Nuel]

I wrote a nice long response to obp and SDN ate it.

Type in an MSWord or text document, then login, then copy and paste. click submit. Learnt when I used to argue extensively in the Everyone forum.

Or click "preview post" as often as possible so that the memory of your prospective post still stands.

 

[Nuel]

Most physician-scientists do basic science research that straight PhD PI's can perform, if not better.(I guess because the glory is in basic science.) So creating a separate RO1 category for physician-scientists is a ridiculous idea. There are some category K grants for these purposes, to the best of my knowledge.

Secondly, start-up funds are not necessarily a bad thing. Maybe most investigators given start-up funds floundered along the way,however, to take away start-up funds for this reason is silly. Science is hard, and who succeeds is not what MCAT, GPA and GRE scores can predict. Not everyone is going is to become famous and publish four major papers a year, but the more promising candidates should be given some financial support.

People always say be wary about throwing money at problems. Nonetheless, a major factor limiting the increase of physician-scientists is money, just as Neuronix has stated.

Even as an MD/PhD graduate, how could you not be tempted to take the private practice cardiology job and make $300,000 a year, as opposed to worry about the next grant and failed experiments? Science is hard--that is a second reason. It is way more easier to be a clinician and make more money.

Let those who love research do it. This AAMC task-force recommendation is brute force. The best it can do is arouse the interest of those who never thought they loved science for the sake of it, or make others hate it even more.