Letter to the Editor – S. Amanda Ali

Letter to the Editor – S. Amanda Ali

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From: Shabana Amanda Ali

Dear Editor,

My article “MD/PhD = Double Doctors = Double Trouble” appeared in the Spring 2012 issue of the IMS Magazine and posed the question: “Are physician-scientists spreading themselves too thin?” The article was purposefully titled as a question – and not a statement – to provoke useful discussion about the challenges physician-scientists face, and to stimulate critical thinking that may lead to improved physician-scientist training and career success.

And discussion was provoked. I received feedback in person and through the IMS Magazine from across the University of Toronto (U of T): from the MD/PhD Program Director, Dr. Norman Rosenblum, to the MD/PhD Class Council, to the U of T and IMS communities at large. A recent graduate of U of T’s MD/PhD program, Dr. Sagar Dugani, offered his opinion in a Letter to the Editor, published in the Fall 2012 issue.

My informal sampling of U of T’s medical and scientific community revealed disagreement as to whether physician-scientists are “spread too thin.” The division is reflected in the magazine’s online discussion forum at www.imsmagazine.com, where issues surrounding time distribution (“Why not get an MBA and do a 33%-33%-33% split?”) and definitions of success are under debate. I originally asked whether physician-scientists are spread too thin, and this question can be answered by examining the relative success of physician-scientists to their single-discipline peers.

As many do, Dr. Dugani offered publication record and award history as evidence of the success of MD/PhD trainees. This evidence assumes a limited definition of success, and our magazine highlighted the pitfalls of assigning excessive value to high-impact publications (see “Publish and Perish,” Fall 2012). I previously discussed a model from the Association of American Medical Colleges which categorizes personal and organizational factors that contribute to the career success of physician-scientists.(1) The model highlights the need for more comprehensive metrics to evaluate the success – both extrinsic (work-related) and intrinsic (life satisfaction) – of physicians, scientists, and physician-scientists. As Dr. Dugani mentioned himself, “Double Doctors” have “Double Responsibility,” so surely this extra responsibility has some effect on overall success in the lab, in the clinic, and at home.

‘Conflicting demands’ constitute one of the organizational factors which influence the career success of physician-scientists.(1) Scientists are skeptical about theories and physicians are authoritative on diagnoses, and these traits serve both professionals extremely well in the different worlds they inhabit. But skepticism and certainty are antonymous, as are many of the characteristics that are expected of scientists versus physicians. The memorization that is required to be an efficient physician is in stark contrast to the imagination that is required to be a productive scientist. Although these opposing ways of thinking are not mutually exclusive, it is very unlikely that one individual can truly master both.

Some argue that physician-scientists are predominantly physicians or predominantly scientists. This may be an attempt to reconcile conflicting demands. Preference for either science or medicine emerges through a physician-scientist’s division of time; if one “opts for an 80-20 split,” then the individual reveals preference for one endeavor over the other. Throughout a career, time demand may override preference, but the elected distribution of “protected time” still reflects an individual’s priorities. When that priority is established, it can be expected that the physician-scientist will achieve greater success in the preferred discipline, at the expense of success in the other. A 20% commitment is insulting to any endeavour and will inevitably result in compromised performance.

Another organizational factor that influences the career success of physician-scientists is the institution in which they are based.(1) U of T may be better able to provide physician-scientists with the resources and support necessary for success in both the clinic and the lab, whereas newer and smaller institutions may place higher demands on individual physician-scientists. Conversely, during training, newer and smaller programs may offer modern approaches which facilitate success. For example, Queen’s University is launching Canada’s first “Accelerated Route to Medical School” where high-school students are selected for a 2-year undergraduate degree program followed by a 4-year degree program in the Queen’s School of Medicine. As one strategy for reducing the cost and time commitment of medical training, this represents the kind of improvement that is possible with progressive thinking.

U of T’s faculty and students are among the best of forward thinkers, and this is evidenced by the critical assessment of clinician-scientist training undertaken by Dr. Norman Rosenblum in Fall 2011. A Task Force on Physician Scientist Education was established to survey current U of T MD/PhD Program and Clinical Investigator Program trainees. This action demonstrates awareness that there is room for improvement, as Dr. Rosenblum points out in the Spring 2012 edition of the MD/PhD Newsletter Pair O Docs, “In many ways, the educational model for physician scientist training has been static for decades. It is time for a careful review.”(2)

According to survey results, the vast majority of trainees do not regret their decision to be in these dual programs, and intend to pursue careers as physician-scientists. Nevertheless, trainees did voice concerns that support the need for scrupulous appraisal of the existing model. As Dr. Rosenblum summarized, “Results also indicate that MD/PhD students are concerned by lack of integration between the medical and PhD curricula during their training, the length of time it takes to complete undergraduate and postgraduate training, how their career will be configured to include clinical activity and research, the sustainability of a physician scientist career and eventual career ‘burn out.’”(2) With a response rate of 82%, Dr. Dugani can rest assured that these are not but one student’s comments.

The need for physician-scientists is undeniable, but so are the challenges they encounter. This is profound justification for constructive review of current paradigms. Success exists along a spectrum, so we can always be better. As said by Thomas A. Edison, “Discontent is the first necessity of progress.” My views are my own and everyone (students, clinicians, and scientists) can contribute to a meaningful discussion on this topic – but only if it is being discussed.

Shabana Amanda Ali
PhD Candidate

References
1. Rubio DM, Primack BA, Switzer GE, Bryce CL, Seltzer DL, Kapoor WN. A comprehensive career-success model for physician-scientists. Acad Med. 2011 Dec;86(12):1571-6.
2. Rosenblum N. A Critical Assessment of Clinician-Scientist Training. University of Toronto; 2012 [cited 2013 January]; Available from: http://mdphd.utoronto.ca/wp-content/uploads/2012/04/MDPhD-Newsletter-2012.pdf.