Physician-scientists are critical members of the biomedical workforce. The combination of rigorous scientific training and clinical skills uniquely positions them to bridge clinical needs with investigational pursuits by identifying important clinical questions that drive basic discoveries and translating those into therapeutics that improve patient outcomes. The impact of physician-scientists on biomedical science has been profound. Indeed, the recipients of the 2019 Nobel Prize in Physiology or Medicine, William Kaelin Jr., Gregg Semenza, and Peter Ratcliffe, are all physician-scientists. Furthermore, physician-scientists have been well represented as Nobel laureates (including Frederick Banting, Carl Cori, Earl Sutherland, Alfred Gilman, Michael Brown, Joseph Goldstein, Bernardo Houssay, Edwin Krebs, Peter Agre, Harold Varmus, Robert Lefkowitz, Brian Kobilka, and Ralph Steinman, to name a few). Yet, as the need for novel therapies has grown, the number of physician-scientists has declined (1). The reasons for this decline are numerous, including length and cost of clinical training, declining funding opportunities, reduced visibility of physician-scientist role models, and compensation disparities between academic and private practice careers. Residency, fellowship training, and entry into faculty — important entry points for budding physician-scientists and a period of continuity for those who wish to build on their earlier research experiences — are critical junctures where attrition occurs along the physician-scientist training timeline (2–5). Here, we describe innovative strategies implemented at three academic medical centers in the United States that are working to fill the physician-scientist pipeline. These strategies promote research during clinical training with an emphasis on cultivating intellectual curiosity, protecting research time, promoting physician-scientist leadership, tailoring mentor support, and fostering early career development, as well as providing financial resources to support trainees and young faculty. Additionally, we propose potential outcomes to measure the success of these strategies in strengthening the physician-scientist workforce.

The loss of role models for clinical trainees negatively impacts their choice to participate in research (1, 5). Unless physician-scientists are part of academic medical center and medical education leadership, the development of future physician-scientists is unlikely to be a training priority. There are two emerging paradigms that promote institution-wide physician-scientist leadership: a centralized model and an integrated model, although these models are not mutually exclusive (Figure 1A).

Institutional approaches and funding opportunities for physician-scientists in training and the early career stage. (A) Structure and approaches taken by MGH Internal Medicine, Duke University School of Medicine (centralized in the Office of Physician Scientist Development [OPSD]), and Vanderbilt University School of Medicine to train and support new physician-scientists. (B) Funding from the NIH, the US Department of Veterans Affairs (VA), the Burroughs Wellcome Fund (BWF), the Doris Duke Charitable Foundation (DDCF), and Howard Hughes Medical Institute (HHMI). These mechanisms include the Physician-Scientist Institutional Award (PSIA), the Physician Scientist Fellowship (PSF), the Loan Repayment Program (LRP), the Fund to Retain Clinical Scientists (FRCS), and the Career Development Award (CDA). Symbols highlight mechanisms used to fund the institutional physician-scientist programs featured in this perspective. CSDA, Clinical Scientist Development Award: DSP, Diversity Supplement; HHGF, Hannah H. Gray fellows; MSTP, Medical Scientist Training Program; PS, physician-scientist. Adapted with permission from Dr. Shawn Gaillard (NIH).

The centralized model, as demonstrated by Duke University’s Office of Physician-Scientist Development and Vanderbilt University’s Office of Clinical and Translational Scientist Development, provides an institution-wide resource for physician-scientists and department-based programs to provide coordinated programming in career development and training efforts. The centralized model facilitates interactions among multiple departments, centers, and institutes to leverage institutional resources and invest in tailored programming. The Vanderbilt Physician Scientist Societies and affiliate programming (Medical Scientist Training Program, Harrison Society [Department of Medicine (DOM) ABIM Research Pathway], Newman Society [junior faculty development program]) and the Massachusetts General Hospital (MGH) DOM Stanbury Physician-Scientist Pathway are examples of an integrated model, which supports the development of physician-scientists throughout career transitions from graduate medical education to early and established faculty within each department. This model allows for sustained mentorship and training of physician-scientists. Although a perceived disadvantage of these institution-wide models might be an inability to provide individualized training, in fact, our collective experience has been that institution-wide programming allows leveraging of institutional resources to tailor mentoring to each trainee.

Physician-scientist leadership is essential and can be provided not only through institution-wide initiatives but also within specialties and during critical training periods, as demonstrated by MGH’s DOM resident–focused approach. Residency-focused models aim to provide directed support and mentorship in academic medicine to residents through a variety of mechanisms, as discussed below. A common thread throughout these three paradigms is integration of physician-scientists into leadership positions that set priorities for medical education and research training, while also reflecting the diversity of trainees. Indeed, our institutions each have examples of physician-scientists serving as directors, associate deans, faculty directors, program managers, and residency program directors. Incorporating successful physician-scientists into clinical and research training leadership provides new trainees with strong role models, consistent guidance regarding research opportunities, and support for funded programs dedicated to physician-scientists.

Specialty board-sanctioned research pathways provide a framework for integrating clinical and research training at academic medical centers. The persistent paucity of physician-scientists engaged in research-intensive careers at the conclusion of training underscores the need for institutions to develop additional programs to enhance professional research development. Mentorship during both residency and fellowship is critical to prepare trainees for success as they transition to faculty. Dedicated physician-scientist training programs (PSTPs) offer several advantages to trainees over standard residency and fellowship programs, including direct mentorship by active physician-scientists overseeing these programs. If developed appropriately, physician-scientist communities created by PSTPs catalyze peer-peer and near-peer mentoring relationships that facilitate the dissemination of critical stage-specific information through seminar series, social events, and career development workshops. Moreover, many PSTPs function as de facto “farm teams” for institutional faculty recruitment. Inclusion of alumni who have successfully transitioned to junior faculty in the institutional PSTP community (e.g., Vanderbilt’s Harrison Society, Duke’s Robert J. Lefkowitz Society, and MGH’s Jackson Society) enriches training experiences through vertical integration across career stages, increasing opportunities for intrainstitutional networking.

Specific program features can significantly contribute to physician-scientist training success. During residency, structured curricula help maintain scientific curiosity despite time-intensive clinical obligations (e.g., MGH DOM Pathways Initiative) (1, 3). Protected research time during a fellowship is critical to provide an immersive research experience for trainees so they can begin establishing independent lines of scientific investigation. Benefits such as salary supplementation and child care disincentivize moonlighting and reduce the pressure to pursue careers in private practice. Activities including career trajectory and scholarly goal planning and focused grant-writing programs and grant concept reviews, coupled with financial resources (e.g., research stipends, technical support grants, pilot project grants) facilitate the acquisition of research funding. Mentoring committees composed of established physician-scientists ensure that trainees receive feedback on their research progress at regular intervals throughout their training and pair seamlessly with supplemental programs (e.g., career development consultation, curriculum vitae/biosketch clinics, community-building activities). Dissemination of such programs throughout academic medical centers will likely contribute to increased retention of trainees in the physician-scientist pipeline.

Sustaining successful physician-scientist pipelines requires a funding strategy that includes coverage for (a) protected time for both research and professional training; (b) research funding for scholars at various points in their career development; and (c) administrative support for mentorship, training, and evaluation. MGH, Duke, and Vanderbilt have used a variety of funding mechanisms to achieve these goals. NIH and VA funding opportunities provide research and training support for premedical, medical, and graduate students (T32, R25, F30/31), residents and fellows (T32, F32, R25, R38, K38, VA-CDA), and fellows/early career faculty (K12/KL2) (Figure 1B). These NIH-funded mechanisms aim to support research education activities (R25), stimulate access to research during residency (R38), and enhance mentored research training opportunities (T32, K12, K38). These mechanisms are not available through all NIH institutes; specifically, the R38 is currently offered by only four institutes. Structural and administrative support to build professional development programs and administer internal research funding programs has largely been funded internally through medical school deans’ offices, departments, and endowments and through large institutional grants (e.g., the Burroughs Wellcome Fund Physician-Scientist Institutional Award). Foundations such as the Doris Duke Charitable Foundation may be engaged to retain physician-scientists at early career faculty stages, when many struggle with balancing clinical, research, and home life responsibilities. Additional opportunities are offered by the Howard Hughes Medical Institute to promote diversity among physician-scientist trainees. Finally, for trainees who devote at least 50% of their efforts to research, the NIH Loan Repayment Program can offer a reduction in educational debt, and applications to this program should be highly encouraged beginning in residency. Overall, we have found that a strong and diverse portfolio of funding is necessary and that a variety of external opportunities exist to tackle the problem of a shrinking physician-scientist pipeline. Ultimately, institutional dedication to supporting trainees in pursuing these awards is critical to the success of a sustainably funded physician-scientist training program.

Collecting metrics that demonstrate outcomes of institutional physician-scientist development programs will be important to inform the best use of limited resources to support these programs over the long term. Standard measures of success of scientific training programs typically include numbers and, more important, the impact of manuscripts, abstract presentations, grants applied for and received, awards received, and the proportion of graduates who stay in academic positions. However, additional metrics that may be harder to track are nonetheless vital to determining an institutional program’s success, including the number of successful K-to-R grant transitions and the proportion of the program graduates’ effort committed to research in early and later faculty years. Moreover, nonresearch factors (i.e., impact of educational debt, work-life integration, and physician burnout) should be followed and compared with those in primarily clinical careers. The development and maintenance of robust physician-scientist pathways can be framed as a strategy to diversify and strengthen the physician workforce and improve the health of the population, which should be a priority for both health systems and medical schools.

The decline in the physician-scientist pipeline is increasingly evident. We have described potential solutions to address this decline by incorporating physician-scientists into clinical and research training program leadership, establishing key programming during training, providing funding mechanisms to assist with research support, and creating new opportunities for professional development. Our programs represent three distinct but complementary approaches to provide robust physician-scientist development during clinical training, when it is often ignored. Broader implementation of such potential solutions will strengthen the physician-scientist workforce and revitalize this important component of academic medicine.

The authors would like to thank Katrina Armstrong (Physician-in-Chief, Department of Medicine, MGH); Nancy Brown (Chair, Department of Medicine, Vanderbilt University School of Medicine); Mary Klotman (Dean, Duke University School of Medicine); and Jeffrey Balser (Dean, Vanderbilt University School of Medicine) for their thoughtful advice and support. This work was supported in part by NIH grants (R25AI147393, to JMV; R38AI140297 and R38HL143612, to SRP; and R38HL143619, to CSW) and a Burroughs Wellcome Fund Physician-Scientist Institutional Award (PSIA) (1018899, to RAG).

Conflict of interest: The authors have declared that no conflict of interest exists.

Copyright: © 2020, American Society for Clinical Investigation.

Reference information: J Clin Invest. 2020;130(3):1058–1061. https://doi.org/10.1172/JCI136181.

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医师科学家是生物医学工作者的重要成员。严格的科学训练和临床技能的结合，使他们能够通过识别驱动基本发现的重要临床问题并将其转化为可改善患者预后的治疗方法，从而将临床需求与研究追求联系起来。医师科学家对生物医学的影响是深远的。实际上，2019年诺贝尔生理学或医学奖得主，小威廉·凯林（William Kaelin），格雷格·塞缅扎（Gregg Semenza）和彼得·拉特克利夫（Peter Ratcliffe）都是医师科学家。此外，作为诺贝尔奖获得者的医师科学家也得到了很好的代表（包括弗雷德里克·班廷，卡尔·科里，伯爵·萨瑟兰，阿尔弗雷德·吉尔曼，迈克尔·布朗，约瑟夫·戈德斯坦，伯纳多·侯赛，埃德温·克雷布斯，彼得·阿格里，哈罗德·瓦尔姆斯，罗伯特·莱夫科维茨，布赖恩·科比尔卡（Brian Kobilka）和拉尔夫·斯坦曼（Ralph Steinman）等。然而，随着对新疗法的需求的增长，医师医师的数量有所下降（1）。这种下降的原因很多，包括临床培训的时间和成本，资金机会的减少，医师-科学家榜样的可见度降低以及学术和私人执业职业之间的薪酬差距。住院医师，研究金培训和教职人员-对萌芽的医师科学家来说是重要的切入点，对于希望基于其早期研究经验的人们来说是连续的-是在医师科学家培训时间轴上损耗的关键时刻（2 –5）。在这里，我们描述了在美国三个学术医学中心实施的创新战略，这些战略正在努力填补医师-科学家的血统。这些策略可促进临床培训期间的研究，重点在于培养知识好奇心，保护研究时间，促进医师-科学家的领导力，调整导师的支持，促进早期职业发展以及为支持受训者和年轻教师提供财务资源。此外，我们提出了可能的结果，以衡量这些策略在增强医师-科学家队伍中是否成功。

临床受训者榜样的流失会对他们参与研究的选择产生负面影响（1，5）。除非医师科学家是学术医学中心和医学教育领导者的一部分，否则未来医师科学家的发展不太可能成为培训的重点。有两种新兴的范式可以促进机构范围内的医师-科学家领导力：集中式模型和集成式模型，尽管这些模型不是互斥的（图1A）。

医师和科学家在培训和职业早期阶段的机构方法和资金机会。（A）MGH内科医学，杜克大学医学院（集中在内科医师发展办公室[OPSD]）和范德比尔特大学医学院采取的结构和方法，以培训和支持新的医师科学家。（B）由NIH，美国退伍军人事务部（VA），Burroughs Wellcome基金会（BWF），Doris Duke慈善基金会（DDCF）和Howard Hughes医学院（HHMI）资助。这些机制包括医师-科学家机构奖（PSIA），医师科学家奖学金（PSF），贷款还款计划（LRP），保留临床科学家基金（FRCS）和职业发展奖（CDA）。符号突出显示了用于资助这种观点下的机构医师-科学家计划的机制。CSDA，临床科学家发展奖：DSP，多样性补充；HHGF，Hannah H. Gray研究员；MSTP，医学科学家培训计划；PS，医师科学家。经Shawn Gaillard博士（NIH）许可改编。

杜克大学的内科医生与科学家发展办公室和范德比尔特大学的临床与转化科学家发展办公室证明了这种集中化模型，该模型为医师科学家和基于部门的计划提供了机构范围的资源，以提供职业发展和培训方面的协调计划努力。集中式模型促进了多个部门，中心和机构之间的交互，以利用机构资源并投资于定制的计划。范德比尔特医师协会和会员计划（哈里森学会[医学部（ABIM）ABIM研究途径]的医学科学家培训计划，纽曼协会[初级教师发展计划]和马萨诸塞州总医院（MGH）DOM斯坦伯里医师-科学家之路是集成模型的示例，该模型在从研究生医学教育到早期建立的教师的整个职业过渡过程中，支持医师-科学家的发展。在每个部门内。该模型允许持续的指导和医师科学家的培训。尽管这些机构范围模型的缺点可能是无法提供个性化培训，但实际上，我们的集体经验是，机构范围的编程可以利用机构资源为每个受训者量身定制辅导。在从研究生医学教育到各个部门内早期和已建立的教师的整个职业过渡过程中，它支持医师科学家的发展。该模型允许持续的指导和医师科学家的培训。尽管这些机构范围模型的缺点可能是无法提供个性化培训，但实际上，我们的集体经验是，机构范围的编程可以利用机构资源为每个受训者量身定制辅导。在从研究生医学教育到各个部门内早期和已建立的教师的整个职业过渡过程中，它支持医师科学家的发展。该模型允许持续的指导和医师科学家的培训。尽管这些机构范围模型的缺点可能是无法提供个性化培训，但实际上，我们的集体经验是，机构范围的编程可以利用机构资源为每个受训者量身定制辅导。

医师-科学家的领导是必不可少的，不仅可以通过机构范围内的举措提供，而且可以在专业内和关键培训期间提供，正如MGH的以DOM居民为中心的方法所证明的。以居留为中心的模型旨在通过多种机制向居民提供学术医学方面的定向支持和指导，如下所述。这三个范式的共同点是将医师-科学家整合到领导职位中，这些职位确定了医学教育和研究培训的重点，同时也反映了学员的多样性。确实，我们的每个机构都有由医师-科学家担任董事，副院长，教职主任，项目经理和住院医师项目主任的例子。

专业委员会批准的研究途径为在学术医学中心整合临床和研究培训提供了框架。在培训结束时，从事研究密集型职业的医师科学家的持续匮乏突显出机构需要制定更多计划以增强专业研究发展的必要性。实习和进修期间的指导对于培训学员过渡到学院的成功至关重要。专用的医师-科学家培训计划（PSTP）为学员提供了优于标准住院医师和研究金计划的多项优势，包括监督这些计划的积极医师-科学家的直接指导。如果开发得当，由PSTP创建的医师-科学家社区促进了对等和近对等的指导关系，通过研讨会系列，社交活动和职业发展研讨会促进了关键阶段特定信息的传播。此外，许多PSTP实际上是机构教师招聘的“农场团队”。成功进入机构PSTP社区（例如，范德比尔特的Harrison学会，杜克大学的Robert J. Lefkowitz学会和MGH的Jackson学会）的初级教师的校友的加入，通过跨职业阶段的垂直整合丰富了培训经验，增加了培训网络的机会。许多PSTP充当了事实上的“农场团队”，用于机构教师的招聘。成功进入机构PSTP社区（例如，范德比尔特的Harrison学会，杜克大学的Robert J. Lefkowitz学会和MGH的Jackson学会）的初级教师的校友包括在内，通过跨职业阶段的垂直整合丰富了培训经验，增加了机构网络的机会。许多PSTP充当了事实上的“农场团队”，用于机构教师的招聘。成功进入机构PSTP社区（例如，范德比尔特的Harrison学会，杜克大学的Robert J. Lefkowitz学会和MGH的Jackson学会）的初级教师的校友包括在内，通过跨职业阶段的垂直整合丰富了培训经验，增加了机构网络的机会。

特定的程序功能可以极大地促进医师-科学家培训的成功。在住院期间，尽管有大量时间的临床义务（例如，MGH DOM Pathways Initiative），结构化课程仍有助于保持科学的好奇心（1，3）。奖学金期间受保护的研究时间对于为受训者提供身临其境的研究经验至关重要，这样他们就可以开始建立独立的科学研究路线。诸如增加薪水和育儿之类的福利消除了月光的刺激，并减轻了从事私人执业职业的压力。包括职业发展轨迹和学术目标规划，重点写作计划和赠款概念审查在内的活动，再加上财政资源（例如研究津贴，技术支持赠款，试点项目赠款），都有助于获得研究经费。由资深医师科学家组成的指导委员会可确保受训者在整个培训过程中定期获得有关其研究进展的反馈，并与补充计划（例如，职业发展咨询，履历/生物素描诊所，社区建设活动）。在学术医学中心中传播此类程序可能会有助于增加学员在医师-科学家队伍中的保留率。

要维持成功的医师-科学家渠道，就需要一项筹资战略，其中应包括：（a）保护研究和专业培训的时间；（b）为学者在职业发展的各个阶段提供研究经费；（c）为指导，培训和评估提供行政支持。MGH，Duke和Vanderbilt已使用各种筹资机制来实现这些目标。NIH和VA的资助机会为医学，医学和研究生（T32，R25，F30 / 31），居民和研究员（T32，F32，R25，R38，K38，VA-CDA）和研究员/提供了研究和培训支持/早期职业教师（K12 / KL2）（图1B）。这些由美国国立卫生研究院（NIH）资助的机制旨在支持研究教育活动（R25），促进在住院期间获得研究的机会（R38），以及增加受指导的研究培训机会（T32，K12，K38）。这些机制并非在所有NIH机构中都可用；具体来说，R38目前仅由四个机构提供。用于建立专业发展计划和管理内部研究资助计划的结构和行政支持，大部分是通过医学院院长办公室，部门和捐赠以及大型机构赠款（例如，Burroughs Wellcome基金医师-科学家机构奖）内部提供的。当许多人努力平衡临床，研究和家庭生活职责时，诸如多丽丝·杜克（Doris Duke）慈善基金会之类的基金会可能会聘请医师科学家留在职业生涯的早期阶段。霍华德·休斯医学研究所（Howard Hughes Medical Institute）提供了额外的机会，以促进医师科学家培训对象之间的多样性。最后，对于致力于研究至少50％的受训者，NIH贷款还款计划可以减少教育债务，因此从居住地开始应大力鼓励该计划的申请。总的来说，我们发现强大而多样化的资金组合是必要的，并且存在各种外部机会来解决医师-科学家队伍不断缩小的问题。归根结底，机构对支持受训者追求这些奖项的奉献精神对于成功获得可持续资助的医师－科学家培训计划至关重要。我们发现，强大而多样的资金组合是必要的，而且存在各种外部机会来解决医师-科学家渠道不断缩小的问题。归根结底，机构对支持受训者追求这些奖项的奉献精神对于成功获得可持续资助的医师－科学家培训计划至关重要。我们发现，强大而多样的资金组合是必要的，而且存在各种外部机会来解决医师-科学家渠道不断缩小的问题。归根结底，机构对支持受训者追求这些奖项的奉献精神对于成功获得可持续资助的医师－科学家培训计划至关重要。

收集证明机构医师－科学家发展计划成果的指标，对于长期使用最佳资源来支持这些计划至关重要。科学培训计划成功的标准衡量标准通常包括数字，更重要的是，手稿，摘要介绍，申请和获得的资助，所获得的奖励以及留在学术职位的毕业生比例的影响。但是，其他可能难以追踪的指标对于确定机构计划的成功至关重要，包括成功的K到R补助金过渡次数以及该计划的毕业生在早期和以后的教职期间投入研究的努力的比例。此外，非研究因素（例如教育债务的影响，应遵循工作与生活的融合以及医生的倦怠），并将其与主要从事临床工作的人进行比较。稳健的医师-科学家路径的开发和维护可以构架为多样化和加强医师队伍并改善人口健康的战略，这对卫生系统和医学院来说都是优先考虑的。

医生-科学家渠道的下降越来越明显。我们已经描述了通过将医师科学家纳入临床和研究培训计划领导者，在培训期间建立关键计划，提供资助机制以协助研究支持以及为职业发展创造新机会来解决这一下降的潜在解决方案。我们的计划代表了三种截然不同但互补的方法，可在临床培训期间（通常被忽略）提供强大的医师-科学家发展。这种潜在解决方案的更广泛实施将增强医师科学家队伍，并振兴学术医学的这一重要组成部分。

作者要感谢Katrina Armstrong（MGH医学系主任医师）；南希·布朗（范德比尔特大学医学院医学系主任）；Mary Klotman（杜克大学医学院院长）；和Jeffrey Balser（范德比尔特大学医学院院长）提供了周到的建议和支持。NIH赠款（授予JMV的R25AI147393，授予SRP的R38AI140297和R38HL143612以及授予CSW的R38HL143619）和Burroughs惠康基金会医师－科学家机构奖（PSIA）（授予RAG的1018899）部分地支持了这项工作。

利益冲突：作者已经声明不存在利益冲突。

版权所有： ©2020，美国临床研究学会。

参考信息：J Clin Invest。2020; 130（3）：1058–1061。https://doi.org/10.1172/JCI136181。

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