One of the hardest roads in medicine
They juggle two demanding jobs. Their numbers are in decline. The case for physician-scientists and why this tiny branch of medicine merits safeguarding.
May 21, 2018
Story by Rachel Shafer; this article first appeared in Spring 2018 Bridges magazine
Susan Rowell, M.D. F '07, M.C.R. '12*, considers the question: Why does she do two demanding jobs at once? The trauma surgeon and brain injury researcher normally thrums with energy. But now she grows contemplative.
"It's hard to lose people, especially a child," she said, after a moment. "The opportunity to impact the lives of my patients beyond the operating room – that's why I do research."
Her drive is palpable. Brain injury is the leading cause of death from trauma injury, according to the American Association for the Surgery of Trauma. As Dr. Rowell knows, the highest standards of care aren't enough.
So when she's not running the surgical intensive care unit at OHSU Hospital or rounding on trauma patients or teaching residents or parenting three children, Dr. Rowell squeezes in an NIH R01-funded research program investigating new treatment strategies for traumatic brain injury.
For decades, physician-scientists – who typically devote 80 percent of their time to research, 20 percent to patient care – comprised a small subset of the physician workforce with an outsize role in medical advances. The curiosity of OHSU's Brian Druker, M.D.*, for example, wondering why his chronic myeloid leukemia patients weren't responding to standard treatments, led to new lab experiments and the breakthrough drug Gleevec, turning a fatal cancer into a manageable disease. (Notable physician-scientists are alumni, too. Meet two of them.)
"If you look at places doing transformational work, they are heavily populated by physician-scientists," explained oncologist and physician-scientist Joshi Alumkal, M.D.* (pictured above, left) "These types of researchers take critical problems they see in clinic and bring those questions back to the lab. That's fewer obstacles to making a discovery, but it's one of the hardest roads you can take in medicine."
Today, the number of physician-scientists – already small – is declining further, beaten down by a number of factors, including an ultra-competitive funding environment for research and pressure to maximize clinical productivity. A 2014 report by the NIH Physician-Scientist Workforce Working Group found that of almost 1 million U.S. physicians,1.5 percent reported research as their primary focus. At OHSU during that same period, an estimated 4 percent of physicians focused on research.
That's too low for Dean Sharon Anderson, who herself ran labs at Brigham and Women's Hospital and the V.A. Portland Health Care System and continues to care for patients at OHSU and the V.A. "The school needs all kinds of faculty, from full-time providers and scientists to physician-scientists in order to fulfill our mission to rapidly translate new knowledge into better health for all," she said.
Linking science and medicine
Research is a natural fit for anesthesiologist and neuroscientist Eric Schnell, M.D., Ph.D.*, who studies neuronal dysfunction in disease. Dr. Schnell describes himself as a tinkerer, someone who likes to understand how things work. After doing research in college, he pursued an M.D./Ph.D. rather than a Ph.D. because he surmised medical school would be an ideal way to learn how neuroscience relates to human health. He had no intention of ever practicing medicine, he said, but as he progressed through medical school, he found clinical practice more rewarding than he thought.
Years later, he's still doing both and embraces the challenge.He jokes about the conundrum of getting dressed in the morning. "If I wear nice clothes to the lab, I invariably spill bleach on myself or end up crawling around on the floor to troubleshoot malfunctioning equipment. And if I wear my favorite fleece and T-shirt, I find myself in a clinician meeting conspicuously underdressed. It's a metaphor for the challenge of bridging two different cultures and ways of thinking."
He elaborated. "Despite what people think, clinicians and scientists often don't speak the same language or even share the same priorities. Physician-scientists bridge those gaps."
Bringing disparate experts together is key to answering today's complex scientific questions, and it's an area where physician-scientists excel, including neonatologist and pulmonary scientist Cindy McEvoy, M.D., M.C.R. '08.*
Dr. McEvoy finds an infant's transition from life in the uterus to the outside world fascinating. Her bedside observations led her to initiate studies focused on maximizing lung growth as early as possible in order to set term and preterm babies on a positive trajectory. Collaborating with basic scientists from the Oregon National Primate Research Center, she and her team designed a clinical trial that revealed that giving supplemental vitamin C to pregnant smokers improved lung function in their infants and decreased wheezing through 12 months of age.
"We're optimistic this may be an inexpensive and simple approach with continued smoking cessation counseling to decrease some of the effects of smoking in pregnancy on childhood respiratory health," she said. Her results could have a large public health impact.
Dual-identity challenges
The argument for physician-scientists is convincing on paper, but the day-to-day reality is complicated.There's the challenge of balancing it all, said neurologist and neuroscientist Rebecca Spain, M.D.,M.S.P.H.*, who investigates new treatments for progressive multiple sclerosis.
There are fewer jobs, added cardiologist and structural biologist Steven Mansoor, M.D. '09 R '17, Ph.D. '09*, who studies the structure of receptors and ion channels. "Financial pressures make it difficult for departments to hire physician-scientists because clinicians generate more revenue," he explained.
In addition to earning more, clinicians don't face pressure to publish or obtain grant funding. There is instant gratification when patient health improves; scientists can spend months without a positive result.
"But to me, research is worth it because I'm driven by that positive result," said Dr. Mansoor. "There's no greater high than getting an exciting result late at night in the lab when no one else in the world knows what I know at that moment. It's thrilling. And it constantly motivates me."
One of the biggest challenges physician-scientists face is a gap in research funding. In fact, studies suggest that they are most vulnerable early in their careers as they try to transition to independent funding such as an NIH R01 grant.
Worried by these obstacles and shrinking numbers, leaders in the school are working to right the ship. They recruited notable physician-scientists Joan Teno, M.D.*, and Susan Gurley, M.D., Ph.D.*, earlier this year. And the school launched a major strategic program to further expand the ranks of physician-scientists and provide better support.
"Some of the most interesting science happens when clinical questions drive mechanistic experiments," said Mary Heinricher, Ph.D., associate dean for basic research, OHSU School of Medicine. "This comes naturally to physician-scientists, and we want to ensure they have the support they need to make the transformational discoveries we know are possible."
The new program, led by Jeanne-Marie Guise, M.D., M.P.H.*, will help in a number of areas, including career development and protected time policies. And it will provide substantial financial support to gird retention and recruitment efforts.
The program augments existing researcher support services provided by the Oregon Clinical and Translational Research Institute (OCTRI), directed by David Ellison, M.D.* One of OCTRI's most popular programs is the well-regarded Human Investigations Program and its master's in clinical research, led by Cynthia Morris, Ph.D., M.P.H.*
That's all good news for people like Dr. Susan Rowell who, to make it as a surgeon, scientist and mom, learned to delegate where possible, write grants at four in the morning and fit research around her busy clinical and family schedule. The results of her team's traumatic brain injury clinical trial – soon to be published – are the culmination of more than seven years of hard work. She's hopeful the findings will improve outcomes for brain-injured patients and potentially change the standard for care for the management of traumatic brain injury.
"That," she said, "is the ultimate reason to do research."
*Particulars