It was my first week in the lab when I overheard three forbidden words.
A senior investigator asked a junior scientist about his research. From my lab bench, I heard the junior scientist utter three words that would have ended the conversation in my previous career as a dietitian. “I don’t know,” he admitted.
In the clinic, telling a physician “I don’t know” exacted a high cost: his or her loss of confidence in my expertise. Physicians relied on my nutritional expertise to ensure that patients healed quickly. “I don’t know” suggested incompetence.
But in the lab, the words “I don’t know” would often spark lively conversation that led to new ideas. That’s when I realized my transition from clinical dietitian to research scientist wasn’t just a change in careers; I was entering a new reality. In this reality, “I don’t know” could indicate brilliance, not incompetence; and ideas, not protocols, drove success.
BRIDGING THE GAP
I welcomed these revelations but also repeatedly saw that these differences discourage collaboration between physicians and scientists, impeding, for example, the development of clinically relevant treatments. Craig Blackstone, scientific director of the MD/PhD Program at the National Institutes of Health, has also encountered this dilemma: “Sometimes,” he says, [physicians and scientists] just don't have enough commonality in the way they approach things to even be able to talk to one another.” After defending my PhD in biochemistry and molecular biology, I wanted to make conversation between these professionals easier, so I founded The Written Science to support the translation of science into medicine.
Traditionally, physician-scientists have bridged the gap between the clinic and lab. They hold professional degrees related to clinical care (i.e., MD, RN, DVM, MD/PhD) but spend most of their time conducting research. Through their unique combination of clinical and research experience, they look for insight into the molecular discordance that underlies disease etiology. They convert scientific findings into clinically relevant applications and elucidate the mechanisms that cause clinical problems.
PHYSICIAN-SCIENTISTS TRANSLATE RESEARCH INTO INNOVATIONS
The discovery of statins—a class of drugs that inhibit cholesterol production—demonstrates the special ability of physician-scientists to connect clinical dilemmas with novel therapies. Joseph Goldstein’s experience treating patients with familial hypercholesterolemia (FH) prompted him and Michael Brown to investigate the disease’s molecular etiology during the 1970s. Together, they discovered that patients with FH lack LDL receptors and exhibit increased LDL cholesterol production. Brown and Goldstein proposed that statins might lower the cholesterol level of such patients. Subsequent studies by these two physician-scientists and other researchers confirmed the therapeutic effect of statins in FH and other patient populations. Now, statins are a regular part of clinical care and have saved millions of lives.
The statin story shows the unique ability and opportunity of physician-scientists to connect patient symptoms with research. A life-saving treatment was discovered, thanks to the seamless flow of information between the clinic and lab.
But due to a combination of circumstances, this fluidity has diminished over time. From 1980 to 2002, the number of biomedical science doctorates increased by over 50 percent, and spending on academic research and development efforts more than doubled. During this same time period, the clinical physician workforce increased nearly twofold, but the number of physicians choosing research-oriented careers remained steady. Scientists were conducting more studies, but fewer translators were available to facilitate the flow of information between the bench and bedside.
A relative decline in the physician-scientist population threatens cross talk between the lab and clinic. Researchers are less aware of potential clinical implications for molecular discoveries and are not privy to the clinical observations and needs that fuel clinically relevant research. The flow of information between the lab and clinic slows.
Blackstone and others worry that physician-scientists will become more scarce in the future, restricting this information stream to a trickle (see here, here and here). With fewer physician-scientists to intercede, cultural and professional differences between physicians and researchers may compromise the flow of information between these worlds, widening the current rift.
The earliest evidence of cultural differences between basic science and clinical practice may appear at the training level: MD students and PhD candidates are visually distinguishable on university campuses. Medical students dress in business clothes, reinforcing their authority and responsibility. Grad students usually wear jeans and T-shirts. These unintentional visual cues encourage the physical separation of lab and clinic in university hallways, where interactions between future physicians and researchers should be the most accessible.
Andrew Schafer, currently professor of medicine in hematology-oncology at New York-Presbyterian, has summarized several of the fundamental professional differences between physicians and scientists, including the following observations from his book The Vanishing Physician-Scientist?:
- Clinician responsibilities demand immediate action; scientists prefer to deliberate.
- Clinicians act in accordance with standards of care and practice guidelines, and they respect hierarchy and authority. Scientists thrive on the unknown and challenge convention.
- Errors cause irreparable damage in the clinic but are, Schafer says, “inevitable manifestations of the creative process” in the lab.
These reality-shaping differences can be liberally generalized as “certainty” versus “wonderment.”
Physicians seek certainty: their jobs and the patients’ lives demand succinct, comprehensive solutions. Scientists, on the other hand, thrive on wonder and possibility. The airtight solutions that ease a physician’s workload are dead-ends for researchers.
So, how can collaboration between these diverse worlds be improved to ensure that scientific discoveries address clinical deficits? Partnerships between physicians and scientists are an essential part of the solution. For these partnerships to be successful, information must flow freely between these professions. Modifications to traditional institutional structures, effective communication tactics, and integrated training techniques will cultivate a shared language that facilitates fluid information exchange and productive collaboration.
REDEFINE AND SUPPORT THE PHYSICIAN-SCIENTIST
Today’s physicians face different professional and personal demands and workflows than those of previous generations. For example, recent changes in institutional demands (e.g., the Affordable Care Act) have altered physician responsibilities. Blackstone believes the structure of traditional academic medical centers does not support the needs and priorities of modern physician-scientists. A fresh model for physician involvement in research may stimulate clinical innovation.
Physicians may find collaborative research with basic scientists who have complementary expertise to be more feasible than independent efforts. Complementary partnerships between clinical physicians and lab-based scientists will fortify the connection between these worlds.
Even collaborative studies require a significant time commitment. Blackstone believes that departmental and institutional leaders can create a supportive research environment for physicians by providing financial assistance and/or reduced patient loads to those involved in scientific studies, offsetting the cost (financial and time) required for these efforts. Institutions that champion physician research fuel biomedical innovation.
ACKNOWLEDGE THE DIFFERENCE
Successful communication is essential for physicians and scientists to collaborate productively, especially as each field’s body of knowledge grows. To improve the flow of scientific discoveries out of the lab, researchers should succinctly summarize their findings for physicians. Physicians must learn to ponder the clinical application of basic science discoveries. As these professionals honor each other’s unique realities, their conversations about the unknown will catalyze clinically relevant innovations.
Training is a prime opportunity for future physicians and scientists to develop valuable communication techniques that foster cross-profession collaboration. Modifications to established training procedures will chip away at the foundational differences between these professionals.
Medical school classes are broad and disease-based. In contrast, PhD classes are specific (i.e., molecular) and often technique-based. Cross-training would provide physicians and researchers with a common language, facilitating collaborative studies.
Some universities have already begun to cross-train PhD and MD students. An increasing number of biomedical PhD programs are intentionally exposing graduate students to clinical medicine. Problem-based learning approaches are used to nurture wonder in medical students, and some programs offer research opportunities to those who are not on the MD/PhD track, cultivating a physician workforce that appreciates and participates in research. As these students become practicing physicians and research scientists, they will share a common language that enables better communication and more productive cross-profession collaboration.
My grad school class had one MD/PhD student. Others constantly sought his insight into the clinical relevance of reported findings, which was dependably enlightening. Once, he rightly questioned the clinical validity of an ex vivo cardiovascular model that flushed fluid through the heart in the opposite direction of blood flow. This perspective encourages clinically relevant discoveries; universities should support environments where MD and PhD student interactions are the norm, not an anomaly.
EMBRACE THE CHANGE
Slight tweaks to traditional research structures, effective communication skills and a more integrated training approach will empower physicians and scientists to establish successful partnerships that generate clinically relevant medicine. Together, these two professions can turn scientific I-don’t-knows into transformative solutions.