Primary Care Physicians an Endangered Species? Kennedy School Review
It was a singular laurels for me to give the second annual James A. Shannon Lecture at the National Institutes of Health last October. Indeed, I would non have been there at all without Shannon. That is not because I knew him personally, but rather considering of the NIH that he — more than anyone else — created between 1949 and 1968. Shannon's intelligence, vision, decisiveness, unmarried-mindedness, and political acumen, first as Acquaintance Director for Inquiry of the National Heart Institute then as Manager of NIH, produced a powerful magnet that attracted me to Bethesda in 1959. 40 years later, I had the opportunity to reflect on why preparing one'due south self for a career in research, as epitomized by coming to NIH, was and so clearly the thing for recent medical school graduates to do then and, just every bit conspicuously and paradoxically, is not the thing to practice today. What follows are my reflections I offered in the Shannon lecture.
I came to Bethesda as a clinical associate in the Metabolism Service of the National Cancer Institute. Things began badly: I didn't get forth with the person to whom I was assigned, and I refused to work on the projection that he proposed. I was rescued by Nathaniel Berlin, chief of the Metabolism Service, who gently reminded me that I was a novice in research, urged me to remind myself of that before jumping to conclusions, so generously allowed me the time and freedom to find a more suitable research setting. I wandered about for the ameliorate role of a year until I became responsible for the intendance of an 8-year-old boy named Steven (Figure 1). He had been admitted to the Clinical Center with a previously undescribed familial disorder characterized past progressive skeletal muscle wasting and a renal tubular defect selective for amino acids. He died ii years later, just every bit two of his brothers had, leaving behind a host of unanswered questions virtually the cause of his disorder and the relationship betwixt its pathophysiologic effects on muscle and kidney ( 1). Meanwhile, I read everything I could near medical genetics and amino acid metabolism, and developed a hypothesis about what was going on. Only I needed a place to work and someone to teach me. These I establish in the laboratory of Stanton Segal in the National Constitute of Arthritis and Metabolic Diseases. Segal, an accomplished physician-scientist, was an ideal mentor for me — interested in understanding the biochemical ground of inherited metabolic diseases, inventive near designing laboratory experiments, nurturing, and tireless. I will never forget the thrill that I felt the start 24-hour interval I conceived, planned, carried out, and interpreted an experiment that measured the uptake of radioisotopically-labeled amino acids by slices of rat renal cortex. Although the findings were inappreciably earth shaking in retrospect, the sense of well being and exuberance they engendered were and then intense that I knew I must direct my career toward medical research.
Effigy 1
Stephen, the proband who kindled my interest in genetic disorders. Reprinted, with permission from Excerpta Medica Inc. (Rowley, P.T., Mueller, P.South., Watkin, D.Chiliad., and Rosenberg, L.E. 1961. Familial growth retardation, renal aminoaciduria, and cor pulmonale. I. Description of a new syndrome with example reports. Am. J. Med. 31:187–204.)
And so I did, and accept done ever since. Later on half-dozen years I moved from NIH to the Yale School of Medicine. During the next 26 years I moved freely among the departments of Internal Medicine, Pediatrics, and Human Genetics, and as freely amidst the cadre functions of a university – research, teaching, patient care, public service, and administration. Just there was one abiding: my inquiry laboratory. Exploiting the rapidly increasing noesis of genetics and the robust technologies emanating from biochemistry, cell, and molecular biology — only always starting at the bedside of a sick child — my colleagues and I sought to sympathize a series of inherited metabolic diseases and to use this understanding toward improved ways of diagnosis, prevention, and treatment (2). Some referred to me every bit a basic scientist because I worked in the laboratory, asked virtually mechanisms of disease, and employed reductionist approaches. Simply I always thought of myself as a clinical investigator, because the inspiration for the piece of work always came from caring for sick children and considering much of the work was carried out with intact patients and their families. I didn't much intendance how our research was classified, as long equally it was of the highest quality possible. Yet others did care, and as you will hear in a few minutes, still do, although I've never been sure why.
And then, in 1991, I left Yale and became President of the Pharmaceutical Research Institute of Bristol-Myers Squibb. I will most recall those seven exciting and turbulent years for the remarkable multi-disciplinary teamwork that is industry's great strength and for the pharmaceuticals that I "put my fingerprints on" — including Taxol, Pravachol, Zerit, Maxipime, and Avapro.
What I did not know when I moved to Bristol-Myers Squibb was that Shannon had made the same transition 45 years earlier. After 15 remarkably productive years at New York University School of Medicine during which he carried out fundamental research in renal physiology and led patient-oriented research on the clinical evaluation of new anti-malarial drugs, Shannon surprised everyone by becoming the director of the Due east.R. Squibb Constitute for Medical Research, the precursor of today's Pharmaceutical Inquiry Plant. He stayed in industry only three years before moving to the National Eye Institute, just that was long plenty to set the Squibb Found's inquiry management, to oversee the development of streptomycin, to initiate the screening programme that led to the development of isoniazid, and to plant work on hypotensive and anti-inflammatory corticosteroids.
Shannon, then, came to NIH with broad experience in academia and industry. He came, too, with profound faith in the power of scientific discipline to transform medicine into a far more than effective musical instrument for improving the human status, with the conviction that only the federal government had pockets deep enough to provide the resources necessary to realize the scientific potential of the state and with the belief that his aspirations could be fulfilled just by a talented research work force led past Ph.D.s and One thousand.D.south. In 13 years Shannon transformed the country's medical research edifice — not alone of course, but with the invaluable assist of colleagues at NIH, a symbiotic partnership with Senator Lister Colina and Representative John Fogarty, and the tireless efforts of the get-go existent denizen/advocate for medical research, Mary Lasker (3).
The accomplishments of the Shannon era, so prodigious that they cannot be overstated, rocketed basic inquiry in the life sciences into a new orbit. Clinical enquiry, too, was propelled as insights from basic scientific discipline were applied to an understanding of diseases and, as important, every bit observations fabricated at the bedside raised new questions about the biology of flesh and other organisms. The proverbial bridge between bedside and bench was built and buttressed. This bridge, and its attendant partnerships between Thousand.D.due south and Ph.D.s, prepare the American medical research enterprise apart from those in Japan and Europe. Some would say information technology was our greatest strength, and this, too, is worth remembering.
Today, the medical research enterprise of the United States is the unquestioned world leader. This complex enterprise consists of a unique, and increasingly interactive, collaboration among regime, academia, industry, contained institutes, foundations, non for profit organizations, voluntary wellness agencies, and public advocacy groups. It is preeminent in scientific discipline — fundamental and applied, basic and clinical, laboratory-based and patient oriented. It has expanded its horizons to concern itself with populations too as individuals, with wellness as well as disease, with ethical dilemmas likewise every bit medical ones.
As the next millennium nears, this enterprise seems poised to make e'er greater contributions to the wellness and well being of people everywhere and, hence, to both the national and international interest. The public senses this excitement and is existence heard. Research!America's national grassroots polls reveal that the public wants medical research to accept a higher priority and believes that a larger fraction of the nation's health expenditures should exist devoted to research. Disease-specific advocates petition Congress for a greater fraction of the federal research "pie"; in turn, Congress asks NIH, direct and through the Institute of Medicine, how it establishes its priorities, and how it should hear from its many public constituencies (four). And, but terminal year, Congress approved a fiscal year 1999 budget for NIH of 15.six billion dollars, 2 billion more than in 1998, and the largest increase always.
All of this should brand me shout "right on!" or "yep!" I assure you, information technology does. Merely I also find myself asking if nosotros are doing enough to sustain and strengthen the treasure that is the American medical inquiry enterprise. Today, I must tell you about a defect in the structure of the state's medical research edifice, which must be repaired soon and well, lest it threaten the unabridged construct. I speak of the progressive, dangerous pass up in the number of medico-scientists. I will use the designation "physician-scientist" for the entire species of One thousand.D.s who devote all or a majority of their professional effort to seeking new knowledge about health and disease using established scientific principles. I intend the designation to be inclusive; that is, it covers basic, disease-oriented, patient-oriented, population-oriented, and prevention-oriented investigation.
This reject is not a new problem. Former NIH director, James Wyngaarden, beginning chosen attention to it twenty years ago in his paper entitled, "The Clinical Investigator equally an Endangered Species" (five). In 1984 Gordon Gill wrote a paper entitled, "The Stop of the Dr.-Scientist?" ( 6). I read each of these thoughtful and well-argued pieces. Afterwards all, I was one of the members of the presumably threatened species. Just I paid no attention. 20 years agone I was having such a marvelous time running my NIH-supported laboratory that I merely couldn't believe that the danger was existent. In 1984 I had just accepted the deanship at Yale and was consumed with its institutional demands. In retrospect, I guess I just couldn't look in the mirror and see a dinosaur. Denial must be mediated past a most stiff neurotransmitter.
After, the trouble has been called to our attention repeatedly but with an important shift of accent away from those doing the science, and toward the kind of science being done — namely, that directly oriented toward patients (7). Since 1991, two panels, one sponsored by the Found of Medicine and chaired by William Kelley ( 8), and the other appointed by Harold Varmus and chaired past David Nathan (and on which I served; ref. 9), take wrestled with the flammable consequence of how to define the term "clinical research," take come up to different estimates of how much is being funded by NIH, and have recommended ways to deal with serious threats to clinical research and clinical researchers. Finally, in last year's Shannon Lecture, Joe Goldstein talked nigh the bewitched, bothered, bewildered, and beloved clinical investigator ( 10).
Given all this activity, equally well as several recent commentaries (11– 13), why exercise I choose to address this event yet again? Offset, because the entire species of physician-scientists is at risk — not just those doing patient-oriented research. Think of it as conservation biologists would: we've been and then focused recently on the spotted owl (that is, physicians who do patient-oriented inquiry) that nosotros haven't noticed that all the owls are at run a risk (that is, all physician-scientists). 2d, because endangering physician-scientists endangers anybody concerned with medical research. Third, because the actions taken to date can't solve the trouble. And quaternary, because this threat can exist averted but past assuming, concerted action on the part of all of the participants in the country'due south medical research enterprise.
I intend to accost 4 questions regarding the proffer that physician-scientists are an endangered species in serious jeopardy of vanishing. First, what is the evidence? 2d, does information technology matter? Third, why has it happened? And fourth, what tin be done?
Showtime, the evidence. It comes largely from detailed analysis of trends in applications for NIH project grants and traineeships. Existence supported by NIH is not, of course, the only way to establish or sustain a enquiry career, just information technology is a bellwether because of the NIH'due south size, national scope, and reputation.
In 1970, M.D.s and Chiliad.D./Ph.D.southward submitted virtually three,000 research project grant applications and received 1,200 awards (Figure 2). In that yr Ph.D.s submitted about 5,800 applications and were awarded about 2000 grants. From then to the nowadays, Ph.D.s have been applying in far larger numbers than have M.D.south and take received correspondingly more than awards. In the most recent yr for which we have information, 1997, One thousand.D.southward were awarded about 2,100 grants as compared to about 5,200 for Ph.D.s. When these data are expressed every bit percentages, they show that in 1967, 43 percent of the awarded inquiry project grants went to M.D.s and M.D./Ph.D.s, compared with 53 pct for Ph.D.s (Figure three). The fraction of awards to Grand.D.due south fell progressively during the side by side 20 years to a depression of 25 per centum in 1987. There has been lilliputian alter in these fractions during the past decade. Throughout this nearly 30-yr interval, the success rates for M.D.s and Ph.D.s have been virtually identical with one some other; that is, M.D.south have fared as well as Ph.D.s have at the hands of NIH study sections and advisory councils when they compete. Simply physician-scientists take become a progressively smaller minority of those seeking and obtaining NIH project support.
As disturbing as this evidence of declining involvement is, it does not account for the alarm I experience. To me, the nearly powerful prove that medico-scientists are progressively endangered comes non from looking at established investigators just rather at contempo trends in the populations of new investigators and trainees. The actual number of first time M.D. applicants for NIH enquiry project grants has plummeted in the past few years from 838 in 1994, to 687 in 1995, to 589 in 1996, to 575 in 1997 — a 31 percentage fall (Effigy four). Since first-time applicants had about a 22 percent success charge per unit in 1997, this means that in 1997 only 126 M.D.s in the entire state were successful the beginning fourth dimension they sought to be P.I.southward on an NIH research project grant. If this progression were to continue linearly, there would be no first-time M.D. applicants past 2003. Furthermore, the drib in first-time M.D. applicants was non made up by Thousand.D./Ph.D.s; there have been fewer than 200 first-time applicants from this group annually and their number shows no significant trend.
Figure 4
Kickoff-time applicants for NIH enquiry project grants.
These data point that progressively fewer immature Thousand.D.s are interested in (or possibly prepared for) careers as independent NIH-supported investigators. This unhappy conclusion is supported by examining information on trainees. In 1980 the total number of M.D. postdoctoral trainees supported by NIH through individual fellowships and grooming grants was 2,241; this number rose during the 80'southward and and then plateaued; but since 1992, the actual number has fallen steadily. In 1992 the number was 2,613; in 1997, one,261 — a 51 percent decrease. When the number of M.D.south and Ph.D.south is expressed equally a fraction of all trainees, the course of events during the past decade is starkly graphic (Effigy 5). If this trend is non changed, there will exist no M.D.s in this pool by 2006. Recent data from the Howard Hughes Medical Institute are simply as discouraging. In the by two years, the number of M.D.s and One thousand.D./Ph.D.s applying for the prestigious HHMI postdoctoral fellowships has fallen from 276 in 1996 to 152 in 1998 – a 45 percent driblet.
Figure 5
NIH postdoctoral research training positions.
Finally, we should note the results of the annual questionnaire of the Association of American Medical Colleges completed by all graduating medical students in the land (Figure half-dozen). In 1989, 14 percent expressed a stiff interest in research as a career; that fraction fell in virtually each successive year, reaching 10 percent in 1996. The human pipeline of dr.-scientists is emptying at the worst possible spot — the young end.
Figure vi
Graduating medical students with strong inquiry career intentions.
Now I want to turn to the second question I posed: Does it matter if physician-scientists constitute a smaller and smaller segment of the customs of medical researchers, and perhaps ultimately even disappear? After all, some say, there are enough of well-trained Ph.D.southward and many of them are now doing clinical inquiry. If One thousand.D.s are unwilling to take the risks of a very competitive research career, so exist it. My respond is as follows. It may be truthful that a medical instruction does not adequately ready i to answer scientific questions, merely information technology is the platonic setting in which to enquire them. Let me illustrate this by imagining our medical enquiry system devoid of physician-scientists. Who will ask why our ability to cure Hodgkin's disease is so much better than that for near other cancers if at that place are no scientifically-trained oncologists who have had to discuss treatment options and prognosis with a teenage girl newly diagnosed with Hodgkin's disease? Who volition enquire how lithium prevents both manic and depressive episodes if there are no research psychiatrists, who have helped rescue a suicidal patient with manic depression? Who will train the md-scientists that the biopharmaceutical industry employs to blueprint, direct, and interpret their clinical trials if there are no physician-scientists in academia doing patient-oriented enquiry? When we accept mapped and sequenced the entire human genome, who is going to make the long-sought connections between these genes and sick people if there are no physicians engaged in answering tomorrow'southward questions about the role that genes play in near all medical problems? It is the diversity in backgrounds of One thousand.D. and Ph.D. scientists that will make reading this "book of man" so exciting. We must not fool ourselves. In the absence of doctor-scientists, the bridge between demote and bedside will weaken — mayhap even collapse. This would not just impair the ability for a new question inspired by a sick person to be taken to the laboratory; it would impede the flow of disease-relevant information from Ph.D.s to their clinical colleagues. Physicians-scientists are a disquisitional link in the medical enquiry chain. They can communicate and collaborate with Ph.D. scientists on 1 side and with health care providers on the other as no other group can. They tin make the case for the clinical relevance of basic research to voluntary health agencies, advocates, and legislators because they are living information technology. Nosotros must not forget that the public equates health with medicine and medicine with physicians. Volition public support for NIH and other "health" research agencies be as strong without physician-scientists, and the many links they forge to the rest of the enterprise? I call up not.
My third question: Why is the number of dr.-scientists declining at the very time that their scientific opportunities are greater than ever before? Why, except for a brief interval between 1950 and 1965, have Yard.D.s who practice scientific discipline not been reproducing themselves in sufficient numbers? Why has my generation of physician-scientists failed to pass the torch to the next generation? Not considering we have lacked our scientific heroes. Since World War II, half of the 122 winners of the Nobel Prize in Physiology or Medicine have been M.D.s. The Lasker Awards brand the same case. Of the 112 winners of the Lasker Award for Basic Medical Research, 53 take been Yard.D.s. Clearly, heroes are not enough.
The stated reasons dr.-scientists are endangered are many and varied. We don't know their relative importance, yet they bear repeating then that they will exist debated, analyzed, and addressed. First, there has been a strong message from the full general public about what club needs from physicians, that is, what a physician's responsibilities should exist. For xxx years, medical educators, medical students, and physicians in training have been hearing that physicians take an obligation: to think more about primary intendance and less nearly specialization; to devote more of their energies to the underserved and underrepresented; to care more well-nigh the public involvement and less virtually their self involvement. There can be no quarrel with these messages, but they have not been balanced past other equally important ones: that improving health requires more research; that, considering of their unique perspective, physicians must be key participants in medical research. Second, there is a ready of economical disincentives that have tended to push the youngest members of the medical profession away from research. These disincentives include the growing debt burden for medical schoolhouse graduates, at present averaging 80 g dollars; the modest stipends paid to postdoctoral trainees by NIH and other sponsors; and, until recently, the big disparity betwixt incomes of practicing medical specialists and those doing research. Tertiary, at that place has been a progressive increase in the number of years of postdoctoral grooming required for physicians undertaking careers in research, often stretching to 10 or more than, and a widely perceived decrease in the adequacy of research training programs, particularly in clinical departments. Such programs, it is argued, take not kept pace with the rate and complication of scientific progress. To earn the name "physician," M.D.s must devote some postgraduate years to caring for the sick. To earn the designation "scientist," M.D.s must acquire to plan, conduct, and interpret experiments with the same rigor their Ph.D. colleagues exercise, whether they are doing patient-oriented enquiry, clinical epidemiology, or basic laboratory investigation. Fourth, the increasing instability of NIH-supported inquiry careers: falling success rates resulting in more time being spent writing and rewriting grant applications; poorly constituted study sections biased against patient-oriented research; increasing competition from the growing puddle of Ph.D. applicants; the brusk "half-life" of funding for new and established investigators; the dearth of alternate sources of enquiry funding, both individual and public. Fifth, the explosive growth of managed care. This has imposed financial constraints on all academic health centers. To make up for this revenue shortfall, leaders of clinical departments have demanded that their faculties encounter more patients. More fourth dimension for patient care, of grade, ways less fourth dimension for enquiry. The relative importance of these factors must surely vary. Collectively, they take resulted in a climatic change in bookish health centers that is toxic to spawning immature investigators. Instead of hearing about the remarkable scientific opportunities that lie alee, medical students hear about how difficult it is to get research funds. Instead of being told what a wonderful time successful investigators take, students are told how little time investigators have for enquiry. Instead of witnessing their mentors practice an academic life style devoted to pedagogy and discovering, students witness faculty harried and harassed by the heavy institutional pressure of the financial "bottom line." Should information technology surprise u.s.a. that students are not flocking to emulate their medico-scientist teachers? It's difficult enough to follow a office model. It'due south harder still when the "role" appears less and less satisfying, and when those who should exist role models go anti-office models instead.
Finally, what's to exist done and who is to do it? Most important, nosotros must reach consensus on several key matters: that the entire course of physician-scientists is at chance; that this volition have a deleterious upshot on all kinds of bones and clinical enquiry — laboratory, patient-oriented, epidemiologic, outcomes; and that a comprehensive, national try volition be required to solve the problem. I suggest nosotros take a page from the book of experiences of conservation biologists and ecologists who take, for some years, been dealing with threatened or endangered species in the wild. Ecologists talk most quantification, surveillance, habitat fragmentation, predators, breeding grounds, and protection. It is not difficult to find an apt analogy for each of these words when addressing the trouble of the endangered physician-scientist, so I'd like to repeat them: quantification, surveillance, habitat fragmentation, predators, breeding grounds, and protection.
Because this problem affects all participants in our national enterprise, its solution, too, demands their involvement. Whereas I endorse the recommendations of the Nathan Panel, and am pleased that several of them have already been acted on, they will not, in my stance, modify the dangerous form nosotros are on, considering these recommendations are directed largely to NIH, and NIH cannot meet this challenge alone. Nor can the IOM or the AAMC or the AMA or the country'south medical schools and academic health centers alone. I believe we need a collaborative national effort, and I believe this can be fashioned all-time past a legislative solution along the lines of a nib originally proposed past Senators Marking Hatfield and Ted Kennedy in 1996. The bill I have in mind would mandate appointment of a broad-based national panel composed of leaders from NIH, academia, industry, foundations, and public life, and accuse the console to develop their initial recommendations in fewer than 12 months. This grouping should reverberate on all of the factors that have led to the endangerment of physician-scientists — motivational, structural, and economic — and be a forceful agent for rapid change.
These are some of the things I hope such a panel would propose in initiating a program for physician-scientist revitalization and repopulation:
First, and foremost, reestablish a supportive environment in academia. This is, after all, the convenance ground for physician-scientists and the very habitat that has undergone fragmentation. Undergraduates with an interest in attending medical schoolhouse should be advised that they demand a potent background in scientific discipline to succeed, and medical school admissions committees should recruit more students with demonstrable delivery to, and aptitude for, research. Would-be medical students are both perceptive and impressionable. Nosotros must pay attention to the signals nosotros send them. Thereafter, the responsibility rests with deans, chairs, and senior faculty. Medical students should be encouraged by them to seek intensive research experiences early, and should be rewarded for so doing. Faculty doing enquiry should be protected by them regardless of the affect on the "lesser line." Perhaps refocusing on the "top line" — namely, acquiring and disseminating new knowledge — is in club. Hospital CEOs should exist reminded by them that tomorrow's medical care depends on today's medical inquiry.
2nd, create and/or expand attractive training programs for medical students, One thousand.D./Ph.D. students, postdoctoral fellows, and junior faculty. NIH'southward role hither is primal, but HHMI and others must participate as well. The newly established K23 and K24 awards for young and mid-career kinesthesia are a small step in the right direction. The MSTP plan should be expanded and modified to permit sequential study toward the Grand.D. and Ph.D. degrees and to include students with interests in such fields as biostatistics, computer science, epidemiology, and population health. The programs enabling medical students to accept a yr out of the regular medical schoolhouse curriculum to do research at NIH or in their ain institutions should be expanded and encouraged. Rigorous, tailored postdoctoral research experiences must exist designed and implemented in order that physician-scientists regain their confidence and belief in a enquiry career. To recruit more than of the best and brightest, these programs must offer financial incentives commensurate with the national demand. Attractive stipends, loan repayment programs, and a higher likelihood of success must be congenital in. Yes, I can hear you say, this will cost money. Of course it will, simply I tin can call up of no improve manner to invest some of the two billion dollars in new money that NIH has been authorized to receive in 1999.
Third, plant a National Eye for Clinical Research linking the Clinical Heart at NIH with the full general clinical enquiry centers and clinical trials programs in academia. Such a network would foster collaborative educational efforts, preparation programs, and enquiry projects aimed at strengthening patient-oriented inquiry. Information technology would stimulate traffic of people and ideas between Bethesda and the medical schools across the nation. It would heighten the visibility of clinical research.
Fourth, increase participation of foundations, biopharmaceutical companies, wellness insurance firms, and the managed care industry. Each of these participants should seek their own ways to partner with NIH and academia. Foundations should expand the range of grooming opportunities and career awards, following the lead shown by the Burroughs Wellcome Fund. Insurance companies and the managed care industry should support population studies and outcomes research, equally well as the young people being educated to bear out these and related studies. Biopharmaceutical companies are ideally positioned to provide mentors, grooming sites, research projects, and funds. I would like to applaud the Pfizer Corporation for their recent 1.5 million dollar contribution to the NIH's National Foundation for Biomedical Research to support medical students who spend a year at NIH doing research. This is the kind of example that others should follow.
Fifth, develop and maintain a national database of doctor-scientists. This database should rail the number of medical students and M.D. graduates entering research grooming, the number of Grand.D.southward supported by NIH and other research sponsors, the number of established investigators in academia, NIH, industry, and independent institutes, the number of Yard.D.s leaving research careers at all levels, and the number of dr.-scientists needed past the various sectors. Fortuitously, the National Research Quango of the National Academy of Sciences has only issued an important report on trends in careers of life-science Ph.D.south (14). This would exist the ideal time to conduct a similar review of physician-scientists.
To conclude, the kind of broad plan just outlined is necessary if nosotros are to contrary the major threat to the nation's medical research ecosystem posed by the endangered physician-scientist. It is unthinkable that the symbolic graveyard of lost species, which ecologists use to dramatize their concerns, could i day contain a stone with the words "physician-scientist" on it. Because we have all waited as well long, recovery will have many years and will be costly. If we wait any longer, we will not only increase the toll but, more than important, volition increase the probability that we will exist besides belatedly to forestall virtual or existent extinction. We must act now to modify the climate in which today's physician-scientists piece of work, considering their words and actions will influence the choices their students make. We must act now to create a national environment conducive to creating a new generation of medico-scientists — rigorous in their training, confident in their power to compete and succeed, and, above all, imbued with the conventionalities that their efforts are essential if we are to meliorate the lives of people everywhere — young and old, woman and man, ill and well.
Source: https://www.jci.org/articles/view/7304