Third 2024 FAPESP Lecture discusses training of physician-scientists in the United States

The lecture was delivered by Antonio Bianco, a professor of medicine at the University of Chicago who has won several awards for research in the thyroid field.

By José Tadeu Arantes  |  Agência FAPESP – Training physician-scientists capable of conducting research in the laboratory and translating their discoveries into effective treatment for patients has become a highly important factor in the structuring of consistent healthcare systems. In the United States, world leader of medical research, almost half a billion dollars per year is invested in medical research grants by the National Institutes of Health (NIH), the main government agency that funds research in biomedicine and public health.

The system is highly selective, and applicants must surmount many hurdles to succeed. A detailed description was provided by Dr. Antonio Bianco in the third 2024 FAPESP Lecture, entitled “Physician-scientists: Bridging the gap between bench and bedside”. Currently a professor of medicine at the University of Chicago, Bianco is himself a physician-scientist and has received several awards for his research in the thyroid field.

In his lecture, he highlighted the Medical Scientist Training Program (MSTP), an NIH-funded grant program that supports MD/PhD trainees at 50 medical schools in the U.S., mainly on the East Coast, basically via three types of grant: MD (Doctor of Medicine), PhD (Doctor of Philosophy), and K-Award (Career Development Award). Although half a billion dollars may seem a large amount, this investment via the MSTP is only 1% of the NIH’s annual budget, which amounts to some USD 50 billion. 

The path traveled by aspiring physician-scientists is long with many narrow bottlenecks. “After four years of college to obtain an undergraduate degree, they study at a medical school for another four years to earn an MD degree. This is followed by residency training, which lasts between one and four years depending on the specialty, and fellowship, an advanced training program in a subspecialty, lasting two to three years,” Bianco said. The degree enables them to practice as physicians, but the possibility of doing scientific research is still some way off.

The most conventional start to a research career entails applying for a MD/PhD grant after completing the second year of medical school and, if successful, pursuing a doctorate for around four years, after which medical school can be completed. According to Bianco, unlike the Brazilian doctorate, the U.S. version focuses on a basic discipline, such as biochemistry, molecular biology, cellular biology, etc., rather than endocrinology, oncology or other specialties. “The idea is to combine basic science with clinical science so that students can be trained to work as bench scientists and become familiarized with the fundamental concepts in this type of research,” he said.

Having earned a PhD, students return to medical school to complete the course and do their residency and fellowship. Another pathway entails applying for a K-Award in order to become a physician-scientist after completing their clinical training.

While 50 schools have MD/PhD programs funded by the NIH via the MSTP, at least another 50 have internally funded programs, Bianco explained. “But the MSTP is very important, not only because of the recognition conferred by the NIH’s hallmark but also because of the funding the program brings to the medical schools involved,” he said.

Why do medical schools want to have MD/PhD programs of their own despite the expense? “Because as a rule the best students enroll in these programs, and many have worked in a laboratory before they even get to medical school,” he said. Schools have an interest in attracting these students because of the prestige they can bring the institution.

The journey does not end with a doctorate. Having completed their degree course, residency and fellowship, and earned a PhD, professionals who want to join the faculty of a medical school or teaching hospital must effectively become physician-scientists by submitting research projects to the NIH or a similar funding agency. A major bottleneck occurs here. 

“In order to obtain a grant, they have to present ‘preliminary results’. In other words, even though they’ve only recently completed their training, they must find a school willing to give them time and money to do research that can produce these ‘preliminary results’, which may take another two or three years. This is the main hurdle a would-be physician-scientist must overcome,” Bianco said.

Once they have ‘preliminary results’, most candidates win grants from the NIH, but only 14% keep their grants over time. NIH support is an essential part of a successful job application. “Grants are very important to protect the researcher’s time. Without them, researchers would have to devote more and more time to clinical activity, at the cost of neglecting their research. That’s the idea that led to creation of this system more than 100 years ago,” Bianco said. 

The system took off in 1903 when business magnate John D. Rockefeller (1839-1937), the first billionaire, was persuaded by an assistant to make a large donation to fund the establishment of a medical research institution without clinical activity. Samuel Meltzer (1851-1920), a physiologist, was invited to head the institution. 

Born in Lithuania into a Jewish family headed by a rabbi, Meltzer studied medicine in Germany before emigrating to New York. Under his leadership, the American Society for Clinical Investigation played a key role in modernizing medicine (the ASCI still exists today). Bianco described the process in detail in his lecture, relating it to the global context of accelerating change.

Bianco earned a PhD in medicine from the medical school of Santa Casa de Misericórdia in São Paulo, Brazil, and a PhD in human physiology from the University of São Paulo’s Biomedical Sciences Institute (ICB-USP). In the U.S., he has held several academic and administrative posts and is a former President of the American Thyroid Association (2016-17). He currently heads an NIH-funded laboratory and recently published a book entitled Rethinking Hypothyroidism: Why Treatment Must Change and What Patients Can Do, in which he criticizes traditional approaches to the treatment of hypothyroidism.

Before delivering the third 2024 FAPESP Lecture, he was introduced by Rui Monteiro de Barros Maciel, Professor Emeritus at the Federal University of São Paulo’s Medical School (EPM-UNIFESP). The event was moderated by Carlos Alfredo Joly, Professor Emeritus at the State University of Campinas (UNICAMP). 

A recording of the lecture can be watched at: www.youtube.com/watch?v=MOrnfLh1wHU.