P&S Medical Review: Mar 1994, Vol.1, No.2
Training for Academic Careers in the Twenty-first Century

Myron L. Weisfeldt, M.D.
Samuel Bard Professor and Chairman of Medicine
Columbia University
College of Physicians and Surgeons, New York, NY

CAREERS in academic medicine have never been more exciting nor have opportunities been more plentiful for individuals educated as physicians. To understand my vision of the future, though, we must agree on the definition of an academic career. In my view, an academic career is one which has as its major goal new understanding or discovery of new concepts in the fields of biomedical research, and as well, delivery of health care, clinical medicine and allied disciplines.

Included as allied disciplines are law applied to medicine, medical informatics, social science as applied to health care issues, psychological aspects of health and disease, medical economics, education as applied to medicine, as well as administration and management of the medical enterprise and other areas. Conventional definitions of careers in academic medicine have been limited to fundamental biomedical research with extension toward clinical investigation but have rarely proposed the depth and breadth of academic opportunity in all of these related areas. This is not to ignore the horizons in fundamental research. Certainly, there has never been a time when real answers to questions of the mechanisms of disease are more likely to be uncovered. The possibility that molecular biology will answer the definitive questions regarding the cause of disease and its multitude of clinical manifestations is not only at hand but is also being expanded everyday. In working to uncover the causes of disease, the investigator who has been trained as a physician is, in my view, far more likely to concentrate on means of modifying the mechanism of disease than the non-physician investigator. Such a line of investigation is likely to reveal potent new ideas, if not specific means, for treatment or modification of the natural history of the disease. There is no greater challenge or opportunity than the application of molecular biology to `one shot' or immediate and permanent cures of such prevalent conditions as hypertension, atherosclerosis, diabetes and chronic psychiatric conditions.

Similarly, the horizons have never been more fertile for clinical investigation by physicians in testing new treatments. Also, highly technical methods are at hand for discovering specific aspects of the cause and development of disease in patients. Although much has been and will be learned about disease through fundamental research and animal biology, ultimately, only studies in patients confirm the relevance of the observations in the basic laboratory or define the relative importance of competing mechanisms of disease in human beings. Ultimately, clinical research results in disease prevention or better treatment. New understanding of human disease through clinical research often involves the testing of new therapeutic strategies. It is in the context of testing such new strategies that we are allowed to pursue clinical research that may cause a patient some discomfort or inconvenience. Rarely does clinical research cause physical harm. Since all clinical research is undertaken toward prevention of disease or improvement in treatment, physical harm generally results from a lack of knowledge which is revealed through such failed human experiments. Hopefully, there is reasoned balance in the mind of the informed patient between the risk and inconvenience of participating in research and the potential for benefit.

Why are the prospects for clinical research done by physicians so promising at this time? First, fundamental research in molecular biology has opened up entirely new therapeutic strategies to treat and to understand disease, which only a few years ago could not have been imagined. The popular phrase `gene therapy' is only the most glamorous of these new approaches. Inserting new genes into cells to modify disease will certainly be successful within the next decade. In addition, more specific pharmaceutical agents are being developed with specific biochemical targets in mind. These targets have been defined by fundamental research and an understanding of mechanisms. Molecular biology has allowed the precise biochemistry and structural sequence of many important receptors and structural components of tissue to be understood. Modification of such receptors as well as control of production or destruction of relevant proteins is now a routine approach. Although much is said at the moment about the difficulty of the large American pharmaceutical companies to continue their commitment to research in drug development, there are enormous resources on a worldwide basis. In many small companies and ventures as well as in medical schools and academic institutions, research is continuing toward new therapies with tremendous promise. As an example, in the field of cancer research we have approaches nearing clinical reality in areas of immunological resistance to cancer, control of master genes that suppress growth potential, and interference with genes that promote growth potential of malignant cells. There is extensive research in understanding both the development of metastatic foci in terms of malignant cell adhesion to normal cells and in the growth of vasculature within tumors. Each of these areas of new understanding have direct therapeutic implications. What if we could increase the immunity of the body to malignancy? What if we could shut off the master genes that promote growth or turn on suppressor genes? What if adhesion of malignant cells to other cells could be interrupted or if the vasculature of malignant lesions be suppressed explicitly?

Clinical research is done by making measurements in patients or volunteers. Increasingly these measurements are made with more sophisticated instruments by which real tissue structure, organ function, biochemistry or molecular changes are studied and measured. Each of the techniques of measurement needs to be understood in terms of information to be obtained as well as the limitations. Clinical investigators also need to understand the limitations and difficulties of clinical research, the proper conduct of clinical trials, and sample size and endpoint determinations. Finally, the clinical investigator needs to have a firm understanding of concepts of research ethics and possess the interpersonal skills necessary to begin adventures in clinical research. The investigator must support the patient who is placed in harm's way by the most aggressive of research protocols. The next generation of clinical investigators needs to understand the molecular biology of promising therapeutic approaches and disease mechanisms. With more ideas to be tested than resources to do the testing, it must be an informed physician-clinical investigator who chooses among the options for pursuit of new treatment.

Funding of basic and applied research by the National Institutes of Health has plateaued. In contrast, funding from industry continues to accelerate. We recognize that new extraordinarily expensive treatment strategies will not be looked upon with favor in a time of financial constraint. But there is clear justification for new strategies that are highly likely to reduce long-term health care costs, as well as the morbidity of disease. Clinical research toward such advances are likely to be embraced and supported with even greater enthusiasm than has been present to this point. In areas of subspecialty clinical medicine and clinical practice, I doubt that our expanding application of technology to medical problems in patients will abate. Even in the last five years an entire field of endoscopic surgery has emerged. Procedures which only a few years ago would have required a week or two of hospitalization along with prolonged discomfort and recovery, are now done through small abdominal incisions with no or one day of hospitalization. Highly skilled academic clinicians with an adventurous and forward looking attitude who desire to provide new understanding and new approaches will be sought and rewarded.

There are two related emerging fields þ health care outcomes, and computer science research and application þ that are of particular promise. Computer science is now beginning to address the problems of medical record keeping, communication among physicians, physician education and implementation of practice standards. Practice standards will reflect the results of outcomes research and cost effectiveness analysis. Those tests and management strategies that work to reduce mortality and morbidity and that society can afford will be identified. Funding in this arena from the federal government is growing on a month by month basis. Individuals who have prepared for these careers are emerging from medical school with academic training and initiative, as well as real expertise in fields of study which complement traditional physician education.

Thus, in summary, horizons for academic careers in medicine are expanding remarkably. There are major needs for greater numbers of physicians with the backing and training necessary to become `bench' and `bedside' investigators. There is as well a tremendous need for individuals with a commitment to creative achievement and problem solving in the area of health care delivery as well as traditional medical specialties.

There are two types of training in medical school which define both the intent of the educational system as well as the horizons and career directions of the student. Perhaps overly simplified, these two directions are technical training and training for careers of academic commitment and growth.

In technical training there is emphasis on mastery of necessary factual knowledge and concentration of effort and attention on a confined `core curriculum.' There is some intent that this core curriculum provide enough basic understanding to place new discoveries and new understanding into the broader array of medical knowledge. There is also intent to provide the broadest possible exposure to as many disciplines of medicine in the clinical arena as possible, with multiple elective subspecialty rotations and again, an understanding of core approaches and technologies of each of the disciplines.

In contrast for academic careers there is substantial emphasis on acquiring in-depth knowledge of one or perhaps two critically important or related disciplines which hold promise for application to the problems of medicine. This in-depth knowledge could focus, for example, on neurobiology or a combined perspective of neurobiology, neurology, clinical epidemiology and statistics. As an example, we have on our faculty a prominent neurobiologist as well as neurologists who approach neurobiological problems such as depression or Alzheimer's Disease from the perspective of its impact on the community. Trainees in such a program are given all possible support to help them identify specialized areas of interest and areas in which there is likely to be a need for creative skills and solid commitment on the part of physicians. There is a hope that the training experience in these specialized areas of interest will involve critical exposure to the difficulties and challenges in the field and also to creative experiences at the absolute cutting edge of research and understanding. Simply stated, the difference between technical training and academic training is the notion that the student being trained technically is in school to learn. The student in school for academic training is to do more than learn. This student is expected, during a period of medical education, to contribute to the field of medicine, to participate in the effort toward creative application of what is learned.

In many fields of fundamental science and mathematics, it is widely understood that the most creative contributions are made by individuals in their twenties. Individuals in this expansive phase of maturation are more open to new suggestions and more able to challenge out-of-date thinking or identify an issue that will change a field than even individuals ten years older. Some aspects of medical school might be viewed as doing the utmost to prevent such thinking or individual development. But once a student seeks an academic career, characterized by growth, changing focus, ideas and creativity, then the essential ingredients of medical education are altered. It is better to have short term exposures to specific areas of concentration which may last for one to three months (an elective period), than to have no such exposure. More often, it is the longer term or repeated commitments which really formulate the educational background necessary for academic careers and creative futures. My enthusiasm for short term exposure relates to the high frequency with which one short term exposure to an excellent environment results in this subsequent longer term commitment and resultant full growth. A student's hesitation to commit to an individualized adventuresome education and career directed training can be easily overcome by one exciting experience!

There are several adages that I have used over the years in trying to advise young people on how to choose the setting and direction for initial efforts and educations they embark on this type of training.

The first of these adages is to pursue a direction which is one level more basic or more fundamental than that at which you ever wish to work when your career is mature. Such a more fundamental approach does not necessarily mean an emphasis on laboratory research. Fundamental training in clinical epidemiology, informatics or medical education involving no laboratory exposure will also lead to quality. Such an experience in training at `one level more basic' equips a person in the best possible fashion to pursue career development at exactly the level that they envision for themselves. In truth, what is fundamental to a discipline today will be in the main line of that discipline tomorrow. What is in microbiology today will be infectious disease in medicine tomorrow. What is involved in theoretical clinical epidemiology today will be therapeutics in clinical trials tomorrow.

The second adage is to seek an environment where discussions focus on primary issues rather than application. Is the individual with whom you work or the laboratory where you intend to spend time involved in what you perceive to be issues that are conceptually new for the field of study? As an alternative, are the individuals in the laboratory only pursuing new applications of already established concepts? Is the laboratory only looking at the effect of some new fundamental agent, issue or idea on some biological or clinical system? Or, does the individual or program intend to understand the determinants which make the system or the problem work as it does? One wants to be involved in asking the question why rather than how much or to what extent.

The third adage is to involve yourself very early in peer review. Discuss your thoughts and ideas broadly with individuals in the environment, both field leaders and people at your own level. Some of the most unproductive and disappointing careers have been those of individuals who decided there was a risk to sharing ideas or who were held back by fear of criticism. There is a misconception that progress is made principally through placing oneself in a room, closing all the doors and windows, and thinking hard about a problem. The truth is that there are a million good ideas which are `cheap' and to some extent of relatively little interest. The important thing is not who has the idea, or if there is an idea, but what idea you decide to pursue. If there are a million ideas out there about a given subject, which is the best idea? What is the idea that can be pursued with the methods available and can lead to an answer that will be unambiguous and conceptually important?

Finally, among my adages is to find a committed mentor to help guide your creative educational experience and hopefully, to continue to relate to you well after the period of direct relationship. Most successful contributors to medicine will speak with tremendous affection about one or two or perhaps as many as three individuals who had a pivotal role in `shaping their career.' Do not miss the point; mentoring is more than having a role model to imitate. A mentor is a person who supports and helps identify your creative thinking and your avenues for contribution. The best of mentors have the time, emotional energy and the sincere desire to foster you and your career directions. Such individuals are not hard to find, but often because of many commitments and demands, they will need prodding and encouragement by the student to serve in a mentoring capacity.

In truth, the best way to find a mentor is to talk with a former trainee. Ask the mentor to name prior trainees. Ask or find out what these trainees are now doing. Successful mentors and teachers are consistently successful. They take pride (as hopefully you will) in their students. Often, a committed mentor will describe his or her students' creative contributions as vividly and directly as their own.

The horizons have never been brighter and the pathway is one of self commitment!

Acknowledgment

The author expresses appreciation to Dr. Glenda Garvey for her critical and helpful review.