Charles Yin in a MD/PhD Candidate at the Schulich School of Medicine and Dentistry at Western University
On June 18, 2015 the Canadian Institutes of Health Research (CIHR) announced that it would be withdrawing funding support for the nation’s 14 MD/PhD programs by the 2016/2017 academic year. This announcement caught program directors and trainees across the country by surprise, and was at odds with the recommendations of two advisory panels commissioned by the CIHR, both of which identified a particular need to improve upon how clinician scientist training in Canada. Although the cutting of the CIHR funding was a blow to MD/PhD programs across the country, it looks like these programs won’t be shutting their doors for the foreseeable future. Rather, this development provides us as clinician scientists, physicians, researchers and policy makers with an opportunity to rekindle discussion over what an effective strategy for bolstering bench-to-bedside research in Canada will look like.
CIHR funding for MD/PhD programs began in 1995 after growing concerns at that time about the decline in the numbers of young, newly-graduated physicians that chose to incorporate basic biomedical research as part of their careers. Though initially small compared to the older and more established Medical Scientist Training Program (MSTP) run by the National Institutes of Health (NIH) in the United States, the CIHR MD/PhD Program grew rapidly, quadrupling in size over the first decade of the 21st century to provide financial support for roughly one in every two Canada MD/PhD trainees for the duration of their training by 2011.
Even at that time there were problems with how MD/PhD training was being administered. Lack of a national oversight body (as the CIHR simply disbursed funds but otherwise did not provide oversight to MD/PhD programs) meant that there was virtually no data on enrollment, funding and outcomes associated with MD/PhD training programs in the nation. How each MD/PhD program chose to make use of funds from the CIHR was also highly variable. Some programs divided all funds equally amongst its trainees whilst others opted to provide full funding for those students who did not otherwise hold external awards. This stands in contrast to the American MTSP, which provided all MD/PhD trainees at MSTP-funded institutions a full tuition remit and a sizable annual salary on top.
So where does the end of the CIHR MD/PhD Program leave MD/PhD programs and their trainees? While it is true that the CIHR has cut funding for MD/PhD trainees and has not announced any plans to date of reinstating funding, this funding source has always been used by MD/PhD programs as salary support for their trainees rather than as operating funds. So while MD/PhD programs across the country aren’t shutting their doors just quite yet, cessation of CIHR funding does come as a huge blow for a training system already struggling to attract and retain students and was faring poorly in competition with the larger MSTP system across our border to the South. While the CIHR argues that MD/PhD students should be well poised to obtain competitive external graduate salary awards, these awards only cover the doctorate portion of an MD/PhD student’s training. And as others have rightly pointed out, MD/PhD trainees are at a disadvantage compared to our MD-only colleagues, as MD/PhD trainees delay their time to receiving an income by an average of 3-4 years.
As potentially damaging as this move by the CIHR to cut MD/PhD funding could be, it also presents an opportunity to rekindle a national dialogue on what clinician scientist training in this country should look like in the next two to three decades. It is widely recognized that clinical practice at the bedside today lags significantly behind biomedical innovation at the bench. Available evidence bears out the argument that MD/PhD training leads to increased interest among young physicians to incorporate research into their careers versus MD-only training. And while long-term outcome data on research productivity is data (probably due to both a lack of outcomes tracking and the inherent difficulty in quantifying productivity), MD/PhD graduates tend to be more successful in securing their first major research grants and early investigator awards than MD-only graduates.
While it is clear that there is a need to strengthen rather than weaken MD/PhD training, funding is just one piece in a more complex puzzle. In particular studies coming out of the University of Toronto MD/PhD program show that trainees, above all, feel that good mentorship was key in their success. Effective mentorship for an MD/PhD student is challenging to achieve, as the student is often caught between two training pathways, each with its own unique opportunities and pitfalls. Effective mentoring means being able to support the MD/PhD student at every stage of their training - a process that might mean having multiple mentors. The Clinician Investigator Trainee Association of Canada (CITAC), the national body that represents MD/PhD trainees, has indicated that a lack of national oversight for MD/PhD training is also detrimental to the success of MD/PhD trainees. Lack of oversight means an inability to effectively track outcomes and best practices and leaves each program isolated.
These are some of the opportunities and challenges on the road ahead as we look to a period of uncertainty in clinician scientist training. For now, it appears that the MD/PhD program will still play an important role in training the next generation of clinician scientists in Canada.
Author's acknowledgements: I write on behalf of the Canadian Federation of Medical Students (CFMS)-Clinician Investigator Trainee Association of Canada (CITAC) Clinician Scientist Training Working Group, the membership of which includes: Ellen Zhou (McGill University), Tavis Apramian (Western University), Abdullah Ishaque (University of Alberta), Patrick Steadman (University of Toronto), Alexandra Kuzyk (University of Manitoba), Kevin Wang (University of Toronto) and Nebras Warsi (McGill University).