It is time to create a clinician scholar program–research profile

Training scholars or researchers?

That was the question. As demonstrated by the quote in the introduction, family medicine itself has experienced a certain degree of confusion between a physician scientist profile and a clinician scholar profile, which has led to a devaluing of the physician scientist profile.^1,3,4

Unlike clinician scholars, physician scientists actively participate in patient care while also consistently devoting 50% to 75% of their time to research, obtaining research funding, and among other things, training future family physician researchers.⁵ Their career trajectory is extremely competitive and demanding and requires robust training in research. Regardless of specialty, this pathway is taken by only a minority of physicians in Canada, estimated at 3%.⁵

How should we train physician researchers?

To answer this question, we conducted a review of the existing literature, specifically on the training required to pursue a career as a physician scientist. We also completed our reflection by corresponding with those who have undertaken that career, which included research directors from the 4 departments of family medicine in Quebec. For the purposes of this commentary, we will cite only the most important studies. The analysis of this literature, which does not report results on the specialty in question,^5-13 identifies 4 educational pathways. Only the study by Workman et al is specifically about family medicine.¹⁴

The 4 pathways focus on integrating research and clinical experience. In fact, the educational pathway to becoming a physician researcher is a continuum that must allow not only for the achievement of specific research competencies, but also for the professionalization of these physicians and their unique profile, which requires them to integrate clinical practice and research throughout their entire careers and to navigate between 2 equally demanding worlds with their own cultures and codes. As such, the challenge is in integrating clinical and research training throughout their entire medical education, both conceptually and operationally.^6,10,11 The research shows that the more individuals are exposed to research early on, the more likely they are to successfully enter a career in research.^6,7,11 While a PhD-level education may seem preferable to an MSc, some research suggests shortening foundational research training and placing greater emphasis on fellowships and postgraduate clerkships that encourage the development of skills and expertise specific to a research area of interest.^6,11

The first pathway allows for the acquisition of a first research degree during postgraduate education, in the form of an MD-MSc or MD-PhD program. Many consider this the preferred pathway because it integrates research into education very early on.^7,12,13 This trajectory is not the most common because learners rarely become interested in research this early. Furthermore, the Canadian Institutes of Health Research eliminated these grant programs in 2015, to the dismay of the scientific community.^7,13

The second pathway is for those entering medicine with an existing research degree. While this trajectory may appear favourable because it does not considerably lengthen the duration of medical education, it is not a very successful one according to experiences reported by our correspondents and in the literature, which suggest that receiving research training before the formation of clinical interests is less likely to result in a successful career as a physician researcher.⁶ The primary challenge for those with general science degrees is reorienting their research expertise toward a domain pertinent to family medicine.

The third pathway is for those who develop an interest in research during their residency. A clinician scholar program would allow them to begin research training during their residency, but not to complete that training. In response to the literature supporting the integration of early research training into graduate studies, the Royal College of Physicians and Surgeons of Canada created a 2-year clinician investigator program for residents.¹⁵ This presents the additional benefit of ensuring residents receive funding before beginning independent practice. This option does not exist for family physicians in Canada.

The fourth pathway is to enter research after having begun a practice. This is the pathway taken by most family physicians who are physician scientists. Funding can come from education grants or re-entry into a clinician scholar program. This approach was advanced by the University of British Columbia, which published a study on the first 15 years of its clinician scholar program.¹⁴ While that study demonstrates that this pathway can lead to an academic career as a scholar, it also reveals that it rarely allows individuals to become physician scientists. The probability of obtaining a research degree diminished by 11% for every year between completing medical school and beginning the clinician scholar program.

We may, therefore, conclude that recent literature^5-14 suggests the first and third pathways best promote the integration of clinical and research training and successfully entering a career as a physician researcher, despite the literature not specifically examining family medicine. It is worth noting that Doubeni et al argued for the establishment of an educational pathway comparable to the third pathway for family medicine residents in the United States.⁴

In support of a 2-year clinician scholar program–research profile

The current clinician scholar program responds to specific needs related to preparing certain family physicians to assume academic responsibilities, but it is not designed to train physician scientists.¹⁶ To ensure equity between individuals enrolled in family medicine and those enrolled in other specialties, family medicine residents must be given the opportunity to obtain their initial research degree during their residency and the third pathway must be made more accessible, similar to the Royal College’s Clinician Investigator Program. This argument was so persuasive that in 2019, the Conférence des Doyens des Facultés de médecine and the Ministère de la Santé et des Services sociaux agreed to fund 4 positions per year for such a residency in Quebec. The new program was quickly recognized by the 4 Quebec medical schools and then by the Collège des médecins du Québec in 2020. The first resident was admitted in July 2021.

To the extent that physician researchers, regardless of specialty, experience similar issues, it would be interesting to consider a common CFPC–Royal College program. This would support the creation of a more inclusive community for future physician researchers and consolidate educators’ expertise. Finally, we realize that proposing to create a research training pathway that prolongs training by a year may seem controversial at a time when work is being done to extend family medicine residencies to 3 years. But there will always be future physicians aspiring to become clinical investigators and ready to accept the impact their career aspirations will have on the duration of their education. Why should future family physicians not have the opportunity to benefit from this educational pathway when their colleagues in other specialties do?