(JAMA. 1999;281:1977) Medical News & Perspectives - June 2, 1999

Association for Patient-Oriented Research
M. J. Friedrich

Atlantic City, NJ: Medical researchers from around the world met here for the first meeting of the Association for Patient-Oriented Research (APOR). Showcased at the conference were a diversity of research topics, including hypertension, obesity, cancer, immunology, and neurology, all of which involve the observation and study of human subjects.

The APOR formed last year to revitalize interest and participation in clinical research carried out with patients by physician-scientists. As David Robertson, MD, professor of medicine, pharmacology, and neurology at Vanderbilt University and the APOR's president, explained in his opening address, the purpose of the APOR is to "foster the science of patient-oriented research, to cultivate innovation and creativity in hypothesis-driven investigation, and to create and embrace new technology required to do our job well."

The society is not limited to the United States, said Robertson, but is directed toward the world community of patient-oriented investigation. Nor is it limited by discipline or degree; founding members include surgeons, nutritionists, psychiatrists, internists, neurologists, and those who hold either an MD, a PhD, or both degrees.

Atlantic City was chosen as the site of the organization's first meeting to serve as a symbol of clinical medicine's vigorous past, said Jules Hirsch, MD, a clinical investigator at Rockefeller University and secretary-treasurer of the APOR. It was here that three organizations central to academic internal medicine (the Association for American Physicians, the American Society for Clinical Investigation, and the American Federation for Clinical Research) held an annual meeting in late April or early May for many years. The tradition began soon after the turn of the century. Recently, due to waning attendance, the trisociety meeting was abandoned.

"DISAPPEARING INVESTIGATORS"
The discontinuation of this traditional medical gathering points to the crisis of the disappearing clinical investigator that has been occurring during the last two decades (JAMA. 1998;280:1427-1431 and 1998;280:1440-1444). Leon Rosenberg, MD, professor of molecular biology at Princeton University, said evidence for this decline is overwhelming. For example, research grants awarded by the National Institutes of Health (NIH) to MDs and MD/PhDs in recent years have made up a progressively smaller fraction of total awards primarily because physician-scientists have become a progressively smaller majority of those seeking NIH support.

"Even more alarming," said Rosenberg, "are recent trends in the population of new investigators and trainees. The number of physician first-time applicants for NIH research project grants plummeted 31% between 1994 and 1997." If this pattern continues, he said, there will be no first-time applicants who have the MD degree in 2003.

Rosenberg stated that the absence of physician-scientists cannot be made up for by well-trained PhDs who are carrying out disease-oriented research. What will be lost if the "endangered" physician-scientist disappears, he explained, are the questions provoked by contact with a patient. "In the absence of physician-scientists, the bridge between bench and bedside will weaken and very likely collapse. This would not only impair the ability for new questions inspired by a sick person to be taken to the laboratory, it would impede the transfer of disease-relevant information from basic scientists to their clinical colleagues."

Several factors have contributed to the diminishing numbers of physician-scientists, said Rosenberg. These include public pressures on medicine to focus on primary care rather than specialization; economic disincentives such as the growing debt burden of medical school graduates and the modest stipends of postdoctoral trainees; growing instability of NIH support and study-section bias against patient-oriented research; and the explosive growth of managed care, causing physicians to spend more time seeing patients and less time doing research.

SEEK TREND REVERSAL
To reverse this trend, Rosenberg said what is needed is a collaborative national effort, with participation from key players, to address the problems facing patient-oriented research. People outside the field, such as members of Congress and those in academia and business, must be alerted to the problems. A comprehensive database of physician-scientists that tracks such facts as how many physician-scientists are entering the field each year and how many are leaving would also be useful, he said. Such a database would help determine how many physician-scientists a country requires and where they are needed.

Academic medical centers can address the problem by fostering a supportive environment for research, said Rosenberg. Such support would include recruiting students with aptitude and enthusiasm for research and providing greater opportunities for medical students to pursue research experiences. Foundations, biopharmaceutical companies, and institutions such as the NIH and the Howard Hughes Medical Institute also can provide mechanisms of support at all levels of the career path for physician-scientists by expanding training opportunities and career awards, he said.

By providing a strong, uncompromising voice for patient-oriented research, said Vanderbilt's Robertson, the APOR hopes to help address these issues. "And most important, we must not fail to appreciate the importance of keeping the focus on the patient," he said. "The patient is not one more experimental animal, but rather the organizing principle of the entire biomedical research enterprise."

(JAMA. 1999;281:1977) Medical News & Perspectives - June 2, 1999