Correspondence

Debt Repayment for Trainees

N Engl J Med 2002; 346:2013-2014June 20, 2002

Article

To the Editor:

Ley and Rosenberg (Jan. 31 issue)1 fail to note that a high average debt load is common among physicians entering private practice and those training for careers in medical science. What differentiates the two pathways financially is salary. Since money is fungible, loan repayment simply increases the net compensation of the selected recipients. As the authors admit, there is no proof that educational-loan repayment itself is especially compelling, yet this is the only rationale offered to justify bestowing a (relative) windfall on certain trainees. Ironically, the repayment program will create an incentive for students considering careers as physician-scientists to accumulate educational debt, whether they need the loans or not.

Nathan (Jan. 31 issue)2 admits that the category “clinical investigator” is “vaguely defined.” Under the current definition, the experimental methods that a scientist uses matter as much as the questions he or she is trying to address. This definition thus creates a compelling and ethically problematic financial incentive for grant applicants to find justifications for incorporating human subjects into their study design. Physician-scientists should be able to ask important questions about human biology and disease without having to worry about whether the design of their experiments will cause them to receive much lower compensation than their peers. Nathan worries about a “barrier of jealousy” between M.D. and Ph.D. researchers, but both Sounding Board articles overlook the effect on morale of allowing some M.D. researchers to receive increased income in the form of loan repayment while others, by dint of their study design or the way their finances are structured, are deemed ineligible to apply for better compensation.

Steven D. Chessler, M.D., Ph.D.
University of Washington, Seattle, WA 98195-7710
chessler@u.washington.edu

2 References

1
Ley TJ, Rosenberg LE. Removing career obstacles for young physician-scientists -- loan-repayment programs. N Engl J Med 2002;346:368-372
Full Text | Web of Science | Medline

2
Nathan DG. Educational-debt relief for clinical investigators -- a vote of confidence. N Engl J Med 2002;346:372-374
Full Text | Web of Science | Medline

To the Editor:

After the National Institutes of Health (NIH) Director's Panel on Clinical Research released its report in December 1997, private grant-making organizations sprang into action. Several quickly developed innovative programs to address the acute shortage of clinical investigators. To aid in this process, 11 prominent foundations that support medical research joined together to form the Clinical Research Alliance, which provided a platform for members to brainstorm and share best practices. In July 2001, we met as a group with NIH leaders to stress our shared concern and to press for implementation of their extramural loan-repayment program.

The response of private organizations has been substantial. A survey of Alliance members revealed that our collective investment in the pipeline of clinical investigators (as defined by the NIH) has more than doubled since 1997 and now exceeds $78.5 million annually. Special features of awards for new investigators include debt repayment, “protected time,” longer award periods, and stipends for mentors. The Clinical Research Alliance continues to meet in order to focus on other initiatives, such as exposing medical students to clinical investigation and recruiting members of underrepresented minority groups for careers in clinical research.

Historically, private grant-making organizations have not been known to collaborate. However, urgent needs call for creative responses. Any impediment to the flow of scientific discovery to patients must be addressed rapidly and effectively. We hope our efforts are just the beginning of new partnerships and innovative solutions to this urgent problem.

Lorraine W. Egan, J.D.
Damon Runyon Cancer Research Foundation, New York, NY 10017
lorraine.egan@drcrf.org

Elaine K. Gallin, Ph.D.
Doris Duke Charitable Foundation, New York, NY 10019

Nancy S. Sung, Ph.D.
Burroughs Wellcome Fund, Research Triangle Park, NC 27709

To the Editor:

Shortly after receiving a favorable score on an NIH K08 grant application, I elected to pursue private practice, weighing my debt and continued need to moonlight against my limited salary increase and the uncertainty of academic success. I needed to look no further than my mentors to reaffirm the prudence of my choice. Few faculty members were, as I was, the sole breadwinners in their families; many were partners in dual-physician relationships or were otherwise financially secure and more insulated against monetary worries. Still, if I had had an opportunity for debt forgiveness, I might have chosen otherwise.

Theodore J. Gronski, Jr., M.D.
2900 W. Oklahoma Ave., Milwaukee, WI 53215-4330
tgronskimd@aol.com

Author/Editor Response

Drs. Ley and Rosenberg reply:

To the Editor: Chessler notes that the debt for all graduating M.D.s is the same, but the salaries in practice and academia are different. The debt figures cited in our article do indeed refer to all medical school graduates, not just those contemplating careers in science. The salary reduction and delayed earning potential of “late bloomers” who choose to become physician-scientists can never be recovered with loan-repayment contracts. Their purpose is not to correct a salary differential but to remove a career obstacle that has affected the pipeline of physician-scientist trainees. We believe that the issue is compelling enough that substantial steps must be taken now. Loan-repayment programs should be seen as one part of a comprehensive strategy to encourage young physicians to consider a career in science. These programs are indeed considered experimental by all who advocate them. We will learn during the next few years just how much incentive they provide. We hope it is considerable.

We applaud the actions of the foundations that Egan, Gallin, and Sung represent and the many others who have participated in the collaboration they describe. The rapid response of medical-research foundations to this problem has been visionary and should have an enormous effect.

We wish that loan-repayment programs had been available to Gronski when he made his career choice, which was based on compelling economic considerations. Loan repayment was not a big consideration for either of us, since our entire tuition bills for medical school were less than the salary that each of us received as an intern. Things have changed. The obstacles to a career in science are real, and the proof is in the numbers. Early steps to address this problem are under way and must be monitored carefully for their effectiveness and modified rapidly if they are insufficient.

Timothy J. Ley, M.D.
Washington University School of Medicine, St. Louis, MO 63110-1092
tley@im.wustl.edu

Leon E. Rosenberg, M.D.
Princeton University, Princeton, NJ 08544

Author/Editor Response

Dr. Nathan replies:

To the Editor: Chessler makes several interesting points. It is true that there are no hard data to prove that educational debt influences the career choices of physicians, but there is a massive “clinical impression” among division chiefs and department chairs that it does. I doubt very much that students will amass debt whether they need loans or not. The risk would be very high, because only a fraction of the applicants will actually be funded in this program. I also doubt that it is unethical to offer incentives to medical students to pursue careers in clinical research. By offering M.D.–Ph.D. programs, we already offer them incentives to be interested in basic research. I would remind Chessler that I do not favor restriction of this program to M.D.s, but if educational debt is keeping M.D.s out of clinical research, I do hope to alleviate that problem.

Egan, Gallin, and Sung correctly point out that private foundations have certainly stepped up to the plate and greatly alleviated the problem with extremely effective granting programs. Difficult problems are best solved by effective collaborations, and the entire medical community is grateful to them and to the boards of trustees of the Damon Runyon Cancer Research Foundation, the Doris Duke Charitable Foundation, and the Burroughs Wellcome Fund. The Howard Hughes Medical Institute has also entered the field with an excellent program in clinical research.

Gronski emphasizes the first point in my response to Chessler. We have not conducted a formal study to prove the point, but if we did, I believe its results would be strongly positive.

David G. Nathan, M.D.
Harvard Medical School, Boston, MA 02115
david_nathan@dfci.harvard.edu

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