In 1925 the American author Sinclair Lewis published the Pulitzer Prize-winning novel, Arrowsmith, which inspired subsequent generations of 20th century high school and college students, including me, to consider a career in medical research.
Arrowsmith relates the tale of the bright and research-minded Martin Arrowsmith, from a small town in a fictional counterpart of Wisconsin, who progresses through medical school, private practice, and a position as a regional health official to become a dedicated medical researcher. In the story, his research talent is recognized by his medical school mentor, and Martin attains a position in a Rockefeller-like institute in New York where he discovers a phage that destroys the bacteria causing bubonic plague.
There’s much more to the plot, and if you haven’t read it yet I suggest you do. The issue at hand, however, is, could Martin, as a medical student and physician interested in research, follow the same path and make as meaningful a contribution in the 21st century? My answer is yes, he could, but if I were Martin’s mentor, I’d suggest other ways that might suit him as well or better.
It is worth noting from a historical point of view that when Arrowsmith was written, the doctor of medicine degree in the United States had only recently gained a full measure of respectability. As a result of the Flexner Report, sponsored by the Carnegie Foundation, the standards and curriculum of present-day medical schools came into being. Medical schools became integral parts of large and established universities, the length of medical education became 4 years, faculty became “true university teachers” typically with full-time university appointments, and students were required to have college or university preparation. Also, medical education came to consist of two years of basic science training followed by two years of clinical work in a teaching hospital.
In this setting, and within the confines of this curriculum, there was opportunity for individuals such as Martin Arrowsmith to identify areas of particular interest and specific researchers they wanted to work with, through the lectures they attended. The students would work in the researchers’ laboratories, under the mentor’s guidance, during their vacation and spare time. This led, in turn, to numerous outstanding and gratifying research careers well into the late 20th century.
It is a path still available to medical students today, but with somewhat greater difficulty, and modified rewards. The alternative routes for a career in medicine or as a clinician-scientist include pursuing a combined M.D.-Ph.D. curriculum, or Ph.D. training before or after getting an M.D. degree. So what are the main advantages and disadvantages of these approaches over the Arrowsmith pathway?
The Arrowsmith approach is easier and more flexible. No formal or written applications, contracts, or other types of commitment are required — just select a researcher and a topic of research according to your desires. The amount of effort and the logistics are arranged to fit with the schedule of the student and researcher. Required reading, seminars to be attended, and courses to be audited are all determined by mutual decision. The length of medical training usually is not extended, unless the student decides to take a year or semester off to devote entirely to research. There are no additional tuition costs — beyond the cost of medical school — and often the trainee can obtain a student grant or be listed on the established researchers grant to help defray his or her living expenses. The entire arrangement is “customized” to suit the student and the teacher. If either is dissatisfied, the arrangement is easily dissolved.
Because of the ongoing clinical training, the Arrowsmith pathway is particularly well suited for careers involving clinical trials, other forms of clinical research, or translational research.The medical degree is sufficient to qualify one for a postdoctoral position and ultimate consideration for a faculty appointment in a clinical academic department.
However, there are some negative aspects to this pathway. With the advent of problem-based learning as a major tool in medical school curricula, there has been a melding of clinical and basic science training. Also, with the explosion of knowledge in the biological sciences in past decades, basic science training for the physician is less comprehensive and rigorous than it used to be in earlier years.
Accordingly, the Arrowsmith pathway is not ideal preparation for a career focused on basic science research. Nor is the M.D. degree alone sufficient for a faculty appointment to most medical school basic science departments. While such preparation suffices for a career in clinical medicine and for concurrent clinical and translational research, it is problematic for assurance of a long-term research career in basic science. These gaps and blind spots in one’s knowledge can be filled in on the basis of individual effort, but this can be difficult.
This problem was illustrated to me in a striking way while I was a clinician-scientist on the Harvard Medical School faculty. There were a number of gifted undergraduates potentially interested in a medical physician-scientist career working in various laboratories in our department. In order to motivate them to consider the Arrowsmith pathway toward a physician-scientist career, our Chair assembled them for a group meeting with a distinguished Ph.D. basic scientist who were also on the medical school faculty. We anticipated an inspirational talk encouraging the undergraduates to pursue such a career. To our surprise, the message given was a short and blunt: “If you follow this pathway for a career in basic science, the PhD’s will ‘eat your lunch.'”
In summary then, while it’s still possible to emulate Martin Arrowsmith, today his pathway is better suited for clinical or translational research than a long-term career in basic science.
An interesting footnote to the Arrowsmith novel is the fact that Lewis was greatly assisted by a Ph.D. microbiologist, Paul de Kruif, now best remembered for his book Microbe Hunters. Even though Lewis was listed as sole author, De Kruif’s contributions were sufficient to merit receipt of 25% of the royalties. Thus, even in the creation of a story of a successful physician-scientist, a Ph.D. proved invaluable.