Conversations With Cardiologists: Mukesh Jain, MD
May 18, 2016 | John J. Lazarus, MD & Mohammed Sabeh, MD
Mukesh Jain, MD, is the Ellery Sedgwick Jr. Chair & Distinguished Scientist, scientific director of the Harrington Discovery Institute, chief scientific officer at the University Hospitals Health System, and vice dean for Medical Sciences at Case Western Reserve University. He is also the immediate past president of the American Society for Clinical Investigation (ASCI). Dr. Jain is widely recognized for pioneering studies establishing a family of transcription factors termed Kruppel-like factors (KLF) as nodal determinants of metabolism and immunity, which influences the cardiovascular system. He has translated this corpus of work in animals and humans, and established KLFs as key targets of pharmacologic agents. Dr. Jain is also a gifted mentor with an exceptional track record of developing independent investigators, efforts that have resulted in mentorship awards from Harvard Medical School and University Hospital Case Medical Center.
In October 2015, the Journal of the American College of Cardiology published a commentary on the current training of physician scientists. Challenges pointed out included decreasing numbers of physician scientists and long periods of training (13 years for MD, PhD and 17 years for MD graduates).
As the president of the ASCI, you focused in large part on the "earlier stages of the life cycle of physician scientists, where birth rates are low and fall out is high" as described in your recent Presidential address. In your opinion, is the current physician scientist training model viable and what should be done on an individual and institutional basis to enable its survival?
This is a very topical issue as there has been great concern about physician-scientist as the "endangered species," which dates back to 1979 when Wyngaarden wrote an editorial about the subject in the New England Journal of Medicine. The number of physician scientists has always been small. However, it has slowly but surely been decreasing in the last decade just like the number of individuals in science in general. The decrease in number is a combination of a decrease in input into the scientific pipeline, as well as a higher attrition throughout different career stages for a variety of reasons.
There are many "internal" and "external" factors that have impacted interest in science and contributed to this decline. Internal or personal factors include the duration of training, debt and lifestyle issues, while external factors include challenging funding environment, support for translation, inadequate mentorship and societal value to different professions.
The amalgamation of these factors has resulted in an overall reduction in number. There have been a number of organizations that have reviewed this issue of the pipeline. The most recent was the National Institutes of Health's "Physician Scientist Workforce Working Group Report," where they advocated for a number of solutions. The ones I found most compelling were sustained support for the MD/PHD programs, physician-scientist-centric grant mechanisms (e.g. K99/R00 for physicians), expanded loan repayment and leveraging clinical and translational science awards to maximize clinical research training. These are obviously broad national efforts. At the local level, leaders of academic medical centers are thinking about developing physician scientist offices to ensure that aspiring individuals get support and a sense of community as they go through clinical training. There is also significant interest in shortening clinical training. This is not a new concept as short tracking via the American Board of Internal Medicine's research pathway is an established approach. Expansion of such programs to accommodate proper individuals is a desirable approach. And finally, there is some discussion focused on shortening medical school training. Specifically, the issue has been raised as to the questionable benefit of the last six months of medical school and the potential to start internships earlier.
I do think that it is really important to emphasize that this issue is at the forefront of academic leadership and there will continue to be vigorous efforts to address this issue in the upcoming years. I hope that this will provide optimism to young aspiring physician scientists.
What are important factors to launching and maintaining a career as a physician scientist?
Passion, purpose, perspiration, patience, and philosophy are really important ingredients in the individual. It is important to acknowledge that the physician-scientist path is certainly not the path of least resistance. But if you enjoy attacking important problems, trying to understand the inner workings of nature through discovery, are willing to work hard (without immediate gratification), and enjoy working with colleagues as part of a collaborative team and sharing in the success it is a great career path. I will say there is no greater high that I have experienced than making a discovery it is really addictive! But this hard work and worthwhile endeavors take time. Remember, life in science and academia is not a sprint, it is a marathon and you have to be patient and pace yourself. Finally, the issue of collegiality and citizenship are very important in my view. All too often trainees think of science as a contact sport; however it doesn't really need to be that way. It is competitive, but there are guiding principles of conduct that should never be sacrificed, it is just not worth it! And finally, cherish the relationship with your colleagues whether it be in the clinic or laboratory. Remember the academic community is really small, which makes these relationships important, and as your career develops they become even more critical.
In addition to aforementioned innate qualities, mentorship is absolutely critical. In fact, in many ways it may be the most important factor to launching a career. Nobel laureate Ralph Steinman once said that the mentor's primary responsibility is to make sure that the trainee makes a great discovery and then everything else will take care of itself. There is no doubt that this is certainly true. I would just add from personal experience that my mentors, in addition to helping me enjoy scientific success, provided a rigorous environment, armed me with the tools of the trade (learning to ask important questions, writing grants/papers, and presenting my work), and positioned me for success. Mentors are not only important in launching one's career but maintaining them as well. A good mentor-mentee relationship can last a lifetime. And along the way, one can establish more than one mentoring relationship depending on the specific circumstance and career stage.
The final key factor is one's family. As I have already mentioned, life in science is not the path of least resistance; there will undoubtedly be many ups and downs. You will need support, and none is greater than that provided by your family.
Did you have any role models along the way?
I have the good fortune to have several mentors in my career. The two most important individuals are Edgar Haber, MD, FACC, and Arthur Lee, MD, FACC, both who we lost to illness much too early, but who were absolutely essential in changing my career trajectory to one that is focused on science in addition to medicine. Despite the loss of two mentors, I was very fortunate to have other faculty step forward to support me: my chief of cardiology Peter Libby, MD, FACC; a senior colleague at the Brigham and Women's Hospital, Thomas Michel, MD, PhD; and our clinical director of cardiology Patrick T. O'Gara, MD, MACC, past president of the ACC, were critical in the early years of launching my career.
You have been very successful in training and launching the careers of many successful physician scientists. Can you comment on your approach to mentorship? What should current FITs seeking careers as physician scientists look for in a mentor?
I had the good fortune of having incredible mentors that instilled in me passion, purpose and confidence. As noted earlier, finding the right mentor is critical to one's success and there are several qualities that are I think are critical.
The best mentors are individuals who provide a strong role model to inspire and engage their trainees. Recently I had the opportunity to listen Robert Lefkowitz, MD, a Nobel laureate who has mentored numerous trainees over his celebrated career. He noted that in addition to serving as a role model, the best mentors instilled in the trainee a sense of the importance of their work. This is a critical point and one that deserves careful consideration. I have tried to convey a sense of enthusiasm and importance in my own trainees it is just absolutely critical.
I would also encourage trainees to identify mentors that have a track-record of developing physician-scientists. Because of the duration of training, many of us are in our 30's by the time we engage (or re-engage if one is an MD-PhD) in research after clinical training. The timeframe to "make it" is finite and in that period you need to publish, acquire the skills needed to develop an independent research career (technical, written, oral), learn how to run a research group, etc. That is a lot to accomplish in a relatively finite timeframe and the mentor's experience and investment in the individual is critical. The research environment that you will work in, which obviously is a reflection of the mentor's vision, is another critical issue. There are environments where people tend to work by themselves in close coordination with their mentors and the publications and credit for work reflects that close interaction.
With respect to my personal philosophy with mentees, I have tried to the best of my ability to place the needs and goals of the trainees to be of primary importance. Their success is the best reflection of who I am as an individual and any legacy that one may wish to have.
Only 10 percent of physician scientists can survive in science, did you ever consider leaving science and if so, then how did you get over that hurdle?
That's a really great question and your percentages reflect the fact that this career choice is not a smooth and effortless one — albeit very rewarding and I would like to emphasize that. The closest that I ever came to leaving science was after my first research project grant (R01) experience. My mentors had passed away at that time and I, quite naively, did not realize that one could ask others for help on how to write an R01 grant. I submitted my first R01, and it was triaged, which means that it was in the bottom half of all grants received and thus not worthy of discussion by the committee. In retrospect the committee was absolutely correct, it was a horrible grant! However, the idea of being completely rejected to the point where your application was not even discussed was demoralizing, and that left me wondering if this path was right for me. Despite the embarrassment, I finally began to speak with senior colleagues who were not only supportive and helpful, but also shared their own trials and tribulations with respect to grant funding. This was extremely encouraging, and I benefitted from their input reading their grants and restructuring my own grant which, following revision, received an acceptable funding score. Over the subsequent dozen years since then I have had the good fortune to maintain funding.
Being a physician scientist you have to balance the demands of being a clinician, a research investigator, and an administrator. How do you maintain your work-life balance, and what is your advice for FITs who have multiple hats?
This question is incredibly important particularly in this era when a dual income household is the norm; it is more the rule than the exception. Success in academia, beyond your mentor and professional colleagues, is very dependent on the support of your family and in particular your significant other / spouse. I think an open communication between you and your spouse is absolutely essential. Your trajectory, your success, your happiness is critically dependent on the strength of this relationship. Most "better halves" will put up with a great deal to allow you to fulfill your goals and aspirations. Indeed that is what being a significant other is all about. At the same time you need to provide in kind support for their careers, their time and their efforts and you will need to acknowledge their important role in achieving your success. If you have a two way street of communication you are likely to be very successful and you're likely to be happy while being successful.
I will end with some global thoughts. Despite the challenges, the uncertainty and the disparity in financial reward, life in academia as a physician scientist has brought unparalleled joy to me. Where else could you have a boredom free existence where you can ask important questions about the nature of life itself and get paid to do it? How else could you impact human health, an absolutely noble goal, in a more substantive way? Where else do you have the joy of hanging out with really smart people who are committed to such a worthy goal? I have emphasized through this the importance of people. This applies to people who are your senior (mentors), it applies to your colleagues, and it applies to your mentees. There are many options in life but this is a remarkable one for its diversity and importance; it has brought great joy to me and I think that it would for many who wish to pursue it.
Choice of music?
Music is incredible form of art and very influential in all our lives. Having been born in the 60s, I have been a product to the music of that general era. So while I enjoy a broad spectrum of music, I still like rock music, particularly Zeplin, the Stones, and Pink Floyd to name a few. That's what I listen to on my way to and from work, along with NPR!
This article was co-authored by John J. Lazarus, MD, an FIT at the University of Michigan, and Mohammed Sabeh, MD, a cardiology fellow at University Hospitals - Case Medical Center.