How Hong Kong can produce a Nobel laureate in medicine
Henry Chan says that committed funding and recognition for research in medicine can one day produce physician-scientists in Hong Kong who are able to push the frontiers of knowledge
Innovation and technology is one area that the Hong Kong government has embraced, and where our universities excel. Yet no Chinese has ever won the Nobel Prize in Physiology or Medicine. The question is: can we produce locally a future clinician-scientist of such calibre, and how can our system be adjusted to facilitate innovation and technology in the future?
A wise old man in the garment manufacturing business once told me that to control shirt quality, he needed to control the quality of the cotton. So we should first look to our medical training system and see what could be improved.
To help, I'd like to cite two examples of great innovators of our time.
Rox Anderson obtained a degree from MIT and was a physics teacher before being accepted at Stanford to do a PhD. He needed a summer job and worked as a lab technician for a dermatologist at Harvard, and ended up in its medical school.
As a second-year student, he went to a lecture on the use of lasers to treat port-wine stains and saw some photos of rather horrific complications. On the way home, he thought about how to reduce such complications and eventually developed the concept of selective photothermolysis, which limits the amount of laser exposure time to prevent unnecessary heat transfer to the surrounding tissue.
That innovation allowed the development of lasers to treat birthmarks, including port-wine stains, with a low risk of complications. It changed the world of dermatology.
Rox is now professor of dermatology at Harvard and has contributed to treatment for vocal cords, kidney stones, glaucoma, heart disease and cancer. He has been awarded more than 60 national and international patents and is one of the few dermatologists of our time who has a chance of a Nobel. It is worth noting that the last photobiologist to win such an honour was Dr Niels Ryberg Finsen in 1903.
The next example is Shinya Yamanaka, who obtained his medical degree from Kobe University, became an orthopaedic surgeon but ended up doing a PhD in pharmacology in Osaka and then a post-doctoral fellowship in California. Working on mice skin cells, he found a combination of four genes that changed these cells back to their embryonic stem cell states.
Professor Yamanaka was the co-winner of the Nobel Prize in 2012 for this work that "revolutionised our understanding of how cells and organisms develop".
What can we learn from all this? Both men are perfect examples of physician-scientists. The combination of medical training and a science background enabled them to be innovators of our time.
Here in Hong Kong, students enter medical school very young, directly from high school, and there is little incentive to spend time in basic scientific learning. Very few candidates have applied for the University of Hong Kong's combined Bachelor of Medicine and Bachelor of Surgery/Doctor of Philosophy programme since it began a few years ago.
This is very different from in North America. For 2013-2014, only a dozen or so students out of over 600 applicants were accepted into the MD/PhD programme at Harvard Medical School. For Johns Hopkins, there were 573 applications; only 15 were accepted. Of the 118 MD/PhD programmes in the US, the average acceptance rate was 9.4 per cent, compared with 46 per cent for regular MD programmes.
The difference with Hong Kong can be explained by the significant financial incentives provided by the US National Institutes of Health. Each year, it provides 170 fully funded medical scientist training programme spots. Trainees get financial support including all tuition and living expenses from US$22,000-US$33,000 per year, depending on the programme and location.
It's also worth mentioning that a PhD degree alone in biomedical science in the US is also paid for by the government at the same rate. The median tuition for an MD degree in 2010-2011 was US$29,000 at a public institution and US$47,000 at a private institution.
Furthermore, to encourage medical doctors to do research after they graduate, the NIH will contribute US$35,000 per year towards repayment of the student loan if a doctor commits a certain amount of time to doing research after medical school.
Also as an incentive, most US clinician training programmes have research requirements and research tract positions allowing time for such work during training. The same applies in the UK, where a clinician undergoing speciality training can apply to be a full-time research registrar with no loss in pay.
Hong Kong, in general, lacks official funding for such posts. The Hospital Authority offers only six months of training, far too short to gain experience in basic scientific research. Research is seriously encouraged in medical schools in the US and Britain, whereas here, besides the two teaching hospitals, it is not considered a high priority.
Perhaps we should provide more incentives for our top students to enter MBBS/PhD programmes, including offering full scholarships and paying living expenses. The other way is to set aside a quota for those with a basic science degree to enter a medical programme.
A more radical approach would be to adopt the North American system, where a medical degree becomes a postgraduate programme.
Another interesting aspect of Anderson and Yamanaka is they are on a research track. Here, the University Grants Committee's research assessment focuses on the ability of academic staff to teach, provide a clinical service and also do research. The only way physician-scientists can be on a research track is as non-clinical staff members, with a much lower pay scale.
In many other countries, clinicians are assessed either through their clinical work or pure research track, allowing the development of different interests. Furthermore, government grants as well as royalties can contribute towards physician- scientists' salaries, meaning their salary can be as good as, if not better than, their clinical colleagues.
It's clear that a critical review of our medical education, health care policy and the University Grants Committee's assessment process, as well as an increase in our research funding, are necessary if we are to produce our own Nobel laureate in this area.
This is an edited version of a recent speech by Henry Hin Lee Chan to the Department of Surgery at the University of Hong Kong as part of its distinguished lecture series