During the last several decades, concerns have been raised about the sustainability and future direction of biomedical science and medicine.1–5 Much of the current biomedical enterprise fails to sufficiently bridge the gap between the bench and bedside, a phenomenon commonly referred to as the “valley of death.”1,2 The result of this failure is an estimated waste of up to 85% of research funding.6 Although it is widely believed that this situation is unsustainable, generating solutions is challenging because the sources of this problem are multidimensional and cross the boundaries of academia, industry, and government.7 One underlying cause that has been frequently identified in the literature is a declining number of clinician–scientists.2,8
Clinician–scientists are commonly defined as health care professionals (e.g., physicians, nurses, physical and occupational therapists) who are expert in both research and clinical practice. Their dual expertise positions them to play a vital role in translating research outcomes to clinical practice (i.e., bridging the bench-to-bedside gap).1,2,9 Yet, health professional (i.e., nonphysician) clinician–scientists are scarce, and data on the status of this workforce are largely lacking. Although physician–scientists are far more numerous, their numbers in the overall biomedical workforce and physician population have markedly declined over the past 50 years.10,11 Moreover, the average age at which physician–scientists enter the workforce has increased.10,12 The existing standards for clinical practice and the highly competitive nature of biomedical research make it difficult to prosper in the 2 worlds of health care and science. As a result, young, scientifically interested health professions graduates struggle to find or create opportunities to develop in the dual roles required of the clinician–scientist.2,12
A multitude of reports exist on the status of the clinician–scientist workforce and its attendant challenges.1,8–10,12,13 The published literature highlights the complexity of both the biomedical science enterprise14 and clinician–scientist training,13,15–17 as well as the sustainability of clinician–scientist jobs in the academic workforce,8,10,18–22 as underlying challenges. Many of these reports provide recommendations for increasing the clinician–scientist workforce, especially in terms of training and career development.8,13,22,23 Yet, despite the implementation of recommended strategies—including federal programs supporting training and career development and federal and institutional programs which aim to promote diversity, mentorship, and engagement of students at educational stages that precede entry into the clinician–scientist pipeline—there continues to exist considerable concern that the clinician–scientist pipeline is threatened. One reason for the limited impact of past analyses and recommendations may be the existence of unidentified gaps in our understanding of key issues faced by the clinician–scientist workforce.
In 2015, the University of Toronto and University Medical Center Utrecht initiated a research collaboration to address current challenges to the sustainability of the clinician–scientist workforce. As part of this collaboration, a steering committee composed of the authors convened an international expert meeting with thought leaders from various backgrounds. By gathering a wide array of perspectives, we anticipated a deep exploration of the clinician–scientist workforce and the determination of previously unaddressed gaps in our understanding about the sustainability of this workforce, for which actionable suggestions for change could then be proposed.
Organizing the International Expert Meeting
Experts were invited (see below) for a 2-day meeting to identify existing gaps in how institutions and society can secure future clinician–scientist workforces and to generate solutions for addressing those gaps. An expert meeting was the preferred method because it has the advantage of bringing together unique perspectives from experts in different fields while at the same time generating solutions for a multidimensional problem by combining the diverse backgrounds and expertise of the participants.
Phase I: Sampling and recruitment
Between June and November 2016, individuals were identified and invited to participate in the expert meeting using both convenience and purposeful sampling approaches.24 Experts were defined as health professionals, researchers, and policymakers who are deeply invested in biomedical research, clinical care, education, or leadership in the academic health professions domain and who are highly aware of the challenges within the clinician–scientist workforce. In composite, the final 19 participants (see below) represented all these areas. Representatives from organizations (e.g., the Association of American Medical Colleges [AAMC]) with a vested interest in the subject were also invited. Before the start of recruitment, the group size was set at approximately 20 participants, as this was estimated to be large enough to include diverse expertise yet small enough to allow for whole-group discussions. Nineteen individuals from Canada, the Netherlands, the United States, and Singapore participated. These 19 individuals (out of the 28 invited) included 5 members of the steering committee (M.K., B.P., N.N.W., O.t.C., N.D.R.); representatives from the AAMC, the Association of Faculties of Medicine of Canada, and the Royal College of Physicians and Surgeons of Canada (RCPSC); and individual physician–scientists, nurse–scientists, education scientists, deans, vice deans, undergraduate and postgraduate medical education program directors, and a medical student.
Phase II: Preexpert meeting work
Participants were asked to submit prework before the expert meeting (see below) to compel them to elaborate on the topic in advance, enable sharing of insights among all participants, and allow for an efficient start to the meeting. The prework focused on 2 questions: (1) What are the main issues related to the clinician–scientist role and its effectiveness in your health care system? and (2) What bold, out-of-the-box solutions could be considered to address up to 3 of the issues mentioned in your answer to question 1? The text of each participant’s prework was analyzed and coded25 by the steering committee (led by M.M.W. and F.F.) and summarized into a report for the participants. From this, 4 themes emerged as the main challenges facing clinician–scientists:
- Job context, which included concerns around career opportunities, time, funding, the academic promotions and reward system, and professional identity formation;
- Career pipeline, which included the need to shorten the total length of training to obtain both clinical and research expertise and create training opportunities that combined these 2 expertise areas for different health professions;
- Integration of clinical and research training, both conceptually (i.e., the integration of clinical and research education, including the formation of a professional identity) and operationally (i.e., allowing time for research training during the clinical educational pathway and vice versa); and
- Accreditation and governance to generate a framework to set standards of education, accreditation, and codes of conduct, which are currently lacking for clinician–scientists.
These 4 themes reflect both commonly documented concerns (job context9,10,12,20,21 and career pipeline8,10,15,18) and new themes (integration of training and accreditation and governance).
Phase III: Expert meeting
The expert meeting was held in March 2017 in Utrecht, the Netherlands. The meeting consisted of highly structured whole-group and small-group discussions. The first day focused on consensus building around the key problem domains, building on the premeeting work. To begin, an overview of the results of the prework was provided by one of the authors (N.D.R.). Next, participants engaged in a facilitated (by Rinze Benedictus) whole-group discussion to better understand all of the prework themes and identify any new emerging themes. After the first whole-group discussion, participants were asked to state what they considered to be the most pressing issue using a round-robin approach, which led to the identification of key problem domains.
On the second day, participants individually considered and recorded solutions with anonymous written comments for each of the key problem domains. Their solutions were then used as starting points for 3 modified World Café rounds,26 in which small groups of 3 to 5 participants further discussed the proposed solutions for each domain in 30-minute rounds. Each domain had 1 facilitator (M.M.W., F.F., R.B.), who provided the incoming groups with a summary of the previous discussion. In the fourth and final modified World Café round,26 all small groups returned to the domain where they had initially started to obtain a full understanding of all of the solutions that were proposed. The groups were then asked to prioritize the proposed solutions based on impact and feasibility. The prioritized solutions (see below) were presented to the whole group for further discussion. A summary of the meeting’s consensus-building process is detailed in Table 1.
Findings From the International Expert Meeting
The expert meeting first identified 3 critical questions to be addressed: (1) What is the particular nature of the clinician–scientist role? (2) How are clinician–scientists to be recognized within the health and health research ecosystem? and (3) How can the value that clinician–scientists add to translational medicine and research be clarified to stakeholders and the public? Then, the expert meeting identified 3 subjects (i.e., a 3-fold agenda) to focus on to address these critical questions: articulating the value proposition of clinician–scientists, supporting professionalization and professional identity development, and integrating clinical and research training. These are described in more detail below.
Articulating the value proposition of clinician–scientists
A need to establish the unique value (i.e., the value proposition) of the clinician–scientist role within the health system received the most attention. Experts observed that while the substantial scientific and medical contributions of clinician–scientists are often referred to in general terms in the literature and accepted within some sectors of academia, the specific nature of this impact is rarely described. Further, the role for clinician–scientists within health care and research systems is not universally defined, recognized, or understood. Articulation of a clear and compelling value proposition is particularly important in securing support from governments and institutions making funding decisions that impact clinician–scientist training and employment.
The lack of a clear value proposition for clinician–scientists is in part due to the lack of a consensus definition of a clinician–scientist. The term often refers to physicians and other health professionals who, through diverse training and career pathways, combine their clinical work with research activities.12,15,27–30 This broad definition encompasses a wide variety of professionals and career paths. The proportion of time a clinician–scientist dedicates to research may vary, as can the focus of research (i.e., basic, clinical, or translational).10,31 The expert meeting recognized the significance of this spectrum of science and the important influence of basic research, in combination with clinical and translational research, on “drug discovery, medical practice, and human health.”32 A prime area for future investigation is, therefore, the identification, exploration, and specification of the definition(s) of clinician–scientist in a way that represents all the roles encompassed by clinician–scientists.
Establishing the value proposition is further complicated by the lack of empirical data capturing the impacts of clinician–scientists at both individual and system levels. Research could focus on empirically demonstrating the ways in which clinician–scientists possess a unique lens with which to analyze and contribute to clinical and research problems. While this is an implicitly recognized capacity within the clinician–scientist community, further work is needed to provide data explicitly demonstrating these capacities to governments and institutions (e.g., funding agencies, research centers, universities, academic hospitals). This could, in turn, support broader recognition for clinician–scientists and serve to inform and build role competency, professional identity, training programs, and career supports for individuals that pursue this challenging career path.
Supporting professionalization and professional identity development
Clinicians who are trained to do research may, in fact, constitute a distinct profession within the health system; however, currently, the clinician–scientist role lacks a formal status. The current lack of regulation and recognition of clinician–scientists from national and international governance bodies could contribute to a lack of career sustainability. Funding and promotion structures are typically focused on rewarding full-time scientists or full-time clinicians instead of individuals who work at the intersection of clinical practice and research. Clinician–scientists who currently sustain a career are able to do so because of support provided by some academic health science centers or because of significant personal efforts to balance 2, often separate, activities.
The expert meeting highlighted the need for professionalization of the clinician–scientist role. Professionalization can be defined as a social process by which an occupation or trade transforms into a profession. This process occurs as occupations define a scientifically based technical practice33 and introduce systematic education and training and formal credentials for conducting this practice.34 This formalization also serves to develop a collective culture with distinct understandings of the social purpose and meaning of the profession’s work, socializing individuals toward generalized cultural and social values for their profession and ways to evaluate (and hence gain recognition for) their work.34 Professionalization for clinician–scientists would thus provide articulation and understanding of the role, engender formal recognition through governance, and enable the establishment of a distinct professional identity. Professionalization requires governing bodies that operate at international, national, institutional, and individual levels. The governing bodies for clinician–scientists would
- Define a shared vision for integrating research and clinical training;
- Generate a framework in which to set standards, track cadres of clinician–scientist trainees, and fund trainees within a national context;
- Credential trainees for successful completion of clinician–scientist competencies; and
- Introduce new reward, promotions, and funding models and elicit changes in how clinician–scientist impact is defined and rewarded.
The expert meeting highlighted additional factors to support clinician–scientist professional identity. These included adequate start-up packages to address financial deterrents during training and along the pathway to independent funding, increasing the values of salary support and career awards (particularly those for early-career clinician–scientists), and a refocusing of the reward and promotions system on health care impact and cross-fertilization between clinical practice and research.
Integrating clinical and research training
The published literature highlights the challenges that the length of training (usually at least 15 years of postsecondary training), debt incurred during training, lack of relevance of research to a clinical career if research training is undertaken before clinical interests are formed,15,31,35–37 and recruitment and retention of clinician–scientists pose to the clinician–scientist workforce.8,15,21,31,37,38 A critical challenge less examined is the lack of integration of clinical and research training. For nonphysician clinician–scientists, formal training programs are rare. For physician–scientists, defined career pathways exist at the undergraduate level, principally through MD/PhD programs, and the postgraduate level, through graduate training (e.g., masters of clinical research) or postdoctoral experiences. However, most clinician–scientist programs lack integration at both the conceptual and operational levels, as clinical and research training often occur in silos (this lack of integration is highlighted in an RCPSC white paper31). Theories of cognitive psychology39 and adaptive expertise40 suggest that conceptual integration should be introduced at the early stages of the educational process by addressing clinical and research domains in the context of the other. Yet, clinical practice and research are generally taught independently of one another, leaving it to students to achieve the actual integration on their own. At the operational level, integration means integrating different blocks of clinical and research training over time, instead of having parallel clinical and science tracks.41 Integrated curricula designed to enhance knowledge of the links between clinical and research skills can facilitate the conceptualization of clinical problems within a scientific framework.39,40
There also exists a need to identify competencies that capture the unique abilities of clinician–scientists. Many health care professions ask themselves what activities society should be able to trust trainees to do upon graduation42–45; a similar question should be asked for clinician–scientists. Existing competency frameworks do not explicitly describe how clinician–scientists are able to integrate different perspectives cognitively or operationally. Further research on integration could inform the articulation of specific clinician–scientist competencies, which, in turn, could provide an evidence-informed framework for implementing integrated training across the educational continuum.
A new model of clinician–scientist education could be developed to train clinician–scientists specifically for what will be used in practice through shortening general training and lengthening fellowship training, which would require individualized pathways. If supported by academic coaching, mentorship, and a community of learners, this has the potential to provide trainees with the education they need to sustain a clinician–scientist career. After training, a key element in the sustainability of clinician–scientists is career support. Mentorship, career guidance, and role modeling are generally considered to be critical success factors for young professionals.9,12,31 However, structured mentorship programs, communities of practice, and other forums are frequently unavailable for physician–scientists, and even fewer are available for nonphysician clinician–scientists as there is a dearth of career mentors. Mentorship and role models during training support the development of a clinician–scientist identity9,30,31 and increase the chances of success in a clinician–scientist career,12,37,41 but there are inadequate mentorship opportunities.10,31 A guild or community of practice for clinician–scientists and trainees could address mentorship and role model needs. This guild could also work to enhance visibility and recognition for clinician–scientists, create a mentorship pool, form a clinician–scientist network, and solidify professional identity.
Implications of the International Expert Meeting
Our expert meeting identified 3 critical challenges (see critical questions above) for the clinician–scientist workforce. These challenges not only highlight issues featured in published literature but also identify new gaps in understanding that had not been previously identified. Our report extends the literature by suggesting a 3-fold agenda to address these critical challenges. First, the expert meeting revealed the need for fundamental work to be done to articulate the value proposition for clinician–scientists. Without satisfactory value propositions, the implementation of published recommendations will not occur; the solutions to this that we present here focus on education, training, and career pathways. Second, professionalization and professional identity emerged as underexplored but impactful issues that need consideration. Third, the expert meeting revealed that the integration of clinical and research knowledge is underrepresented in current education and training discussions.
One of the recommendations from the expert meeting is to examine and articulate the value proposition of clinician–scientists. Currently, the literature suggests that the value of clinician–scientists resides in their pivotal role in translating scientific knowledge to clinical practice and ensuring clinical relevance in scientific inquiries.31,35,36,38,46,47 This proposition is assumed and was previously unquestioned by the clinician–scientist community. It may have remained implicit and uninterrogated because the community understands the influential contributions that clinician–scientists have made in advancing scientific discoveries (e.g., Alexander Fleming’s discovery of penicillin in 1928)10 and new treatments (e.g., Werner Forssmann’s development of human cardiac catheterization).46 Yet, the value proposition does not seem to be clear to administrators, funders, scientists, and clinicians outside of the clinician–scientist community. For example, in 2015, the Canadian Institutes of Health Research stopped funding its MD/PhD program, which trained clinician–scientists.48
With funding for research and health care education decreasing, sustaining a career is more difficult for professionals, such as clinician–scientists, without clearly articulated roles and mandates. While there are many individual examples of successful clinician–scientists who work in institutions that value and support their clinician–scientist employees, their impact is poorly understood outside the clinician–scientist community. Thus, the community must address the need for and actively collect empirical data demonstrating clinician–scientist impact on knowledge translation, health care quality, and cost-effectiveness. Shared language and repetitive messages, along with valid examples of the productivity of clinician–scientists that demonstrate health-related returns on investment in education and research, are needed to sustain the interest of policymakers, funding agencies, department leaders, and directors of training and to encourage investment in governance, training, and career support for clinician–scientists. We are currently undertaking empirical studies to describe and evaluate the impact of clinician–scientist contributions and the unique lens they bring to clinical practice and research. Specifying and illustrating what makes clinician–scientists distinct from other health care professionals could help trainees and others to better understand and value the profession. Failure to address the value proposition will also limit the capacity to address other, previously identified issues, such as defining roles through professionalization, creating training pathways, and generating new funding models.
The categorization, regulation, and professionalization of clinician–scientists could assist in more clearly articulating the value proposition. Because clinician–scientists currently lack regulation, they are invisible in the system. Without regulation and credentialing, the health care system does not act to retain or support their identity. Many aspects of the dual clinician–scientist role can create confusion and threaten professional identity, including vague job descriptions that may cause a “blurring of boundaries,”49,50 which can increase anxieties about identity. A lack of professional identity can result in poor retention in some professions.50 Establishing standards of education, accreditation, and codes of conduct would help inform and construct professional identity (how individuals conceive of themselves as clinician–scientists) and professionalism (“being and displaying the behavior of a professional”).50 A governing body could create a credentialed category for clinician–scientists and make the corresponding systems-level changes needed to appropriately supervise standards of education, accreditation, and conduct. Community building, through the establishment of local, national, or international societies or associations, could further contribute to the recognition of clinician–scientists and the development of a professional identity for these individuals. An example of such an international network is the Eureka Institute for Translational Medicine, which aims to build a global community of professionals in translational medicine through mentoring and educational opportunities.51 Further, a recent Canadian national consensus conference recommended the formation of an independent, national council to oversee physician–scientist training30; such a council could provide a first step toward professionalization.
Education provides qualifications that can affirm professional identity through internalization of roles, responsibilities, values, and ethical standards.50 The expected role of a health professional who excels at and integrates clinical care and investigative research should be modeled, learned, and practiced in integrated ways during training. Currently, training often occurs in silos, as clinical and research degrees are pursued in separate blocks of time.13 Explicit integration of clinical and scientific thinking in training can develop and address the calls for clinician–scientists who understand the unique dual mission of effective clinical practice informed by research and investigating research questions with attention to clinical benefits.1,13
To define what clinician–scientists are, it will be necessary to describe what they can be trusted to do when hired, which would include certain skills, knowledge, competencies, and experience. Analogous to medical training, one may imagine that units of professional practice, framed as tasks, could be specified, embedded in training, and assessed. In the health professions, patient safety concerns are addressed by certifying trainees for entrustable professional activities (EPAs).42–45 In research settings, a similar approach does not yet exist, although the development of EPAs for clinician–scientists is currently being explored by a European consortium as part of the European Union-funded PATHWAY project.52
The sustainability of the clinician–scientist workforce has been a subject of concern in the literature for 45 years.11 Although many have made recommendations for increasing training and career supports for clinician–scien tists,8,10,15,21,31,36–38 no substantial change has yet to be made. No expert meeting, however well sampled and conducted, can solve this problem on its own, but it can clarify the landscape somewhat to enable steps in the direction of a solution. The international expert meeting discussed here identified 3 critical questions that need to be addressed if clinical science is to move forward: (1) What is the particular nature of the clinician–scientist role? (2) How are clinician–scientists to be recognized within the health and health research ecosystem? and (3) How can the value that clinician–scientists add to translational medicine and research be clarified to stakeholders and the public? The meeting also identified a 3-fold agenda to address these questions: (1) articulating the value proposition of clinician–scientists, (2) supporting professionalization and professional identity development, and (3) integrating clinical and research training. Addressing the critical challenges identified during the expert meeting will likely contribute to a wider recognition of the value of clinician–scientists and be a first step in advancing from recommendations toward system-level changes to reinforce the clinician–scientist workforce.
The authors wish to thank the other members of the International Expert Group on the Clinician–Scientist Workforce: Salvatore Albani (MD, PhD, professor, Duke-NUS Medical School, director, Translational Immunology Institute, SingHealth and Duke-NUS Academic Medical Centre, and chair, Understanding Childhood (Chronic) Ailments Network–Asia [UCAN-A]); David A. Hafler (MD, William S. and Lois Stiles Edgerly Professor of Neurology, professor of immunobiology, and chair, Department of Neurology, and neurologist-in-chief, Yale New Haven Hospital); Patricia Houston (MD, MEd, vice dean of MD program and professor of anesthesia, University of Toronto, and staff anesthetist, St. Michael’s Hospital); Kevin Imrie (MD, physician-in-chief, Department of Medicine, Sunnybrook Health Sciences Centre, vice chair of education, Department of Medicine, and haematologist professor, University of Toronto); Ross McKinney Jr (MD, chief scientific officer, Association of American Medical Colleges, and professor of pediatric infectious diseases, Trent Center for Bioethics, Humanities & History of Medicine, Duke University School of Medicine); Sabine van der Laan (MD, PhD student, University Medical Center Utrecht, and cofounder, Apollo Society); Lorelei Lingard (PhD, founding director and senior scientist, Centre for Education Research & Innovation, professor, Department of Medicine and Faculty of Education, adjunct professor, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, and associate scientist, Lawson Health Research Institute); Annet van Royen (MD, PhD, head, Department of Pediatric Rheumatology and Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, and program director of research master program, Selective Utrecht Medical Master [SUMMA], University Medical Center Utrecht); Fedde Scheele (MD, PhD, president, Dutch Association for Medical Education, professor in health systems innovation and education, VU Medisch Centrum, and gynaecologist, obstetrics–gynecology vice program director, and dean, OLVG Teaching Hospital); Marieke J. Schuurmans (RN, PhD, chair and professor in nursing science, University Medical Center Utrecht, and professor of care for chronically ill, HU University of Applied Sciences Utrecht); David P. Sklar (MD, editor-in-chief, Academic Medicine, distinguished professor emeritus, Emergency Medicine, University of New Mexico, and senior advisor to university provost in health policy and health professions education and professor, School for the Science of Health Care Delivery, Arizona State University); Jennifer Stinson (RN-EC, PhD, professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, and Mary Jo Haddad Nursing Chair in Child Health, Hospital for Sick Children); Michael J. Strong (MD, president, Canadian Institutes of Health Research [CIHR], dean, Schulich School of Medicine & Dentistry, distinguished university professor, and Arthur J. Hudson Chair in ALS Research, Western University); and Alison Whelan (MD, chief medical education officer, Association of American Medical Colleges). The authors would also like to thank Rinze Benedictus for his expert facilitation of the meeting.
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