It has often been said that, “Talk is cheap; research is expensive!”4 There is another widely known quote (although I do not know to whom it is attributed) that states, “If you're not talkin' dollars and cents, you're not talkin'.” So, as we start to make our way through the 21st Century attempting to fulfill promises made about how advances in molecular biology, material science, bioengineering, health services research and surgical techniques will advance patient care, we should first answer some very practical questions. How will this all be financed? Who will pay for it? How can we make sure the people who can lead these efforts will be supported adequately and receive the proper incentives?
Advances in medical science are dependent on the pipeline of investigators who have novel ideas and their abilities to translate those ideas into testable hypotheses. Once a so-called proof of concept has been achieved, the next goal is to translate the technology into a clinically meaningful therapy or diagnostic tool. While many individuals with a variety of backgrounds make important contributions to this process, clinician-scientists bring a unique perspective because their scientific questions arise at the bedside. Indeed, regardless of the research endeavor, only clinician-scientists are imprinted with the experience of taking care of patients. Therefore, in addition to their abilities to create bridges from the laboratory to the bedside or to pose the relevant clinical questions, only someone who has been responsible for another person's life or limbs can appreciate the global impact of a specific hypothesis and its potential importance to patients' well-being.
The future of the clinician-scientist throughout the field of medicine, and within the field of orthopaedic surgery, has been addressed in recent reports.5,6,8,13 Although several impediments have been noted, time and financial considerations have been identified as the major reasons for the diminishing numbers of surgeons.5,6 First and foremost, it takes many years to complete medical school and residency training, develop skills as a surgeon, and apply those skills to the care of patients in a way that brings sufficient experience to be certified and credentialed in the subspecialty of orthopaedic surgery. There is little time left to acquire research skills or to obtain specialized research training necessary to gain the knowledge, skills, and experience to be competitive for peer-reviewed funding. Moreover, even if it were possible to carve out this time, the infrastructure of most institutions does not provide a nurturing and supportive environment to develop scientists in orthopaedics. This problem is compounded because most institutions with residency training programs lack adequate financial support and infrastructure for additional education and training in research methodology. Yet, even if these deterrents could be reversed, and the associated problems solved, it seems the most daunting challenges to a successful career as an orthopaedic clinician-scientist fall into the realm of personal financial expectations and difficulties with obtaining research funding.
Medical school tuition is expensive and the career choice to train as a surgeon prolongs the period of debt repayment. In many cases, it may actually lead to an increase in debt. Now that many students engage in the workforce for one or more years between college and medical school, they find the age at which they are able to earn a physician's income is delayed. By the time a young surgeon finishes his or her training, it is likely increasing family and financial responsibilities would compete for any time available for non-income generating activities such as research.
Orthopaedic surgery as a specialty enjoys the position of being among the most lucrative fields in medicine.1 Even after several decades of doomsday predictions by economic pundits that the bubble will burst on the financial rewards of an orthopaedic career, income continues to rise and orthopaedic surgeons continue to thrive. However, to maintain this financial stability and economic health, surgeons have adapted to meeting the pressures of the economic environment by increasing clinical volume and forming more extensive associations with colleagues to share overhead costs. Consequently, even if an individual interested in a career as a clinician-scientist were willing to accept a diminished income in relation to their colleagues, the choice to produce lower clinical volumes or assume a reduction in shared clinical responsibilities and overhead is generally viewed with disdain. Perhaps as much as any other deterrent, negative peer pressure becomes a major problem in the life of an orthopaedic clinician-scientist.5
Finally, the mark of success of a clinician-scientist is his or her ability to gain federally funded research support. Although at the beginning one's career institutions and departments with small amounts of seed dollars set aside for research, or research foundations and professional organizations that have start-up grants available for emerging clinician-scientists, may provide opportunities to help launch research careers, these opportunities do not represent solutions to the challenges of career-long funding of the orthopaedic clinician-scientist; they only help these individuals to get started. Sustained research funding at the federal level with dollars that enable laboratories to attain sufficient size and maintain ongoing research programs will ultimately be needed.
Since its establishment in 1955, the Orthopaedic Research and Education Foundation (OREF) has invested heavily in initiating careers of prospective clinician-scientists. Programs such as the Resident Research Grants, which help to launch research careers when a resident is still in training, and basic and clinical Research Grants provide opportunities for young scientists. However, to specifically support the careers of clinician-scientists, more substantive funding is also available through OREF in the form of Career Development Awards, which provide up to $225,000 over 3 years. More recently, OREF has established Prospective Clinical Awards ($150,000 over 3 years) and Clinical Research Training Fellowships ($140,000 over 2 years). Although competition for these awards is keen, with the exception of the Research Grants, the others are exclusive to orthopaedic surgeons and the OREF typically considers more junior status a positive attribute towards the competitiveness for funding. The goal of these grants is to provide adequate funds for individuals to produce sufficient data upon which to support future applications to federal agencies, such as the NIH. However, the OREF does not view itself as an entity responsible for maintaining ongoing career funding; it initiates and promotes individuals early in their careers. Other organizations providing similar programs include the Arthritis Foundation, March of Dimes and the Shriner's Hospital system. Examples of other non-orthopaedic organizations that provide similar opportunities include Burroughs-Welcome, Doris Duke, and the Howard Hughes Medical Institutes. Few orthopaedic surgeons, however, have taken advantage of these other sources of funding.
In addition to these programs, one of the most exciting initiatives recently established by OREF is the Clinician-Scientist Award. This award is intended to encourage young surgeons to pursue a career as a clinician-scientist, with a special emphasis on continued research activity. The award will be made to an orthopaedic surgeon to allow the recipient to spend 40% or more of his or her time (two workdays each week) in research for a period of up to 3 years. It will provide a stipend to compensate for the projected loss of income that would result from devoting less time to clinical practice and more time to research, but no funds for the costs of the research itself. In return, the recipient is required to serve as a role model for orthopaedic residents, interns, and medical students in the practice and science of musculoskeletal surgery; organize and participate in conferences; and work with students, interns, and residents in the operating room.
Success of the OREF career grant programs has been partially investigated by two surveys of former grant recipients. Although the focus of each was different they did evaluate two common results: NIH funding and journal publications. The most recent survey reviewed 226 grants awarded from 1985 to 1998 including Career and Research Grants. Thirty-seven percent of recipients went on to achieve NIH funding (2.0 median per person) and 30% had more than one paper published. In a survey that reviewed Career, Research, and Resident grants from 1970 through 1988, 58% were associated with future NIH funding, 85% had more than one published journal article, 35% of the principle investigators became department chairmen, and 33% received Kappa Delta awards from the American Academy of Orthopaedic Surgeons.2,12
In recent years, efforts driven by databases such as those obtained from the NIH, the Association of American Medical Colleges, the American Medical Association, and others have provided data on the physician workforce in the United States and the pipeline of physician-scientists. Ley and Rosenberg8 have recently shown the population of physician-scientists in the United States is now smaller and older than it was 25 years ago, and even though physician workforce has continued to increase since 1980, the number of physicians engaged in research and teaching has not. Up until about 3 years ago, research-intensive medical schools and hospitals and the NIH responded to the recognition of this problem by constructing multi-faceted programs aimed at encouraging medical students to become involved with research before and after receiving their medical doctorate degrees and protecting the research time of young physician-scientists during their junior faculty appointments.3,10,14 These initiatives began between 1998 and 2002 against the backdrop of a commitment by the United States Congress to double the NIH budget from approximately $14 billion in 1998 to approximately $28 billion in 2003. In doing so, the NIH established a new Career Development Award for physicians being trained to carry out clinical research (K23), awards for established investigators (K24), and awards for academic institutions with programs supporting clinical research training and infrastructure (K30). These so-called K Awards are part of a program of grant opportunities established by the NIH to promote and nurture research careers (Table 1). They do, however, require specific time commitments, which limit candidate eligibility particularly for surgeons attempting to have a meaningful clinical presence.
Loan Repayment Programs
In 2002, the NIH put in place a series of competitive Loan Repayment Programs (LRPs) offering at least 2 years of tax-free debt relief for young scientists with substantial debt and a serious commitment to clinically oriented research training.7,9 This program, and a similar program currently approved and in development by the OREF, provides hope that a major positive step forward will occur towards funding the mandate for the orthopaedic clinician-scientist.
The NIH loan repayment programs include the Clinical Research LRP, Clinical Research LRP for Individuals from Disadvantaged Backgrounds, Conception and Infertility Research LRP, Health Disparities LRP, and Pediatric Research LRP. With the exception of the Contraception and Infertility Research LRP, the others would seem to be potential sources of debt relief for orthopaedic clinician-scientists. Under the conditions of these programs, the NIH offers to repay up to $35,000 annually of the so-called qualified educational debt of health professionals pursuing careers in biomedical and behavioral research.11 The programs also provide coverage for federal and state tax liabilities. To qualify, applicants must possess a doctorate degree, be willing to devote 50% or more of their time (20 hours per week based on a 40-hour work week) to research funded by a domestic non-profit organization or government entity (federal, state, or local), and have educational loan debt responsibilities equal to or exceeding 20% of their institutional base salary. Applicants must also be US citizens, permanent residents, or US nationals.
The OREF has also taken up the challenge of loan repayment programmatic relief for qualified orthopaedic clinician-scientists. Currently, a program is in place to provide a matching supplement of $35,000 per year for up to 2 years to one new clinician-scientist per year who has obtained one of the NIH LRP awards. In addition, the OREF and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) have signed a memorandum of understanding to provide two supplements of $30,000 per year, for up to 2 years of support, for advanced training that could lead to a Master of Public Health degree or Doctorate of Philosophy.
New programs recently initiated by the NIH, and currently in development in collaboration with the OREF, may have a strong positive impact on the decisions of young surgeons to pursue careers as orthopaedic clinician-scientists. To maintain the trend, however, strong funding commitments will be required at the entry level and must be sustained for several years. There are other stakeholders in this process who have begun to rise to the challenge. Most notably, the American Academy of Orthopaedic Surgeons (AAOS), the American Orthopaedic Association (AOA), the Association of Bone and Joint Surgeons (ABJS), and subspecialty societies have recognized the need to assume some responsibility for ensuring the future of our specialty by supporting these efforts.
To meet the challenge of funding the mandate for the orthopaedic clinician-scientist, it would seem a plan needs to be developed on four levels. Institutions need to develop mechanisms for training future orthopaedic surgeons in research methodology. Centers of excellence should be established at a limited number of medical schools and funding for initial support of these programs could come from orthopaedic organizations including the OREF, the AAOS, the ABJS, and subspecialty organizations. Once a significant body of data is developed, departments or groups of departments, divisions or sections could apply to federal agencies for programmatic funding.
Protected time and expenses need to be established for junior orthopaedic clinician-scientist faculty. This would seem to be the most daunting challenge as it is hard to develop guidelines or programs that would apply countrywide. Perhaps models should be developed by specific departments with exceptional vision to provide a structural framework that other programs could consider for adoption or modification. Such models include dedicating one or two days per week to laboratory research, or dedicating alternating months to research or clinical service. University orthopaedic departments with practice plans should establish reserve funds based on a low percentage allocation of gross receipts to support this initiative. These reserves could also be used as bridge funds when investigators sustain funding shortfalls between grants. Negotiations with medical school deans to match funds should also be held, and deans should understand indirect costs from department research grants already in place can be used to offset some of these costs.
Loan repayment programs already in motion are an excellent start on addressing one of the key challenges to initiating and maintaining an orthopaedic clinician-scientist career. The NIH and the OREF have made early efforts in this direction. Other organizations such as notfor-profit research foundations could also be brought in to develop even more elaborate and, hopefully, more substantive, debt relief efforts.
Finally, the NIH, the OREF, and other research foundations need to continue to develop innovative funding programs to provide seed money (eg, NIH Shannon Award) and mid-career intermediate level research grants for clinician-scientists. More Career Development Awards need to be funded by federal agencies and private foundations, and mentored research awards, such as the NIH K Awards, should limit their requirements regarding percent effort commitment so that the eligibility of prospective surgeon-candidates can be brought into closer alignment with the realistic demands of clinical practice in the 21st century.
If these types of commitments can be initiated and sustained, it is likely they will result in an increase in the number of successful orthopaedic clinician-scientists and provide an optimistic view for the future of our specialty.
The author thanks Ms. Jean McGuire for providing important information regarding the Orthopaedic Research and Education Foundation.