Recent diverse pressures on academic health centers have constrained the time and resources available for young clinicians to become involved in research careers. National political phenomena such as the increasing burden of health care provision for the uninsured, regulatory requirements for clinical care and research, and the recent plateau and decline of the federal research budget of the National Institutes of Health (NIH) have contributed to these pressures, creating increasing impediments to scientific investigation by clinicians. National orthopaedic organizations, such as the Orthopaedic Research Society, the American Academy of Orthopaedic Surgeons, and the American Orthopaedic Association, among others, have recognized the importance of these individuals to our specialty and, in recent years, the problem of an inadequate pool of clinician-scientists in orthopaedics. The importance of clinical input guiding basic research directions has never been greater, and is underscored by the current NIH roadmap, which emphasizes clinical and translational research.7 Despite the increasing opportunities and emphasis on clinician involvement in research, many barriers exist, and some also seem to be increasing.
I will explore the causes and types of barriers clinician-scientists face, as well as provide potential considerations by institutions for addressing and ameliorating these problems.
Causes of Barriers for Clinician-Scientists
The barriers to success of would-be clinician-scientists in orthopaedics are multifactorial, and occur at many levels. The external factors influencing institutions and their ability to facilitate clinician-scientist career pathways include federal and state governments, third-party payers, societal issues, and cultural changes within medicine and orthopaedics. Perhaps the greatest barriers are socioeconomic and political, although factors specific to the field of orthopaedics and changes in the complexity and the increasingly interdisciplinary nature of scientific research probably play a role. Institutional barriers are in large part secondary to the socioeconomic and political influences and cultural changes in medicine. The political effects on institutions include: (1) decreasing governmental funding for research in the context of burgeoning costs of conducting it; (2) flat or declining third-party payer reimbursement rates for clinical care in the face of rapidly escalating hospital and practice costs; and (3) the rapidly expanding burdens of time and effort expended in enforcement and documentation of the dramatically expanding regulatory requirements experienced by hospitals and physicians in clinical care and research activities. The common feature of these effects is decreasing revenues and increasing costs, setting the stage for rising barriers and disincentives for clinicians to conduct research.
The net effect is escalating institutional pressure on clinicians to increase clinical productivity. Remarkable improvements in efficiency of care delivery and leveraging of information technology have helped offset the financial pressures, but these can compensate only so much, and time that might be allocated for research and other academic activities quickly becomes consumed with additional clinical activity. The increased costs of research, which include equipment, space, personnel, and time and/or effort expended on regulatory requirements, in combination with the shrinking margins of hospitals and practitioners, discourages surgeons from involvement in research because of inadequate resources. Institutions have additional pressures that add to the barriers, such as adequate space (and associated cost) for clinical and research activities. Many institutions now focus on strategically supporting the largest research enterprises as a matter of producing the greatest return on investment, and this usually leaves out investment in smaller surgically based specialty research development.
Types of Barriers for Clinician-Scientists
Apart from the underlying causes of barriers to clinician involvement in research, there are a number of different types of barriers. The differential in remuneration for research versus clinical activities remains paramount. Fiscal incentives working as they generally do and despite the increased financial pressures on physicians, it is unlikely there would be such a dearth of orthopaedic clinician-scientists if the activities were financially rewarded at similar levels. It seems likely we are seeing a similar effect of fiscal rewards influencing orthopaedic subspecialty training, given the increasing popularity of sports and spine subspecialization and decreasing interest in adult reconstructive and pediatric orthopaedic surgery fellowships. Generational issues may compound the adverse fiscal influences on clinician involvement in research as the level of college and medical school debt accrued by many residents is enormous, and loyalty to departments and institutions has diminished with Generation X individuals.1 Thus, family and lifestyle pressures exert a negative influence on less financially rewarded activities, such as research. Greater concerns about future educational and healthcare costs of families may also influence career pathway choices of young orthopaedic surgeons. Finally, there is a nagging concern the new work-hour restrictions may subtly create a workshift mentality among young physicians, and additionally decrease willingness to put in the nonremunerated extra time and effort involved in successful research.
The number one force driving institutions appears to be declining reimbursement in the context of increasing costs. Exacerbating payer decreases in reimbursements are the general inflation rate of all goods and services, skyrocketing malpractice insurance premiums, escalating costs of medical technology, a restrictive federal funding research climate, and an increasingly underinsured population preferentially being shunted to academic health centers for their care. The system changes in healthcare delivery over the past decade, such as the advent of managed care, have had a major impact on institutional research activities. This was documented eloquently by Moy et al in 1997 in a study of the numbers and size of NIH awards versus the degree of managed care regional market penetration across 125 academic health centers.4 Remarkably, there was a substantial decrease in the number and size of NIH awards to institutions with a high degree of managed care penetration. Not surprisingly, this effect was far worse for clinical departments than nonclinical departments.3 The data are particularly compelling given the degree of heterogeneity among the large sample of medical centers. A followup study in 2000 also concluded greater NIH funding success was occurring in a smaller number of increasingly research intensive-institutions.3
In the past, many have referred to the ivory tower concept in academics. The economic factors mentioned previously have led to a change in the approach of academic institutions to providing healthcare,5 in addition to the challenges facing the academic research enterprise.2 The new watchwords for financial success of institutions are access and efficiency, which translates to a shift to the service-with-a-smile approach. This has been the only way for academic health centers to successfully compete and respond to the various fiscal pressures with increased patient volumes and more attractive patient complexity and case reimbursement mixes. Thus, increased competition with community providers has occurred, with some beneficial effect in holding down the rising rate of healthcare costs overall, but an adverse effect on willingness of institutions and clinicians to participate in research. In addition, clinical service lines have evolved as cross-disciplinary collaborations to combine sets of highly sub-specialized expertise, enhancing efficiency and access for patients.
On the scientific front, the explosive growth of molecular biology with the human genome project and other advances has exponentially increased the complexity of experimental approaches toward understanding cell and organism biology. This has necessitated a more interdisciplinary and collaborative approach to moving science forward because diversity of expertise and perspective is now often required to make quantum leaps in scientific progress. Accordingly, the past tendency in many academic centers to build vertically within strong scientific groups and create silos of high powered expertise is becoming a failed strategy as scientific teams collaborating across disciplines is proving a more successful approach toward scientific progress and funding. The combinations of changes in the clinical and research arenas have led to what one might consider the dying days of the “ivory silo”, resulting in enhanced collaboration, accessibility, and interaction at all levels of the academic medical enterprise.
Incomplete alignment of incentives between hospitals and physicians, clinicians and scientists, and medical schools and clinical faculty create another type of barrier for clinician-scientists. Hospitals want clinical volume, especially surgical, and minimal lengths of stay, placing ever increasing pressure on physicians to do more clinical work. While many academic health centers emphasize their teaching and research missions, for clinical faculty in the end, the institutional priority of sustainable financial health often causes clinical productivity to take precedence at the expense of the other missions. Financial partnerships between physicians and hospitals exist, but are the exception rather than the rule, and the remaining problem of how to preserve time and financial incentives to promote research and teaching is unsolved. The incentives of clinicians and scientists are also not always well-aligned. Busy clinicians may require more help from scientific colleagues than they are able to provide, given the institutional pressures for funding on basic scientists. Similarly, scientists in basic science departments and clinicians have increasing difficulty meeting teaching needs and expectations of medical schools, given time demands.
Space is another constraint facing young clinician-scientists, and is a major problem in many academic health centers. The competitive climate and physical plant constraints of many centers have led to satellite outpatient clinics, surgi-centers, and outreach clinics to provide regional service and enhance patient volumes. However, the resulting disruption of interactions between clinicians and scientists contributes to the obstacles to collaborative research. Apart from the disconnection of clinical activity sites, different research functions in medical centers may be in widely discontinuous locations. This is a critical and poorly recognized problem in translational research, in interdisciplinary research, and in the interactions between clinicians and scientists. Colocalization is an extremely powerful facilitator of collaborative interactions, and young scientists are able to be more successful when in close contact with other scientists who can serve as mentors. Unfortunately, as the research operations of orthopaedic departments grow, incremental space is often non-contiguous, compounding the difficulty of collaboration.
Collaboration of young orthopaedic clinician-scientists with basic scientists and their ability to seek mentoring from these individuals may be adversely affected by the increasing institutional pressures on scientists. Institutions have fairly stringent expectations of basic scientists in terms of research funding. Salary generation goals for most institutions are in the 50% to 100% range for basic scientists, while clinicians generally can bring in a greater proportion of their salary support from patient care activities. Laboratory space also usually needs to be justified by some formula tied to funding, commonly in the range of $200 to $400/square feet/year. In addition, basic scientists have varying teaching obligations. Scientists in clinical departments may be at an additional disadvantage because these departments may not be provided substantial hard money budgets from medical schools for teaching and research, as is often the case in basic science departments. The collective pressures on scientists may stifle collaboration and mentoring of would-be clinician-scientists in orthopaedics.
There are also cultural barriers in orthopaedics, including a lack of role models, a lack of patience (stereotypical low frustration tolerance of surgeons),6 the surgeon's sense of responsibility to the patient, and clinical income generation peer pressure. Given over the past decade there have generally been only 20 to 30 funded orthopaedic surgeon-scientists as principal investigators on NIH grants at any one time (personal communication), the lack of role models is self-evident. Perhaps the tendency of surgeons to respond to immediate gratification leads to impatience with the necessity of persistence in grant submissions to obtain and maintain research support. The peer pressure to generate clinical income is a major issue for clinician-scientists, and fundamentally relates to differences in remuneration for time spent in clinical versus research activities.
Lack of accessible infrastructure is another serious problem encountered by aspiring clinician-scientists. While all academic health centers have grant administration staff, institutional review boards, animal protocol review committees, etc, help in navigating the maze of regulatory and funding agency requirements, getting institutional grant sign-offs, obtaining biostatistical support, database management, and other functions critical to research activities may not be readily accessible to an inexperienced individual. A point of service approach to providing these functions (ie, at the department level) can tremendously facilitate the engagement of clinical faculty in scientific research. This may include administrative staff to help in all the budgetary and face page preparation of applications, interface with the institutions' review boards and animal review committees, accounting and budget management, and update and facilitate protocols and mandatory training. In addition, readily accessible biostatistical support, clinical coordinators, computer support personnel, and technology transfer support are essential. Such department infrastructure can greatly facilitate the entry of clinicians into scientific research careers, and its absence can pose another major barrier.
Importance of Clinical Perspective in Research
There is no question the benefits of clinical perspective are critical to guiding research into the most productive and highest impact areas. Clinical questions and observations can often generate some of the most interesting new research directions and approaches. The societal impact of research discoveries on healthcare is a social and governmental metric, as reflected by the fact the organization funding the majority of biomedical research is the NIH, which is under the auspices of the Public Health Service. Straddling basic and clinical fields by the clinician-scientist allows an individual to readily see the translation of one to the other. There is currently a strong push toward clinical and translational research, as evidenced by the NIH roadmap and enhanced funding for research translation as part of that initiative.7 The NIH roadmap includes three major components: (1) New Pathways to Discovery; (2) Research Teams of the Future; and (3) Re-engineering the Clinical Research Enterprise. New Pathways includes research data networks, metabolomics, and proteomics. Research Teams of the Future includes mechanisms to enhance interdisciplinary research, public-private partnerships, and NIH Director's Innovation awards to support high-risk/high-impact research. Re-engineering the Clinical Research Enterprise incorporates new training programs, core services, regional translational research centers, clinical research informatics and networks, and development of enabling technologies for clinical outcomes assessments.7 Thus there is an enhanced emphasis on opportunities for clinician-scientists to play an important role in the future of biomedical research. Similarly, the evolution of clinical outcomes research with associated new measurement tools, available training programs, and career development support mechanisms creates another set of opportunities for orthopaedic clinician-scientists. National Institutes of Health funding remains the metric of scientifically competitive biomedical research, and joining the pool of funded orthopaedic clinician-scientists enables a young faculty member to rapidly become part of a small group of individuals with substantial impact and create critical role models for trainees.
Critical Ingredients for Clinician-Scientist Success: “The Time and the Team”
There are several critical ingredients for success as an orthopaedic clinician-scientist. The two most important factors are the time and the team, meaning a mechanism for protecting and supporting research time, and a team of collaborators for the clinical practice and research activities. Additional important ingredients include enthusiasm for research and commitment to it, accessible infrastructure, sufficient start-up funding mechanisms, visible role models, and accessible mentorship. Protected time generally takes the form of defined research time on a weekly or monthly basis. In particular, protection from urgent clinical issues is essential, and generally means the clinician has other practice partners with similar subspecialty expertise who can provide urgent patient care when the clinician-scientist is unavailable. Containment of on-call responsibilities to prevent impingement upon defined research time is also essential. Longer periods of time to learn techniques may be accomplished through sabbaticals or academic leave programs many universities offer. Other uses of research time requiring protection include meeting and travel time and time for visiting or interaction with scientists at other institutions. In the fields of medicine and pediatrics, the academic model generally involves off-service time for research, and clinical time is much more limited than in surgical fields. Accordingly, it is not surprising the majority of federal research funding is based in Departments of Medicine and Pediatrics rather than in surgical departments. Clinical job-sharing arrangements, although uncommon, do exist in surgical fields and can be extremely successful in facilitating long term research productivity and funding.
The team concept is the other critical element for the successful clinician-scientist. The complexity of biomedical science makes the lone researcher an outdated model because different types of expertise are necessary to make advances, which a single scientist may not possess. The need for diverse expertise and perspectives on a research problem is much greater than in the past, and interdisciplinary research has become a powerful method. It takes a critical mass to launch a scientifically competitive research program, and clinician-scientists are better served by working with other principal investigators and using existing resources and experimental models to get started. Similarly, the clinician-scientist needs a clinical team, colleagues who can cover urgent clinical practice issues of the individual to enable time protection. In addition, a clinical team in one's subspecialty area provides greater diversity of clinical perspective on clinically related research problems, just as with the scientific team, and can enhance development of the clinician-scientist's ideas.
Additional ingredients for the successful clinician-scientist previously mentioned include a high level of enthusiasm for research and a commitment to it, adequate mentoring and role models, and sufficient funding to develop the research program. Typical requests for start-up packages for orthopaedic clinician-scientists include technical staff, fellows, equipment and supply budgets, possible salary support, and often a desire for their own laboratory or defined research space. However, equally or more important are the mechanisms for protected time, an appropriate team, and adequate infrastructure. These needs can be met in a variety of ways, but attention to facilitating collaborative interaction can leverage start-up resources and makes longer term success far more likely. Shared personnel, space, and equipment if access is adequate may be more efficient than separating the clinician-scientist from others.
Addressing the Problems of the Clinician-Scientist
What can be done to surmount the numerous institutional barriers for the clinician-scientist? First is a recognition the disappearance of this career pathway would have extremely detrimental long term consequences on successful clinical translation of scientific discoveries. At a national level, continued strong support of MD/PhD training programs demonstrates commitment to this career pathway by scientific and political leaders. Additionally, the national orthopaedic organizations, including the American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Orthopaedic Research and Education Foundation, Orthopaedic Research Society, and others have worked successfully toward enhancing support mechanisms for clinician-scientist career development in recent years. Therefore, the orthopaedic leadership has recognized the problem and undertaken initiatives to address it.
There are many sources of funding for developing the research program of the clinician-scientist, including department resources, industry support, and numerous types of foundation or federal career development awards. Unfortunately, all sources of research funding are currently under duress given the external political and socioeconomic factors previously discussed. Start-up funding is only successful to the extent it leads to ongoing sustainable funding for a research program, and a strong trajectory toward independent funding needs to be a goal and an expectation. Accordingly, enhancement of grant writing skills, mentorship, and presubmission review of grant applications by experienced individuals are essential elements needing to be incorporated early in the research career.
At an institutional level, a number of additional steps should be taken. The first is improving alignment of incentives in components of institutions and their faculty, which will mean ultimately ensuring adequate resources are committed to the research and teaching missions, and appropriate levels of faculty time dedicated. Because of the peer pressure for clinical income generation within Departments, emphasis by Department leaders of the critical importance of clinician-scientists to Orthopaedics, and creation of financial systems which value clinician-scientist contributions are essential. Use of clinical revenues as well as discretionary funding resources toward creation of appropriate and stable support for clinician-scientists can help generate a culture of group support and team sense of pride in scientific accomplishments of members of a Department.
In terms of organizing research programs, we need to be far more attentive to spatial co-localization issues to facilitate team development and scientific collaboration. Strengthening programs that regularly bring clinicians and scientists together to enhance interaction and dialog is also important. In orthopaedics, we need to create and support models for time protection, and strengthen the mentoring programs for young clinician-scientists. Finally, we need to address research administrative infrastructure and research cores to make research easier for the clinician-scientist to carry out. Ensuring accessibility of research infrastructure in more of a point of service mode, ie, at the department level, may be a more effective model for the future.
Obviously the circumstances contributing to rising barriers for clinicians to conduct scientific research are complex and multifactorial, and solutions are unlikely to be either easy or straightforward. A convergence of multiple adverse factors currently exacerbates the barriers for clinician-scientists, and arises from political and governmental, as well as societal and cultural sources. Increasing costs of both clinical care and research in the face of shrinking resources create major disincentives for clinician involvement in research from both institutional and individual perspectives. Surmounting the barriers for clinician-scientists will require increased attention by institutions to creating collaborative research teams and protected research time for these individuals. Enhanced interaction between clinicians and scientists, mentorship and role models, and accessible research infrastructure for clinician-scientists are also necessary components which must be developed.