Question: What are some of the common deterrents
to the young orthopaedic surgeon becoming a clinician-scientist?
1. There is a lack of successful mentors and available role models
to stimulate potential young investigators in our field.
2. There is a widely held perception that basic and in-depth research
is the purview of the PhD scientist and that the orthopaedic surgeon
does not or cannot play a role in this type of research.
3. The infrastructure of most institutions does not provide a nurturing
and supportive environment for a research career in orthopaedics.
4. There is a lack of definition, scope, and perceived security
in this potential career path.
5. There is no existing structure within orthopaedics that can bridge
the organizations capable of reducing the impediments to the choice
of research as a career track.
6. The significant educational debt burden of becoming an orthopaedic
surgeon discourages many from pursuing the research career track.
Such a career choice currently prolongs debt repayment and may actually introduce
more debt.
7. Young surgeons in their early thirties, after years of training and
with increasing family and financial responsibilities, appear more
driven toward enhancing their potential income than toward spending
additional time in research.
8. Institutional emphasis on and support for primary care and generalization
(less subspecialization) during medical school entices potential
clinician-scientists into nonsurgical research careers prior to
their exposure to orthopaedics.
9. There is a lack of adequate financial support for additional education
and training in research following the residency and fellowship
years.
10. There is peer pressure from orthopaedic colleagues to participate
in the sharing of clinical responsibilities. Surgeons often gain
the most recognition and satisfaction from working in a busy surgical
practice. Consequently, less time is spent pursuing in-depth clinical
research.
Question: How much research time is necessary
to be competitive for federal grants?
There are exceptions; however, it would appear that a successful clinician-scientist
needs a minimum
of two days of protected time per week or an equivalent time
allocation per year. The process of becoming a principal or co-investigator
on a major grant is quite competitive. Most individuals receiving
major research grants hold full-time research positions and spend
more than two days per week committed to their research efforts.
The orthopaedic clinician-scientist faces two challenges: (1) obtaining recognition
from the scientific community as a peer, and (2) obtaining recognition
from full-time clinicians that their research (and the time that
it requires) is important to the field of orthopaedics and to the
patients whom we serve. It is difficult to be competitive for grant
support when less than two days per week are devoted to research.
At the same time, it is difficult to remain clinically effective
when less than three days per week are devoted to one's practice.
This is the dichotomy of being a clinician-scientist. The maintenance of
clinical relevance and surgical skills takes time and commitment,
as does scientific research. Orthopaedic clinician-scientists sometimes
feel alienated from both the scientific community and their surgical
colleagues because of the disparate expectations and standards of
the two communities. Adequate protected time, the right basic-science
and/or research team, and the proper institutional infrastructure
are essential in order for the clinician-scientist to reach his
or her full potential.
Question: How much should a young orthopaedic
surgeon pursuing a career as a clinician-scientist expect to earn
per year?
The clinician-scientist must realize that his or her income will
be less than that of a full-time clinician working within an orthopaedic
department. Nonmonetary rewards and support as well as intellectual
satisfaction should be as important to the potential clinician-scientist as
income is. Other critical considerations are the availability of laboratory
space, protected time, technicians, assistants, and mentoring. The
starting income for a young orthopaedic clinician-scientist with
two days of protected time per week is currently less than that
of a full-time clinician. Ideally, it should be the total of two-fifths
of a full-time research scientist's salary plus three-fifths of
a young clinician's compensation, reflecting the individual's participation
in the department's practice plan.
A major financial obstacle that the clinician-scientist often
faces is the overhead costs of maintaining his or her clinical practice,
particularly during protected research time. If the department's
practice plan is providing overhead support, it takes several full-time
clinicians in the department to cover the overhead and to provide
the clinical support that will allow the clinician-scientist to
have the equivalent of two protected days per week. Outside sources
of funding, such as endowments or institutional funds, also can
ease this financial burden and can help the individual to maintain protected
time. Currently, just a few orthopaedic training programs are effectively
addressing the issue of protected research time.
Question: How many career orthopaedic clinician-scientists conducting
research that is competitive for federal grants can we hope to see
emerge in the United States each year?
Because the orthopaedic clinician-scientist is an endangered species,
the goal should be for at least three to six new individuals to
enter and remain in the field each year. A yearly addition of three
to six new individuals who are committed to a twenty to thirty-year
research career would infuse our specialty with a valuable resource.
Recruitment, mentoring, and support are needed in order to obtain
this commitment. Substantial financial support is needed initially,
and in many cases it may be required for up to seven years to ensure the
transition to self-support through grants. Currently, there may
be only ten to twenty institutions with the resources, the "team,"
and the desire to recognize and nurture clinician-scientists.
Question: What will happen if organized orthopaedics
does nothing more and waits for outside solutions?
The current marketplace and the funding mechanisms for resident
training are a deterrent to the development of orthopaedic clinician-scientists
within the existing programs and structure. However, certain changes
might evolve over time outside of orthopaedics.
1. More federal funds and other debt-reduction programs will
be developed in areas of the greatest perceived research need.
2. Individuals currently receiving federal funding for PhD/MD programs
tend to commit to their PhD research before they consider a field
requiring an additional five years of surgical training. They also
tend to be recruited or attracted to nonsurgical fields. Funding
might be restructured to encourage more individuals to select a
musculoskeletal research career after their orthopaedic training.
3. Eventually, the forces of supply and demand may diminish the
income discrepancies currently experienced by clinician-scientists
compared with full-time clinicians.
4. Individuals with a PhD degree may continue to assume a greater portion
of the research effort in orthopaedics.
5. Outside foundations and/or industry may fund or develop specific
programs to address the needs of potential clinician-scientists.
6. If orthopaedic clinician-scientists become extinct, other
scientists will assume the role of assessing orthopaedic treatments,
indications, and outcomes. They also will oversee and evaluate prevention
and disease-management programs in our field. This trend is already developing.
Question: What are the common ingredients of
programs that produce successful clinician-scientists?
1. The availability of and access to role models, mentors, and
colleagues within and outside of the training institution. (This
component is critically important.)
2. A research infrastructure that encourages and facilitates
opportunities for collaborative and co-investigative multifaceted
analysis and research projects.
3. Sufficient institutional funding sources to support an established,
ongoing research program. In most cases, significant funding comes
from the orthopaedic and/or surgical department and the institution,
and additional funding comes from private and public sources.
4. An institutional infrastructure (core facilities, research
libraries, and readily available research assistants) that supports research.
5. Sufficient protected time to conduct research on a consistent basis.
(This component is a high priority.)
6. Rewards for a productive research program.
7. A process for attracting and selecting promising residents,
in the hope that they will become successful researchers.
8. Institutional access to relevant clinical patient populations.
Strategies for the Orthopaedic Community to
Impact the Number of Future Clinician-Scientists in Our Specialty
1. We should build and expand on our current strengths.
(a) Currently, there is a talented pool of individuals in our
orthopaedic training programs who have the potential to become clinician-scientists.
This pool should be tapped.
(b) We should expand, formalize, and monitor our current mentoring
efforts.
(c) We should recognize current orthopaedic clinician-scientist role
models and expose young clinicians to them.
(d) We should support and encourage the ten to twenty programs
with the basic and clinical-research infrastructure capable of developing
more orthopaedic clinician-scientists.
(e) We should parlay, expand, and additionally fund the excellent progress
that the Orthopaedic Research and Education Foundation has demonstrated
in addressing the issues facing the young investigator. As a specialty,
we are fortunate to have in place a research and education foundation
with such a strong record of accomplishment. This demonstrates the
vision of past leadership to address the issue. However, times have
changed, and the effort needs to be increased. The Orthopaedic Research
and Education Foundation is an excellent platform on which we can
continue to build.
(f) A portion (1% to 2%) of the financial reserves of the American
Academy of Orthopaedic Surgeons could be used to match funds for
bold and innovative pilot efforts to develop orthopaedic clinician-scientists.
This is simply "R and D" money that would help to maximize our specialty's
potential to deliver the highest-quality patient care and outcomes.
2. The leadership of the influential orthopaedic organizations that
compose the "House of Orthopaedics" must make a bold and concerted
effort if we wish to maintain orthopaedic clinician-scientists within
our specialty. This will require restructuring or creating an independent
structure within orthopaedics that is able to cross organizational
lines and coordinate all of the organizations that can contribute
to reducing the obstacles to this career choice. No single existing
organization can independently change the current trends. Representatives from
the organizations capable of making an impact must come together
to stimulate, support, and monitor the development of orthopaedic
clinician-scientists. To ensure a sustainable effort, adequate funding
will be needed. The core of this funding must come from the profession
of orthopaedics. Once we have established a methodology and have
demonstrated our resolve with a major financial commitment, we can
pursue supplemental matching funds from federal, private, and industrial
sources.
3. Strategies for coalition-building must be identified, impl
emented, and monitored.(a) We should expand participation in
current coalition efforts for training and research funding in cooperation
with the National Institutes of Health and other federal and private
funding sources. (Our specialty is currently represented in such
organizations as the National Institute of Arthritis and Musculoskeletal
and Skin Diseases Coalition, the Friends of the Department of Veterans
Affairs, and the Ad Hoc Group for Medical Research Funding.)
(b) We should identify health-policy initiatives, which are shared
with a variety of patient and physician groups, to encourage the
forging of new partnerships in the health-policy and funding arena
in order to address the problem of the endangered clinician-scientist.
(c) We should use the opportunity provided by "The Bone and Joint Decade"
to stress the burden of musculoskeletal diseases and the prevalence
of these conditions in the United States. We also should publicize
the need for clinician-scientists to address these major diseases
and conditions in order to enhance quality of life.
4. Orthopaedic leaders should articulate the need for, and work toward,
the development of a cadre of clinician-scientists in musculoskeletal
research.
5. Pilot studies should be undertaken with research-oriented individuals
in specific orthopaedic training programs that have demonstrated
the potential to produce orthopaedic clinician-scientists. This
will mean additional support for institutions that have demonstrated
success in their existing programs.
6. Innovative research training tracks should be developed within
orthopaedics. This may mean interruptions for a few years during
clinical training for a select few, credit for some of the years
of additional scientific training during residency, or possible
geographic displacement during residency or fellowship in order
to acquire specific training.
7. The efforts of organized orthopaedics should be expanded to support
clinician-scientists at each level of their career (particularly
at entry level and at midlevel) by promoting sources of funding,
identifying debt-reduction programs, and recognizing the value of
these individuals to orthopaedics.
8. Mentoring programs should be further formalized and expanded to
encourage the development of orthopaedic clinician-scientists.
9. Medical schools should be actively supported in encouraging
individuals to pursue research careers as clinician-scientists.
Note: The author especially wishes to acknowledge the Orthopaedic
Clinician-Scientist Steering Committee and workshop panel as follows:
Gunnar Andersson, MD, PhD, Scott Boden, MD, Adele Boskey, PhD, Richard
Brand, MD, Joseph Buckwalter, MD, Richard Coutts, MD, Thomas Einhorn, MD,
Michael Ehrlich, MD, Gary Friedlaender, MD, Mark Gebhardt, MD, Michael
Goldberg, MD, Steve Goldstein, PhD, Stuart Goodman, MD, Douglas Jackson,
MD, Joshua Jacobs, MD, Jim Panagis, MD, Larry Rosenthal, PhD, Randy
Rosier, MD, PhD, Peter Rou ghley, PhD, Linda Sandell, PhD, and Russell Warren,
MD.